From the Guidelines
Management of right lower quadrant (RLQ) pain occurring a year after a Loop Electrosurgical Excision Procedure (LEEP) should prioritize a comprehensive evaluation to determine the cause, considering the pain is unlikely to be directly related to the LEEP procedure after such a time interval. The initial approach should include a detailed history and physical examination, focusing on gynecological, gastrointestinal, urological, and musculoskeletal systems. Laboratory tests including complete blood count, urinalysis, and pregnancy test should be ordered.
Key Considerations
- Imaging studies such as transvaginal ultrasound or pelvic CT scan are essential to evaluate for ovarian cysts, endometriosis, pelvic inflammatory disease, or adhesions that might have developed following the LEEP, as suggested by 1.
- For pain management, NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily) can be used initially.
- If infection is suspected, appropriate antibiotics should be prescribed based on culture results.
- Patients with severe pain may require referral to gynecology for further evaluation, possibly including diagnostic laparoscopy.
- It's essential to consider other common causes of RLQ pain such as appendicitis, inflammatory bowel disease, or urinary tract conditions, especially given the time elapsed since the LEEP procedure, as discussed in 1.
Diagnostic Approach
- A step-up approach for diagnosis should be used, tailored to the clinical setting and resources, beginning with clinical and laboratory examination and progressing to imaging examinations, as recommended by 1.
- The value of physical findings in the diagnostic work-up for intra-abdominal infections, such as appendicitis, has been studied, and signs and symptoms can be helpful in diagnosing or excluding appendicitis, as noted in 1.
- Ultrasound (US) and computed tomography (CT) have been used to complete the clinical assessment of patients with intra-abdominal infections, with CT having higher sensitivity and specificity, as mentioned in 1.
Treatment and Referral
- The use of CT abdomen and pelvis is recommended for the evaluation of patients with nonspecific RLQ pain due to its high diagnostic yield for detection of appendicitis and other conditions, as stated in 1.
- Laparoscopy is gaining wider acceptance in emergency surgery and may be used to identify the causative pathology of acute abdominal pain followed by definitive laparoscopic treatment, with high accuracy and definitive diagnosis rates, as reported in 1.
From the Research
Diagnosis Options for RLQ Pain
- Imaging studies such as computed tomography (CT) scans 2, 3 and ultrasonography 4 can be used to diagnose the cause of RLQ pain.
- CT scans can depict abnormalities in the pelvis and abdomen, and can help identify the cause of RLQ pain, including appendicitis and other conditions 2.
- Ultrasonography can be used to diagnose acute appendicitis and other conditions that cause RLQ pain, and has a high sensitivity and specificity for diagnosing appendicitis 4.
Management Options for RLQ Pain
- The management of RLQ pain depends on the underlying cause, and may include surgical or medical treatment 5, 2.
- Patients with suspected appendicitis may undergo surgery, while those with other causes of RLQ pain may be managed with medical treatment or observation 6.
- Active observation and repeated physical examinations can be used to manage patients with RLQ pain who do not have the classical features of appendicitis or peritonitis 6.
Differential Diagnoses for RLQ Pain
- RLQ pain can be caused by a variety of conditions, including appendicitis, inflammatory bowel disease, diverticulitis, and gynecologic diseases 5, 4, 3.
- The differential diagnoses for RLQ pain can be broad, and imaging studies and laboratory tests can be used to help establish a diagnosis 5, 2, 4, 3.
- Clinical signs and symptoms, laboratory tests, and imaging studies can be used to differentiate between the causes of RLQ pain 6.