Can acute appendicitis be considered in a patient with left lower quadrant abdominal pain radiating to the left flank area?

Can Acute Appendicitis Present with Left Lower Quadrant Pain?

Yes, acute appendicitis must be considered in patients with left lower quadrant abdominal pain, though it is rare and typically associated with anatomical variants—failure to consider this diagnosis can lead to delayed treatment, perforation, and increased morbidity.

When to Suspect Left-Sided Appendicitis

While diverticulitis is the most common cause of left lower quadrant pain in adults 1, appendicitis should remain in your differential diagnosis in specific clinical scenarios:

Anatomical Variants That Cause Left-Sided Appendicitis

• Situs inversus totalis: Complete mirror-image reversal of organs, causing the appendix to be anatomically positioned on the left side 2, 3
• Intestinal malrotation: Abnormal rotation during embryonic development can position the cecum and appendix in the left upper or lower quadrant 4
• Redundant/hypermobile ascending colon: An extremely mobile ascending colon can allow the appendix to migrate to the left side 5
• Exceptionally long appendix: A normal right-sided appendix measuring >12 cm can extend across the midline into the left lower quadrant, causing left-sided pain despite normal anatomical positioning 2

Clinical Pitfalls and Diagnostic Challenges

The atypical presentation of left-sided appendicitis significantly increases the risk of delayed diagnosis, perforation, and abscess formation 2:

• Physical examination findings are misleading—tenderness localizes to the left lower quadrant rather than McBurney's point 5, 3
• Classic appendicitis symptoms (periumbilical pain migrating to the right lower quadrant) are absent 2
• Physicians may fail to order appropriate imaging when the clinical presentation suggests diverticulitis or other left-sided pathology 2
• Delayed diagnosis leads to higher rates of perforation and abscess formation compared to typical right-sided appendicitis 2

Diagnostic Approach

Initial Clinical Assessment

Look for these key features that should raise suspicion:

• Fever, anorexia, nausea, and vomiting in a patient with left lower quadrant pain 4, 3
• Leukocytosis and elevated inflammatory markers (CRP, ESR) 4, 3
• Rebound tenderness and guarding in the left lower quadrant 4, 5
• Pain radiating to the left flank (as in your patient) may indicate peritoneal irritation from an inflamed appendix 2

Imaging is Essential

CT abdomen and pelvis with IV contrast is the definitive imaging study and should be obtained when clinical suspicion exists 1:

• CT has >95% sensitivity for detecting appendicitis regardless of location 1
• CT will identify anatomical variants (situs inversus, malrotation, redundant colon) that explain the atypical presentation 4, 5, 3
• CT can differentiate appendicitis from diverticulitis, the primary differential diagnosis for left lower quadrant pain 1

Ultrasound with graded compression is an alternative initial imaging modality, particularly in younger patients or pregnant women, though it may miss atypical appendix locations 1:

• Ultrasound has reasonable sensitivity (76-87%) for typical appendicitis but may be limited in detecting left-sided variants 6
• If ultrasound is non-diagnostic and clinical suspicion remains high, proceed directly to CT 1

Practical Algorithm for Your Patient

For a patient with left lower quadrant pain radiating to the left flank:

1. Obtain vital signs and laboratory studies: Check for fever, leukocytosis, and elevated CRP 4, 3

2. Perform focused physical examination: Assess for left lower quadrant tenderness, rebound, and guarding 5, 3

3. Order CT abdomen and pelvis with IV contrast as the initial imaging study 1:

   • This is rated as "usually appropriate" (rating 9/9) for left lower quadrant pain by the American College of Radiology 1
   • CT will diagnose diverticulitis (the most likely diagnosis) while also identifying appendicitis if present 1

4. Maintain high clinical suspicion: If imaging reveals anatomical variants or an inflamed appendix in an atypical location, proceed to urgent surgical consultation 4, 5, 3

Key Takeaway

Do not exclude appendicitis based solely on pain location—left lower quadrant pain with systemic signs of inflammation warrants imaging that can identify both common causes (diverticulitis) and rare but serious causes (atypical appendicitis) 2, 3. The morbidity from delayed diagnosis of perforated appendicitis far outweighs the cost and radiation exposure of definitive imaging 2.