The Differential Diagnosis of Right Lower Quadrant Pain

Martin E. Kreis, Franz Edler v. Koch, Karl !alter "auch, Klaus Friese

Right lower quadrant pain #ts diagnostic assess$ent %resents a challenge &ecause the leading entities in the differential diagnosis are different de%ending on the %atient's age and se(. History and physical examination: the key elements of case stratification
The history and physical examination are the key elements leading to the determination of the diagnosis and of the further management of the patient (4, e7). The physician should inquire in general about the onset, duration, nature, and intensity of the pain, as well as about the following specific features ! "efecation has the patient noticed any abnormalities# ! $s the patient suffering from nausea, %omiting, or alguria&dysuria (painful or otherwise abnormal micturition)# $n female patients, a gynecological history is obligatory and often points to the diagnosis. $n taking the history, the physician should always try to gain information of differential diagnostic %alue in order to determine which further tests should be performed. The physical examination ser%es the same purpose. The physician should inspect, auscult, and palpate the abdomen, look for guarding and peritoneal signs, check the renal beds and potential hernia sites, and perform a digital rectal examination. 'emale patients should ha%e an intra%aginal examination as well, as a component of the acute gynecological consultation (e().

Diagnostic testing as an adjunct to clinical examination

Testing with diagnostic apparatus should be performed only after the history and physical examination ha%e been completed. $ts purpose is to confirm the diagnosis that seems most likely among the possible differential diagnoses and to exclude all of the competing diagnoses (box). $f appendicitis is suspected, a blood draw for laboratory testing (e), *) and an ultrasonographic examination of the abdomen are indicated (e+,, -). These tests can be performed quickly and with negligible distress to the patient. $t should be borne in mind, howe%er, that these tests are not %ery sensiti%e or specific. .onditions affecting the female reproducti%e tract, such as adnexitis, symptomatic o%arian cysts, or extrauterine pregnancy, are common causes of right lower quadrant pain/ thus, a properly performed gynecological examination is recommended, combined with an endo%aginal ultrasonographic examination, as long as it can be performed in an acceptably

short time frame (7, (). $f a woman with right lower quadrant pain is first seen by a gynecologist and the cause of the trouble is not definiti%ely found to be gynecological, then a general surgeon should be consulted next. The same procedure applies to patients who present with additional symptoms or findingsin the urological area, e.g., renal percussion tenderness, alguria&dysuria, or macrohematuria,or in the orthopedic&neurological area, e.g., mo%ement!related pain, radicular or pseudo!radicular symptoms, and percussion tenderness of the spine. The specialists that are consulted to e%aluate symptoms of these types will then determine the indication for further tests such as ! 0xtended urinalysis ! 1oiding urography ! 2lain x!rays of the pel%is and spine ! 3pinal .T. $f there are right lower quadrant symptoms suggesting perforation (e.g., due to right!sided di%erticulitis) or ileus, then plain abdominal and chest x!rays should be obtained to determine the possible presence of free intraperitoneal air or adynamic intestinal loops (figure +) . 2lain films of the abdomen should not be obtained routinely in the diagnostic assessment of right lower quadrant pain. 4nless these are ordered to answer a specific question, their diagnostic %alue is limited (), e++). $f the initial diagnostic e%aluation has not re%ealed any definiti%e or suspected diagnosis, it would seem more reasonable either to obser%e the

History #n wo$en with right lower )uadrant %ain, a g*necological e(a$ination often leads to the diagnosis. Systematic history-taking #f the %atient has &een e(a$ined &* a g*necologist and her s*$%to$s do not a%%ear to &e due to a g*necological %ro&le$, a general surgeon should &e consulted.

The most common causes of right lower quadrant pain

Surgery !astroenterology " #cute appendicitis " !astroenteritis $%acterial &iral' " (esenteric lymphadenitis $)ersinia enterocolitica infection'

" *erforated or infected cecal pole di&erticulum " Sigmoid di&erticulitis or perforation " +rohn,s disease- ulcerati&e colitis " +arcinoma of the colon " .leus " (eckel,s di&erticulum !ynecology " #dnexitis tu%o-o&arian a%scess " /xtrauterine pregnancy " Torsion of an o&arian cyst 0rology " +ystitis pyelonephritis " 0rolithiasis " Tumors of the urinary tract 1eurology orthopedics " Radicular pseudoradicular symptoms of disc prolapse or protrusion " +oxarthrosis " Sacroileitis " Herpes 2oster

patient further and reassess at close inter%als or to proceed right away to computeri5ed tomography, depending on the se%erity of the symptoms (6+,, ++7/ see also the diagnostic algorithm shown in diagram + ).

Differential diagnosis: the typical causes of right lower quadrant pain

4p to this point, we ha%e discussed the initial steps in the e%aluation of all cases of right lower quadrant pain. 8e will now describe its %arious typical and common causes, classified according to the rele%ant medical specialties. $t should be borne in mind that patients9 complaints are highly %ariable and often atypical. This factor complicates the diagnostic process still further. :oreo%er, in each specialty area there are rarer causes of right lower quadrant pain, not all of which can be listed here.

Surgery gastroenterology
;ppendicitis is probably the most common cause of right lower quadrant pain. The abdominal pain is typically diffuse and poorly locali5able at first, until it becomes concentrated in the right lower quadrant (e)). .lassic symptoms are nausea, %omiting, and cessation of defecation.

*lain a%dominal x-ray Plain fil$s of the a&do$en should not &e o&tained routinel* in the diagnostic assess$ent of right lower )uadrant %ain.

+nless the* are ordered to answer a s%ecific )uestion, their diagnostic value is li$ited. Diagnostic assessment ,%%endicitis is the $ost co$$on cause of right lower )uadrant s*$%to$s.
2atients generally present to medical attention after ha%ing suffered abdominal pain for + or < days. 0xamination usually discloses locali5ed lower abdominal pain and peritoneal signs at :c=urney9s or >an59s point, including percussion tenderness, rebound pain, and local guarding . 2atients with appendicitis may also ha%e the following ! =lumberg9s sign contralateral rebound pain (e), *) ! The psoas sign pain on lifting of the straightened right leg against resistance. This is a classic finding of retrocecal appendicitis. ! ?o%sing9s sign pain when manual pressure is applied to the ascending colon in a retrograde direction.

'e%er may or may not be present. 3tudies ha%e not confirmed the hypothesis that the difference between the axillary and rectal temperatures is of diagnostic significance (+<, e+<). The same holds for the digital rectal examination (e+<, +@), though it is in any case an integral part of a thorough physical examination of the abdomen. 'urther information can be obtained by ultrasonography (concentric ring sign, free fluid) and by laboratory testing (leukocytosis) (e+,, -, +<). :odern computeri5ed tomography enables appendicitis to be diagnosed with high sensiti%ity and specificity (++, +4, e+@).Aonetheless, because of its cost and the radiation exposure associated with it, the use of .T as a routine in%estigation in all patients with acute right lower quadrant pain cannot be Bustified. $f the typical symptoms and signs of appendicitis are present, the correct diagnosis can be established and a decision to operate can be made on clinical grounds alone. The protean manifestations of appendicitis make it impossible to state uni%ersally ;pplicable rules about when to operate. $n general, howe%er, whene%er appendicitis is strongly suspected, the patient should be taken to surgery. The suspicion of appendicitis is

usually based on the clinical findings (local peritoneal signs and guarding) but can also be deri%ed from ancillary tests. To the best of the authors9 knowledge, it is common practice in most hospitals to rely more on the clinical findings than on ancillary tests in cases of doubt. ;ppendicitis can usually be distinguished from bacterial or %iral gastroenteritis on clinical grounds (the latter is associated with recent consumption of possibly tainted food, %omiting, diarrhea, absence of peritoneal signs and guarding, and hyperperistaltic bowel sounds 6+<7). .hronic inflammatory bowel diseases such as .rohn9s disease and ulcerati%e colitis can produce symptoms and signs resembling those of acute gastroenteritis/ these entities should be suspected in patients with chronically recurring diarrhea, weight loss, a history of perianal fistulae, and a prior appendectomy. ?ight lower quadrant pain is an
.

The three steps in the diagnostic assessment of right lower quadrandt pain ! -istor* ! Ph*sical e(a$ination ! #s a%%endicitis sus%ected. #ppendicitis #f the clinical assess$ent reveals entirel* t*%ical findings of a%%endicitis, the diagnosis and the indication for surger* can &e esta&lished on clinical grounds alone.

especially typical feature of terminal ileitis (e+4). Castroenteritis, .rohn9s disease, and ulcerati%e colitis generally do not produce peritoneal signs or guarding unless a perforation has occurred. Dften, these diseases can be distinguished from appendicitis by ultrasonography or .T (e+,, -, e+@). .olonoscopy may be used for the definiti%e diagnosis of chronic inflammatory bowel disease but is not useful as an emergency diagnostic test because it requires prior bowel preparation with appropriate rinsing solutions. 'urther ancillary tests, such as plain x!ray of the abdomen with an emptied gastrointestinal tract and computeri5ed tomography, should be performed in atypical cases and when yet

other possible diagnoses are suspected (e+@). $n the surgical!gastroenterological area, another possible cause of right lower quadrant pain is di%erticulitis (e+*), which is particularlylikely to arise in the right hemicolon in patients of ;sian extraction (+*). 0%en sigmoid di%erticulitis can present in the right lower quadrant if a large sigmoid loop is present. $nfection of a :eckel9s di%erticulum is a special type of di%erticulitis that is only rarely correctly diagnosed preoperati%ely (e+-). Dther diseases causing right lower quadrant pain usually ha%e further accompanying symptoms that can aid in the differential diagnosis. Tumors of the right hemicolon, for example, usually cause right lower quadrant pain only

3urther diagnostic testing Right lower )uadrant %ain is a t*%ical $anifestation of diseases affecting the ter$inal ileu$. , /T or %lain fil$ of the a&do$en should &e o&tained if the constellation of clinical findings is at*%ical.
after a long, chronic course/ the affected patients may also complain of weight loss, altered bowel habits, and blood in the stool. 3ome other conditions causing pain in the right lower quadrant without peritoneal signs are ! :esenteric lymphadenitis due to infection with Eersinia enterocolitica (+-) ! $nguinal hernia (palpable, pain often exacerbated by the 1alsal%a maneu%er);dhesion ileus (symptoms of ileus, lack of flatus or defecation) ! ;dhesion!related pain, classically occurring in a patient who has pre%iously had an appendectomy (+7). $f the clinical examination and ancillary tests do not pro%ide a clear answer and the abdominal symptoms and signs are so se%ere that the presence of a life!threatening condition cannot be ruled out with certainty, diagnostic laparoscopy should be performed (e+7). "iagnostic laparoscopy can also be used instead of laparotomy when an acute disease process in the abdomen has already been successfully diagnosed on the basis of the clinical examination, laboratory tests, and imaging studies. >aparoscopy often enables immediate treatment of the problem, e.g., by laparoscopic appendectomy. The known contraindications to laparoscopy should be borne in mind, howe%er, including a history of extensi%e abdominal surgery (+().

!ynecology
;ppendicitis is suspected and then not confirmed at surgery more often in women than in men (+4, e+(). This fact indicates the maBor importance of gynecological conditions in the differential diagnosis of appendicitis (7). ;mong the %arious types of infectious&inflammatory change coming under the heading of Fpel%ic inflammatory diseaseF (2$"), the most important differential diagnoses of appendicitis are acute adnexitis&salpingitis, abscesses in the adnexal region, and parametritis (e+)). >ike appendicitis, acute adnexitis often presents inatypical fashion and can then be definiti%ely diagnosed only by laparoscopy. $t characteristicallyarises in sexually acti%e women, is often bilateral, and is sometimes accompanied by abnormal %aginal bleeding or discharge.

$n many cases, acute adnexitis arises in connection with the use of an intrauterine contracepti%e de%ice ($4" or spiral) (+)). 2alpation generally yields no definiti%e findings. 4nless an abscess has formed, the o%iducts are often not especially thickened and therefore

Diagnostic laparoscopy Diagnostic la%arosco%* can &e %erfor$ed when the foregoing clinical, la&orator*, and i$aging tests all %oint to an acute intra a&do$inal %rocess.

usually not palpable. There may be lower abdominal guarding, pain on passi%e mo%ement of the cer%ix, and&or uterine tenderness to palpation. >aboratory testing only re%eals ele%ated inflammatory parameters. 1aginal ultrasound can re%eal the diagnosis if the o%iducts are markedly distended by pus or blood (pyosalpinx or hematosalpinx) (e<,). ;nother gynecological disease that can cause acute right lower quadrant pain is ectopic pregnancy (figure <). $ts manifestations include ! 3econdary amenorrhea ! ; positi%e pregnancy test ! Aormal inflammatory parameters ! ;bnormal %aginal bleeding. 0xtrauterine pregnancy often becomes symptomatic when it perforates, causing a potentially life!threatening intra!abdominal hemorrhage (e<+). 2atients may ha%e a history of bouts of adnexitis or a prior extrauterine pregnancy. The diagnosis can often be made with endo%aginal ultrasonography (<,). ;n adnexal mass is seen/ sometimes the fetal heartbeat can be seen as well. The uterine ca%ity is usually empty e%en though the endometriumis greatly thickened. The Fpseudogestational sacF that is sometimes found in the uterineca%ity by ultrasonography makes an intrauterine pregnancy more difficult to rule out. 0xtrauterine pregnancies are often found in the o%iducts but can also be located in an o%ary or in the peritoneal ca%ity. Torsion of an o%arian tumor or cyst, or cyst rupture, can also cause acute right lower quadrant pain. $n cases of torsion, ultrasonography usually re%ealsa fairly large o%arian cyst (G * cm). $n many cases, "oppler ultrasonography re%eals diminished or absent blood flow in the affected o%ary (<+). This entity causes %ery se%ere pain that generally arises quite suddenly, e.g., in connection with intense physical acti%itysuch as sport or dancing.

$n premenopausal women, o%ulation itself can sometimes cause acute lower abdominal pain, e%en if the menstrual cycles are regular. ; carefully obtained history (last menstrualperiod, pre%ious episodes of mid!cycle pain) can yield important diagnostic clues (<).8hene%er the clinical findings lead to no clear diagnosis, and particularly in young womenwho may be suffering either from appendicitis or from adnexitis, laparoscopy is a goodoption (e+)) that should be considered if the patient wishes to a%oid the radiation exposureassociated with .T.

0rological causes Lower a&do$inal %ain can also &e due to urological causes such as $acro or $icrohe$aturia, renal tenderness, and d*s or alguria. 0rology
?ight lower quadrant pain is rarely the maBor clinical finding of an acute urological illness, but it can ne%ertheless be the presenting symptom of pyelonephritis, urinary colic, cystitis, or a tumor of the urinary tract. $n all of these cases, it is usually accompanied by other symptoms or signs pointing to the urological origin of the problem (<<), including macro! or microhematuria, renal percussion tenderness, and dys! or alguria. Dbstructions to the flow of urine can often be seen when ultrasonography is performed as part of the emergency diagnostic e%aluation. $f any of the abo%e manifestations are present in a patient with acute right lower quadrant pain, urological consultation should be obtained. $f the urologist also suspects a urological condition, contrast!enhanced .T or micturition urography can be performed to complete the diagnostic e%aluation (e<<).

4rthopedics neurology
Drthopedic and neurological conditions, like urological conditions, generally do not cause isolated right lower quadrant pain/ rather, the pain is typically accompanied by other symptomsand signs. >eukocytosis is absent, and abdominal ultrasonography is unremarkable. The pain is classically associated with mo%ement and can be deliberately manually pro%oked at its site of origin (e() when it is due to conditions such as ! .oxarthrosis ! 3acroileitis ! $nter%ertebral disc prolapsed ! >umbago. The absence of fe%er and laboratory changes indicating inflammation is a further criterion by which these processes can be distinguished from an acute infectious&inflammatory disease in the abdomen.

Rare causes of right lower quadrant pain

There are a large number of rarer causes of right lower quadrant pain, including common

iliac artery aneurysm (<@), infarction of the cecal pole (<4), cecal %ol%ulus (<*), and intussusception (+)). These entities can usually be recogni5ed by .T or by laparoscopy. ;bdominal pain is only rarely caused by a systemic metabolic disease or temporary metabolic derangement. "iabetic ketoacidosis is easily distinguished from an infectious or inflammatory process in the abdomen by the history and by simple laboratory tests. ;cute intermittent porphyria is exceedingly rare and often hard to diagnose because its abdominal manifestations are combined with mental changes and %ariable neurological manifestations. ; change of the color of the urine to dark red on exposure to light is the classic diagnostic criterion. 0%en if the patient is known to suffer from a systemic metabolic disease, this disease is not necessarily the cause of the abdominal pain, because an intra!abdominal cause may be present as well. Thus, the treating physician should always take care to exclude other causes. 'urther systemic diseases that can mimic a local abdominal disturbance include hea%y metal poisoning (lead, thallium, arsenic) and familial hyperlipoproteinemias with hypertriglyceridemia. 8hen poisoning is suspected, the physician should attempt to determine the nature of the exposure/ in lipid metabolic disorders, further manifestations of the disease should be sought, e.g., xanthomatoses or lipemic retinitis (e<@).

4&er&iew
?ight lower quadrant pain can be due to a large %ariety of diseases whose causes must be diagnosed and treated by physicians from a number of different specialties. $f the clinical

Rare causes ,&do$inal %ain is onl* rarel* due to a $eta&olic distur&ance or s*ste$ic $eta&olic disease.
manifestations are sufficiently typical, extensi%e ancillary diagnostic testing can often be dispensed with. $f the findings are unclear, howe%er, modern radiological studies should be performed as soon as possible, as these will make an important contribution to the diagnostic process. 8hen the cause of acute right lower quadrant pain is not immediately e%ident, a rapid and interdisciplinary e%aluation is essential, because delays in treatment lead to excess morbidity and mortality.