A patient with right lower quadrant pain

If a patient presents with right lower quadrant pain, one should consider following differential diagnoses considering site such as   

Appendicitis

Salpingitis

Inguinal hernia

Ectopic pregnancy

Nephrolithiasis

Inflammatory bowel disease

Mesenteric lymphadenitis

 

        A patient with right iliac fossa pain

A 25 yrs old lady presented with pain in the right iliac fossa for 2 days.

 

What are the diagnoses striking in your mind?

·       Acute appendicitis

·       Salphingitis

·       Ectopic pregnancy

·       Ureterolithiasis

 

What key questions would you ask?

Pain-

§  Pain usually starts as vague, often colicky periumbilical or epigastric pain and within 12 hours the pain shifts to the right iliac fossa- acute appendicitis.

§  Constant pain in right or left lower quadrant or pelvic region in a sexually active female- acute salphingitis.

§  Sudden severe lower abdominal pain following a missed period- ectopic pregnancy.

§  Colicky pain in right iliac fossa which radiates to loin and groin- ureteric stone.

      Vomiting-

        Nausea with one or two episodes of vomiting- acute appendicitis.

Vomiting may occur in other causes

      Bowel habit- A sense of constipation is typical in acute appendicitis.

      Temperature- raised in appendicitis and also salphingitis. 

      Menustral history– A missed period raises the suspicion of ectopic pregnancy.

      History of haematuria– ureteric stone.

What will you examine?

General examination- distressed with pain, dehydrated and raised temperature.

Abdominal examination-

§  Localized tenderness with guarding in the right iliac fossa (McBurney’s point tender) – acute appendicitis.

§  In young, sexually active women with fever and bilateral lower abdominal or pelvic tenderness- Acute salphingitis.  

§  Sudden severe abdominal pain with diffuse pelvic tenderness and shock suggests a ruptured ectopic pregnancy.

 

Clinical diagnosis–

 Pain starting in periumbilical or epigastric region settled in the right iliac fossa, vomiting, constipation, fever and tender McBurney’s point^* suggest the diagnosis of acute appendicitis.

 

Investigation-

§  CBC- Moderate leucocytosis (10,000–20,000/cmm) with neutrophilia is common.

§  USG of the abdomen- is useful in diagnosing appendicitis as well as excluding other diseases- ectopic pregnancy, salphingitis.

§  Pregnancy test- to exclude ectopic pregnancy.

§  Plain X-ray KUB- to exclude ureteric stone.

 

Treatment-

§  The treatment of uncomplicated appendicitis (usually within 24 hours) is surgical appendectomy through a laparotomy or by laparoscopy. So referral for surgical consultation.

§  Prior to surgery or if surgery (Emergency appendectomy) is not possible,

§  Rest

§  Nothing by mouth till patient settles

§  Parenteral nutrition.

§  Maintenance of fluid and electrolyte balance.

§  Systemic antibiotics- parenteral ceftriaxone or ciprofloxacin with metronidazole.

§  An interval appendectomy after 6 weeks to prevent recurrent appendicitis.