Chapter 11 Right Lower Quadrant Pain in a 28-Year-Old Female (Case 1)
PATIENT CARE
Clinical Thinking
• Think of what surgical condition in the differential dx would lead to trouble quickly. In this instance it’s ectopic pregnancy, which is a hemorrhagic condition. Keep this in mind as you sort the differential dx.
History
• Appendicitis has a typical prodrome beginning with vague periumbilical discomfort for 12 to 24 hours before inflammatory symptoms settle in the RLQ.
• Menstrual hx is vital to the dx of ectopic pregnancy. Late or missed period is common, but patients are not always sure of this.
• Sexual hx is key to suspecting PID and tubo-ovarian abscess, including hx of vaginal discharge and previous hx of PID.
• Pyelonephritis—look for associated dysuria and urinary frequency and hx of previous UTIs. “Colicky pain” and the presence of hematuria are characteristic of ureteral colic.
• Patients presenting with Crohn’s disease (ileocolitis) will usually have a previous protracted hx of intermittent abdominal pain and diarrhea.
Physical Examination
• VS: Fever suggests an inflammatory process. Hypotension can be associated with dehydration, sepsis, or hypovolemia secondary to a bleeding ectopic pregnancy.
• Observation: patients with colicky pain can’t find a position of comfort, whereas patients with peritoneal findings prefer to lie still.
• Peritoneal findings (tenderness, guarding, rebound) are more likely in appendicitis, ectopic pregnancy, PID, tubo-ovarian abscess, and torsion; not present in gastroenteritis. CVA tenderness may be prominent in pyelonephritis or renal colic.
• Decreased bowel sounds are more frequently associated with a GI inflammatory process than a GU process. More diffuse lower abdominal tenderness may suggest perforated appendicitis, PID, tubo-ovarian abscess, or blood from an ectopic pregnancy.
Tests for Consideration
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| Clinical Entities | Medical Knowledge |
|---|---|
| Appendicitis | |
| PΦ | Appendicitis is an inflammation of the appendix usually brought about by occlusion of the appendiceal lumen by a fecalith. Initially, the distended appendix produces vague abdominal pain sensed as a vague “stomach ache” in the periumbilical region. |
| TP | As the serosa of the appendix becomes inflamed, the patient becomes aware that the pain has migrated to the RLQ. Usually associated with a mild leukocytosis. |
| Dx | If the prodromal pattern and the subsequent physical findings of RLQ peritoneal irritation are characteristic, a clinical dx of appendicitis can be made. A markedly elevated WBC, fever, or wider distribution of peritoneal findings may suggest perforated appendicitis. When the diagnosis is unclear, CT is the most helpful test. |
| Tx | Laparoscopic or open appendectomy. See Sabiston 49, Becker 15. |
| Pelvic Inflammatory Disease | |
| PΦ | After acquisition of a vaginal or cervical infection, the infection then ascends into the upper genital tract, leading to salpingitis. The organisms most commonly associated are Neisseria gonorrhoeae and Chlamydia trachomatis, but the infection may be polymicrobial in nature, including mixed anaerobic and aerobic bacteria. |
| TP | Personal sexual hx is key; physical examination is usually characterized by tenderness in the lower abdomen and tenderness of the adnexae (usually noted on movement of the cervix or uterus), associated fever, and vaginal discharge. |
| Dx | Dx is based on clinical picture and vaginal cultures. Pelvic ultrasonography or CT should differentiate from appendicitis. Laparoscopy may be required for dx and may be helpful for pelvic lavage. |
| Tx | Tx for acute pelvic inflammatory disease can include cefoxitin, ampicillin, tetracycline, doxycycline, clindamycin, or metronidazole. Tx is with oral or IV antibiotics, depending on severity. A patient’s likelihood of compliance may be an issue, and may guide how you proceed with therapy. See Sabiston 75, Becker 14. |
| Tubo-ovarian Abscess | |
| PΦ | Tubo-ovarian abscess is essentially a later stage PID characterized by more complex adnexal masses with thickened walls and central fluid. |
| TP | Presentation is similar to that of PID but often on the background of previous clinical episodes. |
| Dx | The typical ultrasonographic appearance of a tubo-ovarian abscess is a multilocular, cystic, complex adnexal mass, often with debris and thick septations. |
| Tx | When a patient is unresponsive to a triple antibiotic regimen of IV antibiotics (e.g., ampicillin, clindamycin, and flagyl), the condition requires surgical intervention which may include total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) for definitive therapy. See Sabiston 75. |
| Ectopic Pregnancy | |
| PΦ | Ectopic pregnancy, a pregnancy in which the fertilized ovum implants on any tissue other than the endometrial lining of the uterus (95% occur in the fallopian tube), is a potentially hemorrhagic and life-threatening condition and must be r/o first when seeing a young woman with lower abdominal pain. Risk for an ectopic pregnancy is increased 6 to 10 times in a woman with a hx of PID. |
| TP | A hx of missed period is characteristic. β-hCG is important for all women with child-bearing potential. The clinical impression is the most important factor in making a timely dx of ectopic pregnancy. |
| Dx | Vaginal probe ultrasonography is best for imaging the uterus. A normal gestational sac can be seen by the time the β-hCG level reaches 2,000 mIU/mL. By 5.5 to 6 weeks of pregnancy (1.5–2 weeks after the missed period) intrauterine pregnancies should be seen by vaginal ultrasonography. The most common finding for ectopic pregnancy is a unilateral adnexal mass, some fluid in the pelvis, and no normal pregnancy structures in the uterus; however, 20% to 30% of ectopic pregnancies will have no abnormal ultrasonographic findings. |
| Tx | In the face of significant hemorrhage, laparotomy is preferred as it can be carried out more rapidly. Otherwise, tx of ectopic pregnancy can be performed via laparoscopy and usually consists of salpingectomy (removal of the tube) or salpingotomy (opening of the tube and removal of the implant). In general, salpingectomy will be the procedure of choice if future fertility is of no concern, if the tube is ruptured, if there is significant anatomic distortion, or if there is overt hemorrhage. In many instances, if the patient is entirely stable, ectopic pregnancy is managed medically by administering methotrexate. See Sabiston 75, Becker 14. |
| Pyelonephritis | |
| PΦ | Pyelonephritis is an infection of the upper urinary tract most often caused by gram-negative organisms, most commonly Escherichia coli, Klebsiella, Proteus mirabilis. Enterococcus (gram-positive) is also common. Pseudomonas aeruginosa is often detected in hospital-acquired UTIs. |
| TP | The patient usually presents with fever, back or flank pain, and dysuria and frequency. |
| Dx | Dx should be recognized by pattern recognition of hx, physical examination, and U/A. CVA tenderness is usually present. Guarding and rebound may be present on the anterior abdominal wall, mimicking the diagnoses of cholecystitis or appendicitis. White cell casts may be present in the urine. Contrast-enhanced CT scans may be very sensitive for the detection of acute renal parenchymal inflammatory disease, but are not indicated in acute pyelonephritis because CT dx does not change management. |
| Tx | Tx is appropriate antibiotic therapy. |
| Urinary Tract Infection | |
| PΦ | Pyelonephritis has been considered above. Lower tract infections such as cystitis may also present with lower abdominal pain. |
| TP | Symptoms of dysuria and frequency and the absence of peritoneal signs should help distinguish UTIs from surgical conditions. |
| Dx | As with pyelonephritis, U/A and urine culture and sensitivity (C & S) are the mainstays of dx. |
| Tx | C & S defines appropriate antibiotic tx. See Becker 10. |
| Mesenteric Adenitis | |
| PΦ | Mesenteric adenitis of the ileocolic mesentery is most frequently caused by viral pathogens, but other infectious agents have been implicated, including Yersinia enterocolitica, Helicobacter jejuni, Campylobacter jejuni, and Salmonella or Shigella species. An association with streptococcal infections of the upper respiratory tract, particularly the pharynx, has been reported. Particularly in children, lymph node involvement may be a reactive process to a primary enteric pathogen. |
| Mesenteric adenitis is a self-limited condition characterized by fever, abdominal pain, nausea, and, occasionally, diarrhea. | |
| TP | Pain and tenderness are often centered in the RLQ, but they may be more diffuse than in appendicitis. The site of tenderness may shift when the patient’s position changes, whereas the site of the tenderness tends to remain localized with appendicitis. Leukocytosis is common. |
| Dx | The dx of mesenteric adenitis is one of exclusion. Ultrasonography of the RLQ with graded compression has been the mainstay of dx in children. Recently, many centers have adopted CT as a primary diagnostic modality. |
| Tx | Management is nonoperative. See Sabiston 43. |
| Ureterolithiasis | |
| PΦ | Ureterolithiasis usually presents as intermittent “colicky” flank, back, or abdominal pain characterized by the patient’s inability to find a comfortable position. The pain usually begins in the side or upper abdomen and travels down to the lower abdomen. It may radiate into the pubic region. In men the pain commonly radiates into the penis or testicles. Hematuria is often present. |
| TP | CVA tenderness on the affected side is characteristic. Peritoneal findings should be absent; however, there is often anterior abdominal tenderness and possible rebound tenderness, which must be carefully interpreted. |
| Dx | Urinalysis looking for hematuria is key (85% will have RBCs). The dx can be made by simple KUB, if a stone is radiopaque (60%– 70%). Ultrasonography is good for detecting hydronephorosis. IVP or CT urography are more definitive tests. |
| Tx | Retrograde pyelography may be indicated when there is a need for an endoscopic surgical procedure. While most smaller stones will pass spontaneously, extracorporeal shock wave lithotripsy is a highly effective tx. See Sabiston 77, Becker 63. |
| Ruptured Ovarian Cyst | |
| PΦ | Ovarian cysts are typically functional (not disease related) and disappear on their own. |
| TP | During the days preceding ovulation, a follicle grows. If a follicle fails to rupture and release an egg, the fluid within the follicle may persist. Such functional cysts usually disappear within 60 days without tx and are relatively common. Functional ovarian cysts are not to be confused with other disease conditions involving ovarian cysts, specifically benign cysts of various types that must be treated to resolve. There are also true cystic ovarian tumors. |
| A cystic rupture usually presents as acute lower abdominal pain without any significant prodrome. Often there is a previous hx of ovarian cysts. | |
| Dx | Pelvic examination usually shows tenderness on cervical motion and anterior tenderness when the adnexa are put on stretch. Hx and physical examination should differentiate ovarian cysts from appendicitis and PID. A ruptured ovarian cyst can produce a massive hemoperitoneum with clinical symptoms and sonographic features that closely mimic ectopic pregnancy. Pelvic ultrasonography will often show cysts or cyst remnants. β-hCG is important to r/o ectopic pregnancy. |
| Tx | Tx is excision by laparoscopy or laparotomy. See Sabiston 75. |
| Ovarian Torsion | |
| PΦ | Ovarian torsion usually presents as acute RLQ pain without any significant prodrome. |
| TP | Often there is a previous hx of ovarian cysts. Pelvic examination usually shows tenderness on cervical motion and anterior tenderness when the adnexa are put on stretch. |
| Dx | Dx of this condition is difficult, and is generally clinical. |
| Ultrasonography with Doppler flow is sometimes helpful. | |
| Tx | Tx is by laparoscopy or laparotomy. In some instances the torsion may be surgically “untwisted” and the tube and ovary may be left in situ. In the face of obvious necrosis or diminished blood flow, the ovarian complex should be surgically removed. See Sabiston 75. |
| Crohn’s Disease/Terminal Ileitis | |
| PΦ | Crohn’s disease is inflammatory bowel disease, which can present in adolescents and young adults. |
| TP | Crohn’s disease frequently presents with episodes of abdominal pain and diarrhea. Though the typical patient usually presents with a more chronic, episodic hx, Crohn’s ileitis should be kept in mind when approaching the patient with RLQ pain. |
| Dx | In patients not previously diagnosed, look for thickening of the distal ileum on CT. |
| Tx | By laparoscopy or by laparotomy, Crohn’s of the distal ileum is characterized grossly by inflammation of the bowel and “creeping fat”—mesenteric fat creeping over the bowel. If the appendix is normal at laparotomy for suspected appendicitis, the distal ileum should be inspected to exclude inflammatory bowel disease. If the dx is Crohn’s ileitis, the appendix should be removed if the base of the appendix is healthy (see also Case 6, Abdominal Pain and Diarrhea). See Sabiston 48, 50; Becker 22. |
a. Meckel’s diverticulum: diverticulum located approximately 20 cm from ileocecal valve. Can become infected much like appendicitis. If appendectomy is performed, but the appendix is normal, the terminal ileum should be carefully examined to exclude both Crohn’s and Meckel’s. See Sabiston 48, Becker 57.
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