Right Lower Quadrant Pain: Diagnostic and Management Approach
Initial Imaging Strategy
Obtain a CT abdomen and pelvis with IV contrast immediately as your first-line diagnostic test for right lower quadrant pain. 1
- CT with IV contrast achieves 95% sensitivity and 94% specificity for appendicitis and identifies alternative diagnoses in 94.3% of cases 1
- CT without enteral contrast is preferred to avoid delays, with sensitivities of 90-100% and specificities of 94.8-100% 1
- Ultrasound and MRI are reserved for pregnant patients where radiation exposure must be avoided 2
Key Differential Diagnoses
While appendicitis remains the most common surgical cause requiring exclusion, CT readily identifies the following conditions 1, 3:
- Appendicitis - most common surgical pathology, but fever, nausea, and vomiting are present in only 50% of cases 1
- Right colonic diverticulitis - common cause readily identified on CT 1
- Inflammatory bowel disease - including Crohn's disease affecting the ileocecal region 1
- Constipation/fecal impaction - benign finding when isolated 1
- Gastroenteritis and colitis 1
- Benign adnexal masses in women 1
- Epiploic appendagitis and omental conditions 3
Management Algorithm Based on CT Results
If CT Shows Acute Surgical Pathology (Appendicitis, Diverticulitis)
Obtain immediate surgical consultation - 41% of these patients require hospitalization and 22% need surgical or image-guided intervention 1
If CT Shows Only Constipation or No Acute Findings
Initiate conservative management with the following protocol: 1, 4
- Start bowel regimen with stool softeners and/or osmotic laxatives 4
- Provide symptomatic pain relief with appropriate analgesics 4
- Reassess clinical status within 24-48 hours 4
- Only 14% of these patients require hospitalization and 4% need intervention 4
Critical Red Flags Requiring Reimaging
Reimage immediately if any of the following develop: 1, 4
- Fever development
- Persistent vomiting
- Worsening pain or development of peritoneal signs
- Inability to tolerate oral intake
- Clinical deterioration despite conservative management
Do not repeat imaging if symptoms are stable or improving - this increases radiation exposure without changing management 1, 4
Essential Clinical Pitfalls to Avoid
- Never exclude appendicitis based on absence of fever and leukocytosis - these classic findings are absent in 50% of cases, particularly in atypical or early presentations 1, 4
- Do not dismiss persistent pain after 24-48 hours of conservative management - this warrants consideration of alternative diagnoses or delayed presentation of appendicitis 1, 4
- Avoid unnecessary repeat CT in improving patients - radiation exposure without clinical benefit 4
- Consider patient-specific factors such as age and gender when symptoms persist despite negative initial imaging 4