Right Lower Quadrant Pain

Most cases of acute RLQ pain are considered appendicitis until proven otherwise, but every physician has been fooled 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. Anatomy is the key to recalling an inclusive list of causes of all 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 women) 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.

1. Skin and abdominal wall. Herpes zoster, cellulitis, contusion, and especially inguinal or femoral hernias are significant causes of RLQ pain.

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   LEFT UPPER QUADRANT PAIN

   	I	C	A	T	E
   	Intoxication	Congenital	Autoimmune	Trauma	Endocrine
   			or Allergic
   				Contusion Hernia
   			Periarteritis nodosa	Ruptured spleen
   	Gastric dilatation in pneumonia	Cascade stomach Hiatal hernia		Ruptured stomach
   		Diverticulum	Granulomatous colitis	Ruptured colon
   					Waterhouse– Friderichsen syndrome
   		Nephroptosis			Renal calculus
   				Fracture Ruptured disc	Osteoporosis

   ---

2. Appendix. Appendicitis is a major cause of RLQ pain.
3. Terminal ileum. Regional ileitis, tuberculosis, or typhoid and intussusceptions may involve the ileum and cause 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 congenital anomaly 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.

   ---

   RIGHT LOWER QUADRANT PAIN

   	V	I	N	D
   	Vascular	Inflammatory	Neoplasm	Degenerative
   				and Deficiency
   Skin and Abdominal Wall		Herpes zoster Cellulitis
   Terminal Ileum	Mesenteric infarct	Tuberculosis Typhoid Mesenteric adenitis
   Cecum		Diverticulitis Amebic colitis Shigella Ascaris	Colon carcinoma
   Appendix		Appendicitis Enterobiasis	Carcinoid
   Meckel Diverticulum		Meckel diverticulitis Cellulitis
   Ureter		Ureteritis
   Ovary and Tubes		Mumps Oophoritis Salpingitis	Ovarian cyst Neoplasm Endometriosis
   Aorta	Dissecting aneurysm Embolism
   Spine and Pelvis	Pott disease	Metastatic carcinoma Myeloma Hodgkin lymphoma	Osteoarthritis

   ---

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.

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RIGHT LOWER QUADRANT PAIN

	I	C	A	T	E
	Intoxication	Congenital	Autoimmune	Trauma	Endocrine
			Allergic
		Inguinal hernia Femoral hernia		Contusion Incisional hernia
		Intussusception	Regional ileitis Whipple disease
	Toxic megacolon	Diverticulum	Granulomatous colitis	Impacted feces Ruptured bowel
				Fecalith
		Ectopic gastric and pancreatic tissue
		Aberrant blood vessel or congenital band			Ureteral calculus
		Ectopic pregnancy			Ruptured graafian folicle (mittelschmerz)
			Rheumatoid spondylitis Ileitis	Fracture Ruptured disc

---

---

LEFT LOWER QUADRANT PAIN

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
				and Deficiency
Skin and Abdominal Wall		Herpes zoster Cellulitis
Small Intestine	Mesenteric thrombosis	Parasite	Polyp with intussusception Carcinoma Leiomyoma
Sigmoid Colon	Ischemic colitis Mesenteric infarct	Diverticulitis Mesenteric adenitis	Carcinoma of the sigmoid
Ureters		Ureteritis	Papilloma
Ovary and Tubes		Mumps Oophoritis Salpingitis	Benign and malignant ovarian tumors Endometriosis
Aorta	Dissecting aneurysm Emboli
Spine and Pelvis		Pott disease	Metastatic carcinoma Myeloma	Osteoarthritis

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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 curveball. 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.

---

LEFT LOWER QUADRANT PAIN

	I	C	A	T	E
	Intoxication	Congenital	Autoimmune	Trauma	Endocrine
			Allergic
		Inguinal and femoral hernias		Contusion Hernia
	Uremia Lead colic	Intussusception Porphyria Congenital polyposis	Regional ileitis	Rupture Hematoma Adhesion	Diabetic ketosis
			Granulomatous colitis	Contusion Perforation Adhesion
		Congenital band ureterocele			Ureteral calculus
		Ovarian cyst Ectopic pregnancy		Contusion Rupture	Ruptured graafian follicle (mittel- schmerz)
		Spondylolisthesis	Rheumatoid spondylitis	Fracture Ruptured disc

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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 lymphoma)
10. Urine porphobilinogen (porphyria)
11. Small-bowel series (Meckel diverticulum)
12. Blood lead level

Pictures

Book Source Details

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

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

More About Causes of Lower back pain

• Back to symptom: Lower back pain: Introduction (review 78 causes)
• Next Book Extract About Lower back pain: Back, Joint, and Extremity Pain (Pediatric Complaints and Diagnostic Dilemmas)
• All Book Extracts: All Online Book Extracts for Lower back pain

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

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