Differential Diagnosis for Persistent Lower Pelvic Abdominal Pain

Single Most Likely Diagnosis

• Adhesions or Scar Tissue: Given the patient's history of hysterectomy, adhesions or scar tissue formation is a common cause of persistent lower pelvic abdominal pain. These can cause bowel obstruction or compress surrounding structures, leading to pain.

Other Likely Diagnoses

• Liver Lesion: Although the CT scan showed a lesion on the liver, it's essential to consider the possibility that this lesion could be causing referred pain to the lower pelvic area, especially if the lesion is large or located near the diaphragm.
• Diverticulitis: This condition can cause lower abdominal pain, especially if the diverticula are located in the sigmoid colon, which is near the pelvic area.
• Inflammatory Bowel Disease (IBD): Conditions like Crohn's disease or ulcerative colitis can cause chronic abdominal pain, including in the lower pelvic area, and may not be directly related to the hysterectomy.

Do Not Miss Diagnoses

• Ovarian Remnant Syndrome: Even after a hysterectomy, remnants of ovarian tissue can cause cyclic pain if they produce hormones. This is a critical diagnosis not to miss, as it can significantly impact the patient's quality of life.
• Bowel Obstruction: Although the CT scan did not show any obvious obstruction, a partial or intermittent obstruction could still cause significant pain and would be a medical emergency if not addressed promptly.
• Intra-abdominal Infection or Abscess: An infection or abscess in the abdominal cavity can cause severe pain and would require immediate medical attention to prevent serious complications.

Rare Diagnoses

• Neurogenic Pain: Conditions affecting the nerves, such as neuroma formation at the site of the hysterectomy scar or nerve entrapment, can cause chronic pain in the lower pelvic area.
• Endometriosis: Although less likely in a post-hysterectomy patient, if endometrial tissue was left behind or if there was a recurrence, it could cause pain, especially if the tissue is located in areas that were not removed during the surgery.
• Primary or Metastatic Tumors: Other than the identified liver lesion, primary tumors of the pelvic organs or metastatic disease to the pelvis could cause pain, although these would be less common and typically associated with other symptoms or findings on imaging.