What is the diagnosis and management for a female adult with mild to moderate (4/10) abdominal pain localized to the right abdomen?

Right Abdominal Pain in Adult Female: Diagnosis and Management

For an adult female with 4/10 right-sided abdominal pain, the diagnostic approach depends critically on whether the pain is in the right upper quadrant (RUQ) or right lower quadrant (RLQ), with ultrasonography being first-line for RUQ pain and CT with contrast being first-line for RLQ pain. 1

Initial Critical Step: Pregnancy Testing

• Beta-hCG testing is mandatory before any imaging in all women of reproductive age to rule out ectopic pregnancy and avoid radiation exposure to a potential pregnancy 1, 2
• This single test can fundamentally change your diagnostic pathway and management

Diagnostic Approach Based on Pain Location

Right Upper Quadrant Pain

Primary imaging: Abdominal ultrasonography (rated 9/9 by ACR) 1

• Acute cholecystitis is the primary diagnostic consideration for RUQ pain 1
• Ultrasonography has 81% sensitivity and 83% specificity for cholecystitis, is readily available, identifies alternative diagnoses, and avoids radiation 1
• If ultrasonography is equivocal, proceed to cholescintigraphy (96% sensitivity, 90% specificity) or CT with contrast 1

Laboratory workup for RUQ pain:

• Complete blood count to assess for leukocytosis 2
• Comprehensive metabolic panel with liver function tests (ALT, AST, alkaline phosphatase, bilirubin) 2
• Serum lipase (more specific than amylase for pancreatitis) 2
• Urinalysis 2

Right Lower Quadrant Pain

Primary imaging: CT of abdomen and pelvis with contrast media (rated 9/9 by ACR) 1

• Appendicitis is the primary concern, affecting 15.9-28.1% of patients with acute abdominal pain 3
• CT with contrast has superior sensitivity for appendicitis and can identify periappendiceal abscess or other complications 1
• Alternative radiation-sparing approach: Start with graded compression ultrasonography (rated 6/9), then proceed to CT only if inconclusive 1
  • This strategy significantly decreases CT use while maintaining diagnostic accuracy 1
  • Particularly appropriate for younger women to minimize radiation exposure 1

Laboratory workup for RLQ pain:

• Complete blood count with differential to assess for leukocytosis 2
• Comprehensive metabolic panel 2
• Urinalysis to exclude urinary tract infection or nephrolithiasis 2
• Serum lipase 2

Critical Gynecologic Considerations in Women

Must evaluate for:

• Ectopic pregnancy - use transvaginal and transabdominal pelvic ultrasonography if β-hCG positive 1
• Ovarian torsion - pelvic ultrasonography (transvaginal and transabdominal) 1
• Pelvic inflammatory disease - imaging typically not indicated, but consider if diagnosis unclear 1
• Pelvic ultrasonography is rated 5/9 appropriateness for women with RLQ pain and pelvic symptoms 1

Pain Management

Provide analgesia early without waiting for definitive diagnosis 3

• Early analgesia reduces patient discomfort without impairing diagnostic accuracy 3
• For mild-moderate pain: Ibuprofen 400 mg every 4-6 hours as needed 4
• Judicious provision of analgesia is safe and recommended based on prospective randomized trials 3

Common Pitfalls to Avoid

• Failing to obtain pregnancy testing before imaging leads to delayed diagnosis of ectopic pregnancy and unnecessary radiation exposure 1, 2
• Conventional radiography has limited diagnostic value (49% sensitivity for bowel obstruction) and should not be routinely ordered except when pneumoperitoneum is suspected 1, 5
• Assuming all right-sided pain is the same - RUQ and RLQ require completely different imaging approaches 1
• Withholding analgesia while awaiting diagnosis - this outdated practice increases patient suffering without improving diagnostic accuracy 3

When Imaging is Equivocal or Unavailable

• If ultrasonography is nondiagnostic for RUQ pain, consider cholescintigraphy or CT with contrast 1
• If CT is unavailable for suspected appendicitis, MRI shows excellent sensitivity (97%) and specificity (95%) without radiation 1
• For pregnant patients with inconclusive ultrasonography, MRI is preferred over CT when available 6

Conditions That May Not Require Imaging

Based on clinical presentation, imaging may not be needed for 1:

• Gastroenteritis
• Pelvic inflammatory disease (clinical diagnosis)
• Urinary tract infection
• Muscle strain

However, if serious pathology remains a clinical concern despite initial workup, proceed with location-appropriate imaging 1