RIGHT LOWER QUADRANT PAIN

Most cases of acute right lower quadrant (RLQ) pain are considered appendicitis until proven otherwise, but every physician has been wronged by this axiom more times than he or she would like to remember. For this reason, the astute clinician will want to have a good list of possibilities in mind. For all abdominal pain, anatomy is the key to recalling an inclusive list of causes of RLQ pain. Visualizing the structures, layer by layer, one finds the skin and abdominal wall in the first layer; the terminal ileum, cecum, appendix, and Meckel diverticulum in the second layer; the ureters, tubes, and ovaries (in females) in the third layer; and the muscles, spine, and terminal aorta in the fourth layer. Now the organs can be cross-indexed with the various etiologies that may be encountered by using the mnemonic VINDICATE (Table 9). The following discussion emphasizes the most important diseases in the differential diagnosis.

ABDOMINAL PAIN, RLQ

1. Skin and abdominal wall. Herpes zoster, cellulitis, contusion, and especially inguinal or femoral hernias are significant causes of RLQ pain.
2. Appendix. Appendicitis is a major cause of RLQ pain.
3. Terminal ileum. Regional ileitis, tuberculosis, or typhoid and intussusceptions may involve the ileum, causing severe pain. Mesenteric adenitis and infarcts may also affect the ileum.
4. Cecum. Diverticulitis, colitis (e.g., granulomatous or amebic), and colon carcinoma are culprits that may cause RLQ pain originating in the cecum. Impacted feces are also a possible cause.
5. Meckel diverticulum. This may become obstructed and inflamed, develop a pancreatitis or a perforated peptic ulcer, or communicate with a periumbilical cellulitis. All of these may cause RLQ pain.
6. Ureters. Renal calculi and hydronephrosis may cause RLQ pain.
7. Ovary and fallopian tubes. A mumps oophoritis may cause pain in the RLQ. Ovarian cysts may twist on their pedicles or rupture, causing pain, as may the rupture of a small graafian follicle in the normal cycle (mittelschmerz). Three significant lesions may involve the tube: salpingitis, endometriosis, and ectopic pregnancy. All three are painful.
8. Aorta. Dissecting aneurysms or emboli of the terminal aorta and its branches may seize the patient with acute pain.
9. Pelvis and spine. Osteoarthritis, ruptured disc, metastatic carcinoma, Pott disease, and rheumatoid spondylitis should be considered here.
10. Miscellaneous structures. A ruptured peptic ulcer or inflamed gallbladder may leak fluid into the right colic gutter and cause RLQ pain. Any of the numerous causes of intestinal obstruction (e.g., adhesions or volvulus) may cause pain. Omental infarcts are another miscellaneous cause. Referred pain from pneumonia or pulmonary infarct has encouraged some surgeons to insist on a chest x-ray prior to surgery.

Approach to the Diagnosis

Obviously, acute RLQ pain is suspected to be acute appendicitis until proven otherwise. However, it is wise to order flat plate and upright films of the abdomen, CBC, urinalysis, and an amylase level before surgery to dodge a curve ball. Some surgeons want a chest x-ray as well, because pneumonia and other chest conditions can present with RLQ pain. A pregnancy test should be ordered for women of childbearing age to help rule out a ruptured ectopic pregnancy, but ultrasonography is even better. Surprisingly, many patients get to the operating room without a rectal or vaginal examination. In cases of chronic RLQ pain, contrast studies such as a barium enema, IVP, upper GI series, and cholecystogram may be indicated. If these are not diagnostic, further investigation with colonoscopy, cystoscopy, culdoscopy, or laparoscopy may be needed. A CT scan of the abdomen and pelvis can often reveal the diagnosis.

Other Useful Tests

1. Stool for occult blood (mesenteric thrombosis, neoplasm)
2. Stool for ova and parasites
3. Gallium or indium scan (diverticulitis, abscess)
4. Angiogram (mesenteric thrombosis)
5. X-ray of lumbar spine (herniated disc, etc.)
6. Urine culture, sensitivity, and colony count
7. Chemistry panel
8. Sedimentation rate (inflammation)
9. Lymphangiogram (Hodgkin disease)
10. Urine porphobilinogen (porphyria)
11. Small-bowel series (Meckel diverticulum)
12. Blood lead level

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Lower abdominal pain

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Lower abdominal pain: Introduction (review 32 causes)
• Next Book Extract About Lower abdominal pain: Abdominal distention (Handbook of Signs & Symptoms (Third Edition))
• All Book Extracts: All Online Book Extracts for Lower abdominal pain

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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