Management of RLQ Pain with Negative CT Showing Stool
When CT shows only stool in a patient with RLQ pain and no other acute pathology, treat this as functional constipation and manage conservatively with bowel regimen, symptomatic care, and close clinical follow-up rather than pursuing additional imaging or surgical intervention. 1
Clinical Context and Interpretation
The finding of stool on CT in the absence of other acute pathology (appendicitis, diverticulitis, obstruction, inflammatory changes) represents a common scenario where imaging has effectively excluded surgical emergencies. 1
- CT has 95% sensitivity and 94% specificity for appendicitis, making a negative study highly reliable for excluding this diagnosis 1
- Among patients with RLQ pain where CT shows no acute diagnosis, only 14% require hospitalization and 4% need surgical or image-guided intervention, compared to 41% hospitalization and 22% intervention rates when CT identifies pathology 1
- The most common CT diagnoses in patients without surgical pathology include constipation, gastroenteritis, colitis, benign adnexal masses, and inflammatory bowel disease 1
Recommended Management Approach
Immediate Management
- Initiate bowel regimen with stool softeners and/or osmotic laxatives to address the constipation identified on imaging 1
- Provide symptomatic pain relief with appropriate analgesics while avoiding opioids that may worsen constipation 1
- Reassess clinical status within 24-48 hours to ensure symptom improvement and exclude evolving pathology 1
Clinical Monitoring
- Watch for red flag symptoms including fever, persistent vomiting, worsening pain, peritoneal signs, or inability to tolerate oral intake that would suggest evolving acute pathology 1, 2
- Reimage only if clinical deterioration occurs or new concerning features develop, as repeat imaging is not indicated for stable or improving symptoms 1
- Consider alternative diagnoses if pain persists despite bowel management, including gynecologic pathology in women, urinary tract conditions, or functional disorders 1, 2
Important Clinical Pitfalls
Avoid unnecessary repeat imaging in patients whose symptoms are improving or stable, as this increases radiation exposure without changing management. 1 The high negative predictive value of CT means that acute surgical pathology is extremely unlikely when the initial study is negative.
Do not dismiss persistent pain that fails to improve with conservative management, as approximately 8% of RLQ pain cases represent right colonic diverticulitis and 3% represent obstruction that may evolve over time. 1 However, these conditions would typically show CT findings beyond simple stool burden.
Consider patient-specific factors such as age and gender when persistent symptoms occur—elderly patients may present atypically, and women of reproductive age require consideration of gynecologic pathology including ovarian torsion or ectopic pregnancy. 2, 3, 4