What is the initial workup and management for a female with right lower quadrant pain, especially with movement?

Initial Workup and Management for Right Lower Quadrant Pain in a Female

CT of the abdomen and pelvis is the recommended initial imaging modality for females with right lower quadrant pain, especially with movement, due to its high diagnostic yield for detecting appendicitis and other etiologies with a sensitivity of 95% and specificity of 94%. 1

Initial Clinical Assessment

• Key symptoms to evaluate:

  • Pain characteristics: location, radiation, aggravating/alleviating factors, especially with movement
  • Associated symptoms: fever, nausea/vomiting, diarrhea, vaginal discharge
  • Menstrual history and pregnancy status

• Physical examination focus:

  • Vital signs (fever, tachycardia)
  • Abdominal examination (rebound tenderness, guarding)
  • Pelvic examination in women of reproductive age

Laboratory Testing

• Essential laboratory tests:
  • Complete blood count (CBC) to assess for leukocytosis
  • Basic metabolic panel
  • Urinalysis
  • Pregnancy test (β-hCG) in all women of reproductive age before imaging 2
  • Consider liver function tests and lipase/amylase if clinically indicated

Imaging Algorithm

1. First-line imaging:

   • CT abdomen and pelvis with contrast (97% sensitivity, 94% specificity for appendicitis) 1, 2

2. Special populations:

   • Pregnant patients: Ultrasound first, followed by MRI if inconclusive 2
   • Premenopausal women with suspected gynecologic etiology: Transvaginal ultrasound 1, 2

Differential Diagnosis for Right Lower Quadrant Pain in Females

• Gastrointestinal causes:

  • Appendicitis (most common surgical cause)
  • Mesenteric adenitis
  • Inflammatory bowel disease
  • Right-sided diverticulitis
  • Epiploic appendagitis 3

• Gynecologic causes:

  • Ovarian cyst/torsion
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Endometriosis
  • Postpartum ovarian vein thrombosis 4

• Urologic causes:

  • Urolithiasis
  • Urinary tract infection
  • Pyelonephritis

Management Approach

1. Initial stabilization:

   • Fluid resuscitation for dehydrated patients
   • Pain management with multimodal analgesia (scheduled acetaminophen and NSAIDs as first-line) 2

2. Treatment based on diagnosis:

   • Appendicitis: Surgical consultation; consider antibiotics-first approach in uncomplicated cases 2
   • Abscess: Antibiotics for small abscesses (<3 cm); percutaneous drainage plus antibiotics for larger abscesses (>3 cm) 2
   • Gynecologic causes: Appropriate consultation based on specific diagnosis

Common Pitfalls to Avoid

• Missing gynecologic causes in women of reproductive age
• Inadequate pain control
• Delaying imaging in patients with concerning signs (fever, peritoneal signs)
• Failing to consider postpartum ovarian vein thrombosis, which can mimic appendicitis 4
• Overlooking serious pathology in immunocompromised or elderly patients 2

Key Points for Right Lower Quadrant Pain with Movement

• Pain exacerbated by movement often suggests peritoneal irritation
• Consider appendicitis as a primary concern when pain is worsened by movement
• CT abdomen and pelvis remains the gold standard for evaluation, with high sensitivity and specificity 1
• In young women, always consider gynecologic causes that may mimic appendicitis