Right Lower Quadrant Abdominal Pain


Diagnosis

History and physical/other

Mimicking features

Inflammatory bowel disease (IBD)

Abdominal pain, severe cramps, weight loss, bloody diarrhea, anemia, enterocutaneous fistula/anal fissures (Crohn’s), toxic megacolon (ulcerative colitis)

Crohn’s can present with RLQ pain due to inflammation limited to the ileocecal region (known as regional enteritis)

Pancreatitis

Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, gallstones, or alcohol abuse

Predominantly epigastric pain. With severe pancreatitis, ascites forms and may track down the right paracolic gutter (depressions found between the colon and abdominal wall) causing RLQ pain

Cholecystitis

Right upper quadrant (RUQ) pain radiating to back, nausea, vomiting, fever, palpation of RUQ during inspiration stops inspiration secondary to pain (Murphy’s sign)

Though pain is typically RUQ, a large inflamed gallbladder may cause RLQ pain

Appendicitis

Anorexia, vague periumbilical abdominal pain, vomiting, localized right lower quadrant pain (McBurney’s point), Rovsing’s sign, psoas sign


Gastroenteritis

Nausea, vomiting, watery diarrhea (viral), bloody diarrhea (certain bacteria), myalgia, fever

May cause diffuse abdominal tenderness and marked leukocytosis

Nephrolithiasis

Colicky flank pain that may radiate to inner thigh or genitals, nausea, vomiting, dysuria, hematuria

Ureteral pain may refer to RLQ

Perforated duodenal ulcer (Valentino’s syndrome)

Sudden onset of epigastric pain, rigid abdomen, history of dyspepsia, NSAID use, recurrent ulcers, H. pylori infection

Initial pain is epigastric, then diffuse, but duodenal perforation may seal, enteric contents may track down right paracolic gutter causing subsequent RLQ pain

Pyelonephritis

Costovertebral angle tenderness, fever, pain on urination, vomiting

Renal and ureteral pain can refer to RLQ

Sigmoid diverticulitis

Pain in LLQ, fever, leukocytosis, nausea, diarrhea, constipation, common in elderly (acquired)

A large, floppy, redundant sigmoid colon may lie in the RLQ, thus presenting with RLQ instead of left lower quadrant (LLQ) pain

Cecal diverticulitis

Congenital solitary diverticulum

Identical to appendicitis

Meckel’s diverticulitis

“Rule of 2’s”: males 2× more common than females, occurs within 2 ft of the ileocecal valve, 2 types of tissue (pancreatic, gastric), found in 2 % of the population, can present at 2 years of age (with painless rectal bleeding)

Identical to appendicitis, in an adult, a Meckel’s diverticulum can become infected (Meckel’s diverticulitis) and present with RLQ pain




What is the Differential Diagnosis of Appendicitis in Women and What Clues on History and Physical Might Direct you Towards a Specific Diagnosis?
























Diagnosis

History and physical

Pelvic inflammatory disease

Neisseria gonorrhoeae or Chlamydia infection, purulent cervical discharge, cervical motion tenderness, adnexal tenderness, dysuria

Ovarian torsion

Acute onset of severe pelvic pain, adnexal mass, history of ovarian cysts

Mittelschmerz

Physiologic recurrent mid-cycle pain, mild and unilateral, duration ranges from few hours to few days, normal pelvic exam

Ruptured ectopic

Typically presents 6–8 weeks after last normal menstrual period, abdominal pain, amenorrhea, vaginal bleeding, breast tenderness, anemia (rarely hemorrhagic shock)


What is the differential diagnosis of appendicitis in a child and what clues on history and physical might direct you towards a specific diagnosis?



























Diagnosis

History and physical

Mesenteric lymphadenitis

Concomitant or recent URIa; high fever; enlarged, inflamed, and tender lymph nodes in small bowel mesentery; generalized abdominal pain

Yersinia enterocolitica (pseudoappendicitis)

RLQ pain, fever, vomiting, bloody diarrhea, history of sick contacts (e.g., infected children at daycare)

Pneumococcal pneumonia

May be associated with nausea, vomiting, and diffuse abdominal pain

Gastroenteritis

Nausea, vomiting, watery diarrhea (viral), bloody diarrhea (certain bacteria), myalgia, fever

Intussusception

Nausea, vomiting, crampy abdominal pain, “red currant jelly” stool, “sausage-shaped mass in abdomen (12-month-old infant)


aUpper respiratory tract infection


What Is the Most Likely Diagnosis?


Given the history of initial periumbilical pain that is now localized to the RLQ, associated with tenderness, leukocytosis with increased bands, the most likely diagnosis is acute appendicitis.


Watch Out

Rule out an ectopic pregnancy with a beta-hCG pregnancy test for all women of childbearing age presenting with abdominal pain.



History and Physical



What Is Usually the First Symptom of Appendicitis and What Is the Classic Sequence of Symptoms?


In >95 % of cases of acute appendicitis, anorexia is the first symptom. The classic sequence of symptoms is anorexia, vague periumbilical abdominal pain, vomiting, and then a shift to localized right lower quadrant pain.


What Is the Significance of Absent Bowel Sounds?


Absent bowel sounds indicate a paralytic ileus which in this setting would be secondary to inflamed/infected bowel.


What Is a Hamburger Sign?


The majority of patients with acute appendicitis will have anorexia. If the patient is hungry, acute appendicitis is less likely. Inquire about the patient’s favorite food (e.g., hamburger, pizza), and ask if the patient would like to eat it. Patients with true anorexia will decline their favorite food (positive hamburger sign).


What Are Rovsing’s, Psoas, and Obturator Signs and McBurney’s Point Tenderness?


Appendicitis creates an inflammatory response in the adjacent retroperitoneum and parietal peritoneum. These are signs (Table 20.1) of localized peritonitis in the right lower quadrant due to inflammation. Rovsing’s sign is right lower quadrant pain with palpation of the left lower quadrant. Compression in the LLQ stretches the abdominal wall triggering pain in the inflamed underlying RLQ parietal peritoneum. Appendicitis can also inflame the adjacent psoas or obturator muscles. Psoas sign is right lower quadrant pain on passive extension of the right hip or active flexion of the right hip. Obturator sign is RLQ pain on internal rotation of the hip which can occur with a pelvic appendix. McBurney’s point (Fig. 20.1) is located at one-third of the distance along an imaginary line drawn from the anterior superior iliac spine to the umbilicus and marks the incision site for open appendectomies. McBurney’s sign is maximal tenderness at McBurney’s point.


Table 20.1
Signs of appendicitis






















Sign

Description

Rovsing’s

RLQ pain with palpation of LLQ

Psoas

RLQ pain on passive extension of the right hip or active flexion of the right hip

Obturator

RLQ pain on internal rotation of the hip, typical of a pelvic appendix

McBurney’s

Tenderness to palpation at McBurney’s point


A313183_1_En_20_Fig1_HTML.jpg


Fig. 20.1
McBurney’s point. A. McBurney’s point marked for mini incision. B. Incision appearance on postoperative day 4. The procedure began by making a small incision, 1.5–1.8 cm in length, according to the thickness of abdominal wall, at McBurney’s point (With kind permission from Springer Science + Business Media: Surgical Endoscopy, Gasless single-incision laparoscopic appendectomy, 25, 2011, pg 1473, Chen D et al., Fig. 1)

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May 13, 2017 | Posted by in GENERAL SURGERY | Comments Off on Right Lower Quadrant Abdominal Pain

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