Right lower quadrant abdominal pain

Background

• This page describes the general approach to RLQ pain in adults

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

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)
• GU
  • Ectopic
  • Endometriosis
  • Kidney stone
  • Mittelschmerz
  • Ovarian cyst
  • Ovarian torsion
  • PID
  • Pyelonephritis
• Other
  • Abdominal aortic aneurysm
  • Epiploic appendagitis
  • Mesenteric lymphadenitis
  • Herpes zoster
  • Psoas abscess
  • Testicular torsion

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
  • 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

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

• Abdominal Pain
• Abdominal Pain (Peds)