Right lower quadrant abdominal pain resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2], Amr Marawan, M.D. [3]

Right lower quadrant abdominal pain

Definition

Right lower quadrant of the human abdomen, often abbreviated as RLQ, is used to refer to a portion of the abdomen that allows doctors to localise pain and tenderness, scars, lumps and other items of interest. The RLQ extends from the median plane to the right of the patient, and from the umbilical plane to the right inguinal ligament.

Causes

• Adnexal pathology (cyst or tumor that caused torsion, bleeding or rupture)
• Appendicitis
• Cecum (intussusception, bowel obstruction)
• Colon cancer (ascending colon)
• Ectopic pregnancy
• Endometriosis
• Endometritis
• Inflammatory bowel disease
• Hernia
• Leiomyoma
• Pelvic inflammatory disease
• Testicular torsion

Management

Diagnostic approach

Shown below is an algorithm depicting the diagnostic approach of acute abdominal pain in the right lower quadrant.

Peritoneal signs, shock or toxic appearing

No

No

Yes

Symptoms, signs, risk factors or ECG suggestive of acute coronary syndrome

Symptoms, signs or risk factors suggestive of abdominal aortic aneurysm

❑ Initiate resuscitation ❑ Obtain immediate surgical consultation ❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inverior vena cava) ❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)

No

Yes

Appropriate management

❑ Surgical consultation ❑ Bedside ultrasound ❑ Abdominal CT

History, examination and risk factors suggest mesentric ischemia (pain out of proportion to exam)

Yes

No

❑ Surgical consultation ❑ Abdominal CT

History and examination suggest bowel obstruction (diffuse tenderness with distention and persistent vomiting) or perforation (rigidity with absent bowel sounds

Yes

No

Abdominal x-ray series

Where is pain localized

Presence of free air

Presence of obstruction

Absent free air and absent obstruction

Epigastric or upper right quadrant tenderness

Right lower quadrant tenderness

Left lower quadrant tenderness

Surgical consult

Abdominal CT

Abdominal CT

Left upper quadrant tenderness

History of fever or pain that moves from the periumbilical area to the right lower quadrant of the abdomen

Yes

No

Consider peritonitis or appendicitis

Assess for psoas sign, rigidity, rebound, guarding, or pain on the right side of the rectum

Positive findings

Negative findings

Consider CT with IV contrast media

Perform urine, colon or pelvic examination