Right-lower quadrant abdominal pain
LMP was 3 weeks ago. As you are walking out the room thinking you have already made the diagnosis of appendicitis, she mentions that this pain feels very similar to when she needed an appendectomy three years ago.
What other conditions mimic appendicitis that you need to consider? Appendicitis Background: Abdominal pain is a high volume complaint in the ED, and there are approximately , cases of appendicitis each year. Appendicitis has a complex range of symptoms and atypical presentations, which can lead to missed diagnosis and potential malpractice claims. Appendicitis classically presents with RLQ tenderness, migration of pain from periumbilical to RLQ, and pain prior to vomiting over the course of hours.
There is no individual symptom or physical exam finding that can reliably exclude appendicitis, and atypical presentations are very common . Atypical presentations are common in obese, extremes of age, and diabetics . Workups include CBC, urinalysis, and urine pregnancy testing in women, but the diagnosis is commonly a clinical diagnosis.
Pelvic exam should be considered in female patients with undifferentiated lower abdominal pain; however, cervical motion tenderness does not rule out appendicitis .
These scoring systems help determine who may need further imaging studies, but they do not determine the need for surgical intervention alone . Score of less than 7 has negative LR of 0. In pediatric populations, US is used to diagnose, but not exclude appendicitis.
Pregnant women should be evaluated by ultrasound followed by MRI, if needed . Antibiotics with aerobic and anaerobic coverage should be used. We will discuss the etiologies of right lower quadrant pain that are essential for the emergency physician to consider that are often indistinguishable from the atypical presentations of appendicitis.
Ectopic pregnancy has high morbidity and mortality associated with it, secondary to tubal rupture and life-threatening hemorrhage, and must be considered in female patients presenting with lower abdominal pain . A ruptured ectopic pregnancy should strongly be suspected in a woman that presents with a positive pregnancy test and signs of shock including tachycardia, pallor or syncope .
Suspicion increases if free fluid is visualized . Heterotopic pregnancy combined intrauterine and extrauterine pregnancy should be considered in women with symptoms who have undergone in vitro fertilization . Ectopic pregnancy may be managed by immediate surgical intervention, medically with methotrexate or expectant management depending on presentation and severity of condition.
If an ectopic pregnancy has ruptured, laparoscopy is required. Methotrexate can be given to unruptured tubal pregnancies in women whom are hemodynamically stable, with minimal symptoms and a low volume of free fluid.
Expectant management may be considered if an ectopic is resolving spontaneously by regression or tubal abortion . Torsion is caused by the ovary rotating around its supporting ligaments, leading to occlusion of lymphatics and vasculature .
Pain can be intermittent due to detorsion . Diagnosis is made by ultrasound with Doppler flow transabdominal in children, transvaginal in older females. The most common sign on ultrasound is an enlarged ovary. Blood supply to the ovary includes the tubal and ovarian branches of the uterine artery, and due to the two blood supplies, the US may show normal arterial flow . Definitive management with surgical correction is needed to reverse the torsion and preserve ovarian function.
Management with IVF and broad-spectrum antibiotics should be initiated if signs of sepsis or peritonitis are present . Testicular torsion is a urologic emergency, occurring in 1 in males younger than 25 years of age and a peak incidence during puberty ages . This rotation leads to venous congestion, arterial compromise, and ischemia of the testicle. This highlights the necessity for testicular exam in a young male complaining of lower abdominal pain.
A horizontal, high-riding testicle and absent cremasteric reflex implies torsion. Presence of a cremasteric reflex does not adequately rule out torsion. Testicular ultrasound should not delay the diagnosis, and spontaneous detorsion may yield normal Doppler flow to the testicle. New vaginal discharge is not specific or sensitive. Approximately half of patients have fever . The most useful component is the pelvic exam with mucopurulent endocervical discharge, cervical motion tenderness, and bilateral adnexal tenderness highly suggestive of PID.
Risk factors include prior PID, high number of sexual partners, and unprotected sex . There should be a low threshold for empiric treatment for presumed PID.
Complications of PID include increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. The CDC recommends a fourteen-day course of antibiotics. This occurs in approximately one-third of patients with diagnosed PID when purulence is spread to the ovary via the fallopian tube. TOA is an emergent polymicrobial infection.
Abscess rupture is a surgical emergency, leading to sepsis and ultimately death if not treated. Patients must be hospitalized with aggressive resuscitation, broad-spectrum IV antibiotics, and surgical evaluation if abscess rupture is suspected. Right-Sided Diverticulitis: Cecal diverticulitis is a rare disease in Western countries, with an incidence of 1.
Right-sided diverticula occur more often as true diverticula, with younger populations. Symptoms typically mimic appendicitis with right lower quadrant pain, nausea, vomiting, low-grade fever, and leukocytosis. Due to this presentation, diagnosis of cecal diverticulitis is commonly made in the operating room.
Treatment is controversial for non-perforated cecal diverticulitis. Preoperative diagnosis is treated with bowel rest and IV antibiotics. If diagnosed intraoperative, appendectomy and possible diverticulectomy is performed; however, if large amounts of inflammation or abscess is found then right hemicolectomy is recommended by most surgeons to prevent recurrence . Most cases are self-limiting, but some may lead to obstruction or hemorrhage .
Yersinia enterocolitica can cause enterocolitis after ingesting contaminated food or water and may present as pseudoappendicitis. Definitive diagnosis is made by stool culture, and CT reveals a thickened and nodular mucosal pattern in the terminal ileum. Yersinia can also lead to mesenteric adenitis with terminal ileitis, mimicking appendicitis . Campylobacter colitis is a common bacterial foodborne illness affecting 2.
Patients may present with fever, abdominal pain, and bloody stools, often requiring fourteen-day courses of antibiotics. Diagnosis is made with stool culture, and most self-limiting infections are treated with supportive care . Salmonella is one of the most common foodborne illnesses in the U. Salmonella is typically a self—limiting gastroenteritis but can lead to septicemia in pediatric, immunocompromised, and geriatric patients .
Neutropenic or immunocompromised patients can present with typhlitis, an acute life-threatening inflammatory condition of the cecum and ascending colon that can progress to transmural necrosis and perforation . Treatment is primarily supportive, but anti-motility and antibiotics are contraindicated in these cases, as they may lead to increased toxin release.
Patients may present with abdominal pain, anorexia, fever, weight loss, and diarrhea with hematochezia. Symptoms typically occur in a relapsing and remitting nature with intermittent symptoms. Annually in the U. Diagnosis is most commonly made in late adolescence and early adulthood with a mean age of 33 . It is imperative for the emergency physician to identify complications associated with CD that may lead to acute abdomen, sepsis, and GI hemorrhage.
CD has a propensity to involve the terminal ileum and appendix causing RLQ abdominal tenderness. Treatment in acute flares is with IV fluids, IV steroids, and antibiotics ciprofloxacin and metronidazole if infectious colitis is suspected. Broad-spectrum antibiotics should be given and surgical consult obtained if abscess, perforation, or toxic megacolon is found.
Cecal Volvulus: Cecal volvulus is a rare cause of intestinal obstruction Patients may present with abdominal pain, distension, nausea, vomiting, and diarrhea or constipation. There is thought to be an anatomical predisposition due to incomplete intestinal rotation leading to inadequate right colon fixation .
Volvulus is rarely diagnosed correctly at time of presentation due to low incidence. CT reveals cecal distension, cecal apex in left upper quadrant, small bowel distension, mesenteric whirl, and absence of gas in colon .
Acute volvulus presents very similar to SBO and can lead to peritonitis, gangrene and hemodynamic compromise . Early laparoscopic surgical intervention by untwisting the cecum and performing cecopexy is the definitive treatment. Intussusception: Intussusception is a rare but important diagnosis to consider in adult populations. Often, malignant neoplasms adenocarcinoma most commonly are found. Pediatric populations also have non-specific symptoms, such as paroxysmal abdominal pain, vomiting, bloody stools, and a palpable abdominal mass in the RUQ.
Pediatric intussusception is often preceded by viral infection and can be seen as a complication of other disease processes like CF and HSP . If US is unavailable or questionable then air enema may be used for both diagnosis and treatment. CT scan is the preferred imaging for adults, which usually shows the lead point. Adults are managed surgically, as the underlying etiology is structural .
Patients classically present with acute onset epigastric abdominal pain that generalizes to lower quadrants with peritoneal signs; however, peritonitis may be minimal in patients with contained leaks. Labs are often non-specific acutely but may reveal metabolic acidosis and leukocytosis. Fever and hypotension is typically a late finding. CT abdomen with IV and PO contrast can further characterize intra-peritoneal fluid and pneumoperitoneum and improve diagnostic accuracy .
Patients should be resuscitated, nasogastric suction begun, and broad-spectrum antibiotics administered immediately. If ongoing signs of peritonitis or pneumoperitoneum are present, then operative laparoscopy treatment with omental patch, abdominal lavage, and subsequent eradication of H.
Ureterolithiasis: Kidney stones are very common and seen in 16 of 10, patients. Patients often have hematuria; however, absence of hematuria does not rule out a stone . When a stone is obstructed in the ureterovesical junction a patient may also present with dysuria and frequency. Calculi are caused by super-saturation of a urinary solute causing crystal formation. Uric acid, struvite, and cysteine stones account for the remainder of stones in decreasing order.
Strep, flu, or mono and right lower quadrant pain: Do you need an ultrasound?
Children typically present with fever, anorexia, migratory pain originating in the periumbilical region and moving to the RLQ. Laboratory findings can show a leukocytosis with a neutrophilic predominance that may support the diagnosis. These tools are meant to be used alongside other clinical information and diagnostic testing to guide further imaging and workup.
However similar abdominal symptoms can overlap with other more common diagnoses: influenza, strep pharyngitis, and infectious mononucleosis are examples of infectious illnesses that often present with abdominal symptoms. Oftentimes due to clinical uncertainty patients receive a RLQ ultrasound after already testing positive for these illnesses. But how frequent is the concurrent diagnosis of influenza, strep pharyngitis, or infectious mononucleosis AND appendicitis?
Strep Pharyngitis Strep pharyngitis can present with abdominal symptoms; one study by Igarashi et. A meta analysis looking at patients aged years diagnosed with strep found abdominal pain had a similar positive likelihood ratio of 1.
Though neither study demonstrated statistical significance of abdominal pain in diagnosing GAS, both highlight that abdominal pain is a common presenting symptom in the pediatric population. There is, as expected, scant evidence about the risk of appendicitis when a patient already carries a diagnosis of strep pharyngitis. Upon review there is one case report citing strep pharyngitis associated with a complicated appendicitis 6.
Nielsen et. Influenza Influenza can also present with similar abdominal manifestations. There does not appear to be a significant difference in abdominal pain between Influenza A and Influenza B 9.
There have been only three case reports of appendicitis in association with influenza, all published during the swine flu H1N1 epidemic. These three case reports describe a 16 year old, 15 year old, and 12 year old that all presented with influenza-like illness with some abdominal predominance and were subsequently found to have appendicitis.
One patient had a previous history of appendicitis four years prior that was managed conservatively Two patients were diagnosed on presentation, with one being diagnosed on hospital day three after demonstrating classic migratory pain PCR testing of appendix tissue for the H1N1 virus was negative in one of the cases The exact trigger for luminal obstruction in appendicitis remains unknown, with viral etiology thought to be a contributing factor.
A study conducted by Alder et al. They found influenza and appendicitis have parallel incidence curves; both decreasing in prevalence from and increasing since.
However, given the discordance of appendicitis clustering in the summer and influenza in the winter they concluded the two were unlikely to be directly linked However, abdominal pain concurrent with EVB is alarming given increased concern for splenomegaly and potential of splenic rupture.
Pain from splenic rupture can be nonspecific and difficult to diagnose which can lead to delay in management and increased mortality Though the association between infectious mononucleosis and splenic rupture is well understood, there is little data published on its association with appendicitis.
Other case reports have described a variety of associations from incidental findings on CT scan done for splenic rupture to fatal peritonitis from appendicitis in an EBV positive patient 17, Interestingly, testing appendix tissue for Epstein Barr nuclear antigen was negative similarly to influenza In summary, the jury is still out on if flu, strep, or infectious mononucleosis can occur at the same time as appendicitis.
The strongest data is present in strep pharyngitis — showing no association in a single, small study. There is limited data in influenza, but the concurrent risk appears to be low and there does not seem to be a direct causality between the virus and appendicitis. Abdominal pain in infectious mononucleosis should be thought of more stringently.
With an unclear symptom prevalence, and the risk of splenomegaly and splenic rupture, these patients should remain at a lower threshold to receive abdominal imaging. In patients who present with right lower quadrant abdominal pain better understanding the prevalence and individual likelihood of concurrent diagnoses can help save unnecessary work up. If you are going to send the child home without performing an ultrasound, strict return precautions worsening pain, fever, emesis, pain when hopping should be communicated.
If the child has peritoneal signs a workup for a surgical abdomen is always warranted. Perhaps a large database, multicenter study could answer these questions more fully. References 1. Indian J Pediatr. Pediatr Med Chir. Published Apr 2. Abdominal pain and nausea in the diagnosis of streptococcal pharyngitis in boys. Int J Gen Med. Published Sep S 5. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review.
J Pediatr. Arch Pediatr. Streptococcal Pharyngitis and Appendicitis in Children. Clin Pediatr Phila. Clinical Predictors of Influenza in Children. Arch Pediatr Adolesc Med. Swine flu presenting as acute appendicitis. Acute appendicitis in a child with swine influenza H1N1.
BMJ Case Rep. Published Mar Swine influenza H1N1 and acute appendicitis. Heart Lung. Association of viral infection and appendicitis. Arch Surg. Prospective studies of infectious mononucleosis in university students. Clin Transl Immunology. Published Aug Abdominal pain in acute infectious mononucleosis. Thalayasingam B. Acute appendicitis and infectious mononucleosis. Een fataal verlopende combinatie van appendicitis acuta en mononucleosis infectiosa [Fatal course of acute appendicitis associated with infectious mononucleosis].
Ned Tijdschr Geneeskd. CT diagnosis of a clinically unsuspected acute appendicitis complicating infectious mononucleosis. Clin Imaging. Acute appendicitis complicating infectious mononucleosis: case report and review.
Rev Infect Dis.
Abdominal pain in infectious mononucleosis should be thought of more stringently. With an unclear symptom prevalence, and the risk of splenomegaly and splenic rupture, these patients should remain at a lower threshold to receive abdominal imaging. In patients who present with right lower quadrant abdominal pain better understanding the prevalence and individual likelihood of concurrent diagnoses can help save unnecessary work up. If you are going to send the child home without performing an ultrasound, strict return precautions worsening pain, fever, emesis, pain when hopping should be communicated.
If the child has peritoneal signs a workup for a surgical abdomen is always warranted. Perhaps a large database, multicenter study could answer these questions more fully. References 1. Indian J Pediatr. Pediatr Med Chir.
81. Specific RLQ pain ddx
Published Apr 2. Abdominal pain and nausea in the diagnosis of streptococcal pharyngitis in boys. Int J Gen Med. Published Sep S 5. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review.
J Pediatr. Arch Pediatr. Streptococcal Pharyngitis and Appendicitis in Children. Clin Pediatr Phila. Clinical Predictors of Influenza in Children. Arch Pediatr Adolesc Med. Swine flu presenting as acute appendicitis. Acute appendicitis in a child with swine influenza H1N1. BMJ Case Rep. Published Mar Swine influenza H1N1 and acute appendicitis. Heart Lung.
Appendicitis Mimics: ED Focused Management
Association of viral infection and appendicitis. Arch Surg. Prospective studies of infectious mononucleosis in university students. Clin Transl Immunology. Published Aug Abdominal pain in acute infectious mononucleosis.
Case Study: Pain in the Right Lower Abdomen
Thalayasingam B. Acute appendicitis and infectious mononucleosis. Een fataal verlopende combinatie van appendicitis acuta en mononucleosis infectiosa [Fatal course of acute appendicitis associated with infectious mononucleosis]. You start with three data tables: The R matrix is a site x environment table: sites are rows and columns are environmental descriptors.
The L matrix is a site x species table, where rows are sites and columns are abundances of specific species. The Q matrix is a species x trait table, where rows are species and columns are biological traits of those species.
The vast majority of the work is actually in constructing V. First, you do a principle components analysis on both R and Q and a correspondance analysis on L. You then pass these analyses to the rlq function. To figure out how RLQ works, I took apart the rlq function, then several secondary functions called by rlq.
The row and column weights are simply the sum of the observations in a row divided by the sum of the matrix and similarly for columns. You can verify this by checking the table from the dudi.