Left lower quadrant abdominal pain
Background
- This page outlines the general approach to adult left lower quadrant (LLQ) pain
- LLQ contains: sigmoid colon, descending colon, left ureter, left ovary/fallopian tube (females), left spermatic cord (males)
- Key EM considerations: diverticulitis (most common surgical cause in adults >40), ovarian torsion, ectopic pregnancy, renal colic
- Always consider pregnancy-related emergencies in women of reproductive age
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
History
- Onset, character, location, radiation, aggravating/alleviating factors
- Prior episodes of similar pain (recurrent diverticulitis)
- Change in bowel habits, blood in stool (colitis, diverticulitis, malignancy)
- Urinary symptoms (UTI, nephrolithiasis)
- Menstrual/gynecologic history: LMP, vaginal bleeding/discharge, sexual activity
- Fever (infectious/inflammatory cause)
- Diet: low fiber (diverticular disease)
- Age: diverticulitis more common >40 years
Physical Exam
- LLQ tenderness, guarding, rebound (peritonitis)
- Palpable mass (abscess, tumor)
- CVA tenderness (pyelonephritis, nephrolithiasis)
- Pelvic exam: cervical motion tenderness, adnexal mass/tenderness (ectopic, torsion, PID)
- Rectal exam: stool guaiac, rectal mass
- Testicular exam in males (referred pain from hernia or testicular pathology)
Red Flags
- Hemodynamic instability with LLQ pain + positive pregnancy test (ectopic pregnancy)
- Acute onset severe pain with no prior history (torsion, mesenteric ischemia, perforation)
- Fever + peritoneal signs (perforation, abscess)
- Free air on imaging (perforated diverticulitis or other hollow viscus)
Differential Diagnosis
Must Not Miss
- Ectopic pregnancy in reproductive-age women
- Ovarian torsion
- Perforated diverticulitis
- Mesenteric ischemia (especially elderly with atrial fibrillation)
- Large bowel obstruction / volvulus (sigmoid volvulus)
Evaluation
Laboratory
- CBC, BMP
- Urinalysis
- Urine pregnancy test (mandatory in reproductive-age women)
- LFTs, lipase
- Lactate if concern for ischemia or sepsis
- CRP/ESR may support diverticulitis diagnosis
- GC/CT NAAT if PID suspected
Imaging
- CT abdomen pelvis with IV contrast: gold standard for diverticulitis, abscess, volvulus, mesenteric ischemia
- Pelvic ultrasound (transvaginal): first-line for suspected ovarian torsion, ectopic pregnancy
- POCUS: free fluid, hydronephrosis, IUP identification
- Abdominal X-ray: useful for obstruction or volvulus (coffee bean sign in sigmoid volvulus)
Management
- Treat underlying disease process
- IV fluids, analgesia
- Diverticulitis: uncomplicated — outpatient antibiotics or observation without antibiotics per recent guidelines; complicated (abscess, perforation, obstruction) — IV antibiotics, surgical consultation
- Ectopic pregnancy: emergent OB/GYN consultation
- Ovarian torsion: emergent GYN consultation for surgical detorsion
- Sigmoid volvulus: GI consultation for endoscopic decompression; surgery if peritonitis
- Nephrolithiasis: analgesia (NSAIDs first-line), hydration
Disposition
- Admit: complicated diverticulitis, ectopic pregnancy requiring intervention, ovarian torsion, bowel obstruction/volvulus, mesenteric ischemia
- Discharge: uncomplicated diverticulitis, stable renal colic, benign ovarian cyst, with appropriate follow-up and return precautions