What is the diagnosis and treatment for an adult patient with recurrent lower quadrant abdominal pain and unknown medical history?

Recurrent Lower Quadrant Abdominal Pain: Diagnostic and Treatment Approach

For an adult with recurrent lower quadrant abdominal pain, obtain CT abdomen and pelvis with IV contrast as the definitive diagnostic test, as it has 98% accuracy for identifying the underlying cause and guides appropriate treatment. 1

Initial Diagnostic Strategy

Computed tomography with IV contrast is the imaging modality of choice for both right and left lower quadrant pain, rated 8/9 (usually appropriate) by the American College of Radiology. 1, 2 This single test provides:

• Comprehensive evaluation of all potential causes including appendicitis, diverticulitis, inflammatory bowel disease, bowel obstruction, hernias, and malignancy 2
• Detection of complications such as abscess, perforation, fistula, and obstruction 1, 2
• Identification of alternative diagnoses in 49% of cases where clinical suspicion differs from actual pathology 1
• Superior sensitivity (>95%) and specificity (99-100%) for most acute abdominal pathology 1

Do not rely on clinical examination alone—misdiagnosis rates are 34-68% without imaging. 3, 2

Right Lower Quadrant Pain: Key Considerations

The most common cause is appendicitis, which requires urgent diagnosis to prevent perforation and associated morbidity. 1

Critical diagnostic points:

• Clinical scoring systems like the Alvarado score have mixed results and should not replace imaging 1
• The negative appendectomy rate without imaging is unacceptably high at 25% 1
• CT imaging decreases negative appendectomy rates without increasing perforation rates from diagnostic delays 1

Alternative diagnoses to consider:

• Right colonic diverticulitis 1
• Ureteral stone 1
• Colitis or inflammatory bowel disease 1
• Intestinal obstruction 1
• In women of reproductive age: ovarian pathology, ectopic pregnancy, pelvic inflammatory disease 2

Left Lower Quadrant Pain: Key Considerations

The most common cause is sigmoid diverticulitis, particularly in adults over 40 years. 1

Critical diagnostic points:

• The classic triad of left lower quadrant pain, fever, and leukocytosis is present in only 25% of diverticulitis cases 2
• When left lower quadrant tenderness, CRP >50 mg/L, and absence of vomiting are all present, diagnostic accuracy reaches 97%, but this occurs in only 24% of patients 2
• CT has sensitivity and specificity approaching 100% for sigmoid diverticulitis 2

Alternative diagnoses to consider:

• Colitis or inflammatory bowel disease 2
• Epiploic appendagitis 2
• Bowel obstruction 2
• Renal colic or pyelonephritis 2
• In women: ovarian cysts, ovarian torsion, ectopic pregnancy 2
• Rarely: situs inversus with left-sided appendicitis 4

Special Population Modifications

For premenopausal women with suspected gynecologic pathology:

• Obtain pregnancy test first 2
• Consider pelvic/transvaginal ultrasound as initial imaging 2
• If gynecologic causes are excluded clinically or sonographically, proceed to CT 2

For elderly patients (>65 years):

• Recognize atypical presentations—only 50% have pain in the expected quadrant, only 17% have fever 3
• In-hospital mortality increases dramatically with age: 1.6% (<65 years), 9.7% (65-79 years), 17.8% (>80 years) 3
• Lower threshold for imaging and admission 3

Treatment Algorithm Based on CT Findings

Right Lower Quadrant: Appendicitis Confirmed

• Immediate surgical consultation for appendectomy 1
• Start broad-spectrum IV antibiotics if perforation or abscess present 3

Left Lower Quadrant: Uncomplicated Diverticulitis

• Immunocompetent patients: Conservative management WITHOUT antibiotics 2
• Clear liquid diet advancement and oral analgesics 2
• Immunocompromised or elderly patients: Antibiotics for maximum 7 days (Ertapenem 1g q24h or Eravacycline 1mg/kg q12h) 2

Left Lower Quadrant: Complicated Diverticulitis with Small Abscess (<4 cm)

• Antibiotics alone for 7 days without drainage 2

Left Lower Quadrant: Complicated Diverticulitis with Large Abscess (≥4 cm)

• Percutaneous CT-guided drainage PLUS antibiotics for 4 days 3, 2

Perforation with Peritonitis

• Emergency surgical consultation immediately 3, 2
• Broad-spectrum IV antibiotics (carbapenems if septic shock) 3, 2
• NPO status, IV fluid resuscitation, nasogastric decompression 3

Red Flags Requiring Emergency Evaluation

Immediate emergency department evaluation is required for: 2

• Fever with severe abdominal tenderness and guarding 2
• Inability to pass gas or stool with abdominal distension 2
• Vomiting, especially if bilious or feculent 2
• Bloody stools 2
• Signs of shock (hypotension, tachycardia, altered mental status) 3, 2
• Progressively worsening pain over several days 2

These symptoms indicate potential:

• Perforation with peritonitis and risk of septic shock 3, 2
• Complete bowel obstruction with risk of necrosis 2
• Abscess requiring drainage or surgery 3, 2

Critical Pitfalls to Avoid

Do not delay imaging in patients with concerning symptoms—CT alters diagnosis in 49% of cases and changes management in 42% of patients. 1

Do not assume low inflammatory markers exclude serious pathology—39% of patients with complicated diverticulitis have CRP below 175 mg/L. 3

Do not order routine colonoscopy after CT-confirmed uncomplicated diverticulitis—it is only warranted for age-appropriate screening not yet performed, abnormal lymph nodes on CT, luminal mass on CT, or presence of abscess/perforation/fistula. 2

Do not continue antibiotics beyond 7 days in uncomplicated cases—this increases resistance without improving outcomes. 2

Watch for CT findings suggesting malignancy rather than diverticulitis: pericolonic lymphadenopathy >1 cm, which requires colonoscopy for tissue diagnosis. 2

Radiation Exposure Considerations

While CT exposes patients to approximately 10 mSv (compared to 3 mSv annual background radiation), the diagnostic benefits outweigh risks in acute presentations. 1 Strategies to reduce exposure include:

• Using ultrasonography first in suspected appendicitis before CT (though this delays definitive diagnosis) 1
• Low-dose CT protocols when available 1
• MRI as an alternative in pregnant patients or young patients with recurrent symptoms requiring repeat imaging 1

When Conservative Outpatient Management May Be Appropriate

Mild, stable pain without red flags may be managed outpatient if: 2

• No fever or systemic symptoms 2
• Ability to tolerate oral intake 2
• Normal bowel movements continue 2
• No signs of peritonitis on examination 2
• Reliable patient with ability to return if symptoms worsen 2

However, obtain CT imaging first to confirm the diagnosis and exclude complications before deciding on outpatient management. 1, 2