Right lower quadrant abdominal pain: Difference between revisions
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==Background== | ==Background== | ||
*This page describes the general approach to RLQ pain in adults | *This page describes the general approach to RLQ pain in adults | ||
{{Abdominal pain location}} | |||
==Clinical Features== | ==Clinical Features== | ||
*Right lower quadrant abdominal pain | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Abd DDX RLQ}} | {{Abd DDX RLQ}} | ||
==Workup== | ==Evaluation== | ||
===Male=== | ===Appendicitis Risk Scores=== | ||
* | {{Alvarado scoring system}} | ||
* | |||
* | ===Workup=== | ||
* | *Include genital exam (pelvic exam or testicular), if appropriate | ||
* | ====Labs==== | ||
*Abdominal panel | |||
**CBC | |||
**Chemistry | |||
**Consider LFTs + lipase | |||
**Consider coagulation studies (PT, PTT, INR), as a marker of liver function | |||
*[[Urinalysis]] | |||
**Leukocytes will be present in 40% of patients<ref>Baird DLH, Simillis C, Kontovounisios C, Rasheed S, Tekkis PP. Acute appendicitis. BMJ. 2017;357:j1703. Published 2017 Apr 19. doi:10.1136/bmj.j1703</ref> | |||
**Urine pregnancy test (if age and sex appropriate) | |||
===Imaging=== | |||
====Male==== | |||
*Typically start with CT abdomen/pelvis (to rule out [[appy]]) | |||
====Female==== | |||
*Frequently utilize bimanual pelvic exam to determine first study: | |||
**More consistent with pelvic origin | |||
***Pelvic [[ultrasound]] (rule out [[ovarian torsion]]) | |||
****If negative, consider CT abdomen/pelvis^ (to rule out [[appy]]) | |||
**More consistent with intra-abdominal origin | |||
***CT abdomen/pelvis^ (to rule out [[appy]]) | |||
****If negative, consider pelvic [[ultrasound]] (rule out [[ovarian torsion]]) | |||
''^If pregnant, consider substituting MRI for CT'' | |||
=== | ===Diagnosis=== | ||
* | *Definitive diagnosis may be determined via a combination of history, labs, and/or imaging | ||
*About one-third of patients do not have a definitive diagnosis by end of ED workup<ref>Hosiniejad SM, et al. Arch Acad Emerg Med. 2019; 7(1): e44. Published online 2019 Aug 17. One Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study.</ref> | |||
* | |||
==Management== | ==Management== | ||
*Treat underlying disease process | *Treat underlying disease process | ||
**If imaging studies are negative, but bimanual was positive, consider empiric treatment for [[PID]] | |||
==Disposition== | ==Disposition== | ||
| Line 39: | Line 61: | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Symptoms]] | |||
Latest revision as of 23:13, 14 February 2024
Background
- This page describes the general approach to RLQ pain in adults
Classification by Abdominal pain location
| RUQ pain | Epigastric pain | LUQ pain |
| Flank pain | Diffuse abdominal pain | Flank pain |
| RLQ pain | Pelvic pain | LLQ pain |
Clinical Features
- Right lower quadrant abdominal pain
Differential Diagnosis
RLQ Pain
- GI
- Appendicitis
- Perforated appendicitis
- Peritonitis
- Crohn's disease (terminal ileitis)
- Diverticulitis (cecal, Asian patients)
- Inguinal hernia
- Mesenteric ischemia
- Ischemic colitis
- Meckel's diverticulum
- Neutropenic enterocolitis (typhlitis)
- Appendicitis
- GU
- Other
Evaluation
Appendicitis Risk Scores
Alvarado Clinical Scoring System
| Right Lower Quadrant Tenderness | +2 |
| Elevated Temperature (37.3°C or 99.1°F) | +1 |
| Rebound Tenderness | +1 |
| Migration of Pain to the Right Lower Quadrant | +1 |
| Anorexia | +1 |
| Nausea or Vomiting | +1 |
| Leukocytosis > 10,000 | +2 |
| Leukocyte Left Shift | +1 |
Clinical scoring system, where a score (Total=10) is composed on presence/absence of 3 signs, 3 symptoms and 2 lab values to help guide in case management.
- ≤3 = Appendicitis unlikely
- ≥7 = Surgical consultation
- 4-6 = Consider CT
MANTRELS Mnemonic: Migration to the right iliac fossa, Anorexia, Nausea/Vomiting, Tenderness in the right iliac fossa, Rebound pain, Elevated temperature (fever), Leukocytosis, and Shift of leukocytes to the left (factors listed in the same order as presented above).
Workup
- Include genital exam (pelvic exam or testicular), if appropriate
Labs
- Abdominal panel
- CBC
- Chemistry
- Consider LFTs + lipase
- Consider coagulation studies (PT, PTT, INR), as a marker of liver function
- Urinalysis
- Leukocytes will be present in 40% of patients[1]
- Urine pregnancy test (if age and sex appropriate)
Imaging
Male
- Typically start with CT abdomen/pelvis (to rule out appy)
Female
- Frequently utilize bimanual pelvic exam to determine first study:
- More consistent with pelvic origin
- Pelvic ultrasound (rule out ovarian torsion)
- If negative, consider CT abdomen/pelvis^ (to rule out appy)
- Pelvic ultrasound (rule out ovarian torsion)
- More consistent with intra-abdominal origin
- CT abdomen/pelvis^ (to rule out appy)
- If negative, consider pelvic ultrasound (rule out ovarian torsion)
- CT abdomen/pelvis^ (to rule out appy)
- More consistent with pelvic origin
^If pregnant, consider substituting MRI for CT
Diagnosis
- Definitive diagnosis may be determined via a combination of history, labs, and/or imaging
- About one-third of patients do not have a definitive diagnosis by end of ED workup[2]
Management
- Treat underlying disease process
- If imaging studies are negative, but bimanual was positive, consider empiric treatment for PID
Disposition
- Per underlying disease process
See Also
External Links
References
- ↑ Baird DLH, Simillis C, Kontovounisios C, Rasheed S, Tekkis PP. Acute appendicitis. BMJ. 2017;357:j1703. Published 2017 Apr 19. doi:10.1136/bmj.j1703
- ↑ Hosiniejad SM, et al. Arch Acad Emerg Med. 2019; 7(1): e44. Published online 2019 Aug 17. One Month Follow-Up of Patients with Unspecified Abdominal Pain Referring to the Emergency Department; a Cohort Study.