Management of Worsening Left Lower Abdominal Pain After Lifting Heavy Objects
This patient requires urgent clinical evaluation with CT scan of the abdomen and pelvis with IV contrast to rule out serious intra-abdominal pathology, as worsening pain despite conservative measures suggests potential muscle strain, hernia, or less commonly, visceral injury. 1, 2
Immediate Assessment Priorities
Hemodynamic Evaluation
- Check vital signs immediately to determine if the patient is hemodynamically stable (blood pressure, heart rate) as this dictates the urgency and pathway of management 1
- Assess for signs of peritonitis including abdominal rigidity, rebound tenderness, or diffuse abdominal tenderness, which would indicate need for immediate surgical consultation 3, 1
- Evaluate for fever, which may suggest infectious or inflammatory process 1
Key History Elements
- Mechanism of injury matters: lifting heavy objects (pavers) can cause muscular strain, abdominal wall hernias, or rarely, intra-abdominal injury 2
- Pain characteristics: sharp, worsening pain despite heat application suggests progression beyond simple muscle strain 2
- Associated symptoms: nausea, vomiting, inability to pass gas/stool, or fever would elevate concern for intra-abdominal pathology 2
Diagnostic Approach
For Hemodynamically Stable Patients (Most Likely Scenario)
- CT scan with IV contrast is the recommended first-line imaging for left lower quadrant abdominal pain in stable patients 1, 2
- The American College of Radiology recommends CT for evaluation of left lower quadrant pain as it provides comprehensive assessment of both abdominal wall and intra-abdominal structures 2
- Laboratory testing should include complete blood count, lactate level if concerned about ischemia, and urinalysis to exclude urinary tract pathology 1
Critical Differential Diagnoses to Consider
- Abdominal wall pathology: muscle strain, rectus sheath hematoma, or incarcerated hernia (most common after lifting injury) 2, 4
- Intra-abdominal causes: diverticulitis, bowel obstruction, epiploic appendagitis, or colonic pathology 2, 4
- Gynecologic causes: ovarian torsion, ruptured ovarian cyst, or ectopic pregnancy must be excluded in women of reproductive age 2
Management Algorithm
If Hemodynamically Stable with No Peritoneal Signs
- Obtain CT abdomen/pelvis with IV contrast 1, 2
- Provide appropriate analgesia while awaiting imaging - intravenous paracetamol or NSAIDs are first-line for moderate pain 5
- If imaging reveals simple muscle strain or abdominal wall hematoma without complications, conservative management with rest, ice/heat, and analgesics is appropriate 5
- If hernia is identified, urgent surgical consultation is needed to assess for incarceration or strangulation 2
If Hemodynamically Unstable or Peritoneal Signs Present
- Immediate surgical consultation is mandatory as this suggests potential visceral perforation, hemorrhage, or other surgical emergency 3, 1
- FAST examination should be performed immediately in hypotensive patients to detect intra-abdominal bleeding 6
- Initiate fluid resuscitation targeting mean arterial pressure ≥65 mmHg 6, 1
Common Pitfalls to Avoid
- Do not dismiss worsening pain as simple muscle strain without imaging, especially when conservative measures (heat) have failed 1, 2
- Do not delay CT scanning in stable patients - the broad differential for left lower quadrant pain requires imaging for accurate diagnosis 2
- Do not overlook gynecologic causes in women of reproductive age; consider pregnancy test and pelvic ultrasound if indicated 1, 2
- Avoid withholding appropriate analgesia while awaiting diagnosis, as pain control does not interfere with diagnostic accuracy and is ethically appropriate 5
Special Considerations
If Functional Disorder Suspected
- Only after organic pathology has been confidently excluded through appropriate imaging should functional disorders be considered 7
- Repetitive testing is not recommended once functional pain is established 7