Could a left lower quadrant (LLQ) ache that worsens with movement, such as standing, walking, or twisting, be an abdominal hernia?

Diagnosis of Suspected Abdominal Hernia in Left Lower Quadrant Pain

Your symptoms of LLQ pain worsening with positional changes (sitting to standing, walking, twisting) without blood in stool/urine or visible bulge could represent an abdominal hernia, and CT of the abdomen and pelvis with IV contrast is the diagnostic test of choice to confirm or exclude this diagnosis. 1, 2

Clinical Reasoning for Hernia Suspicion

Your symptom pattern is consistent with abdominal wall hernia:

• Pain with movement and position changes (standing, walking, twisting) suggests mechanical stress on a potential hernia defect, which is characteristic of abdominal wall hernias 3, 4
• Absence of visible bulge does not exclude hernia—many abdominal hernias, particularly Spigelian hernias and internal hernias, are interparietal (between muscle layers) and lack obvious external protrusion 3
• LLQ location can represent Spigelian hernia (0.12-2.4% of all abdominal hernias), which typically occurs in the lower abdomen and frequently presents with vague pain without consistent physical findings 3

Recommended Diagnostic Approach

CT abdomen and pelvis with IV contrast is the gold standard imaging modality for evaluating suspected abdominal hernia in your presentation 1, 2, 4:

• Sensitivity and specificity: CT accurately detects hernias that are clinically occult and can identify the anatomic location, hernia contents, and complications such as incarceration or strangulation 2, 5, 4
• IV contrast enhancement improves detection of bowel wall pathology, vascular compromise, and fluid collections that may indicate hernia complications 1
• Multi-detector CT can delineate the "zone of transition" and identify compromised blood supply, which is critical for surgical planning 4

Alternative Imaging Considerations

• Ultrasound can detect abdominal wall hernias (as demonstrated in the Spigelian hernia case) but is operator-dependent and less comprehensive than CT for evaluating hernia contents and complications 3
• Plain radiography has extremely limited utility and should not be used as the initial diagnostic test for suspected hernia 1

Important Differential Diagnoses to Consider

While hernia is possible, the ACR guidelines emphasize that CT is superior for detecting alternative diagnoses causing LLQ pain 1:

• Diverticulitis: CT has 96-98% accuracy for detecting diverticulitis and its complications 1
• Colonic pathology: Including colitis or neoplasm
• Gynecologic causes (if female): Though these typically present with additional pelvic symptoms

Clinical Urgency and Red Flags

Seek emergency evaluation immediately if you develop 4:

• Sudden worsening of pain (suggests possible incarceration)
• Nausea, vomiting, or inability to pass gas/stool (suggests bowel obstruction)
• Fever or systemic symptoms
• Visible bulge that becomes firm and non-reducible

Spigelian hernias carry up to 21% risk of incarceration-related complications, making timely diagnosis and surgical repair important even when symptoms are chronic 3.

Next Steps

1. Schedule CT abdomen/pelvis with IV contrast as the definitive diagnostic test 1, 2

2. Physical examination should specifically assess for:

   • Palpable defect in the abdominal wall during Valsalva maneuver
   • Tenderness along the semilunar line (lateral edge of rectus muscle) where Spigelian hernias occur 3
   • Signs of peritoneal irritation (rebound, guarding)

3. If CT confirms hernia: Surgical repair is generally indicated due to high complication risk, even for chronic symptoms 3

4. If CT is negative for hernia: The study will likely reveal the alternative cause of your LLQ pain 1

Common Pitfalls to Avoid

• Do not rely on absence of visible bulge to exclude hernia—interparietal hernias frequently lack external signs 3
• Do not delay imaging with chronic symptoms, as hernias can progress to incarceration requiring emergency surgery 3, 4
• Do not accept ultrasound as definitive if negative, since CT provides superior diagnostic accuracy for both hernia and alternative diagnoses 1