In an adult female with prior appendectomy, cholecystectomy, hysterectomy and oophorectomy who now presents with severe right lower quadrant (RLQ) pain radiating to the right groin and non‑radiating left upper quadrant (LUQ) pain, what is the most appropriate immediate management?

Immediate Management of Severe RLQ and LUQ Pain in Post-Surgical Female Patient

Obtain contrast-enhanced CT of the abdomen and pelvis with IV contrast immediately as the definitive diagnostic study, as this patient's severe pain (9/10) with groin radiation and extensive surgical history demands urgent imaging to identify the cause and guide management. 1

Why CT is the Appropriate Next Step

CT abdomen/pelvis with IV contrast demonstrates 95% sensitivity and 94% specificity for acute abdominal pathology and will simultaneously evaluate both the RLQ and LUQ pain sources in a single study. 1 This is critical because:

• Clinical examination alone misdiagnoses acute abdominal conditions in 34-68% of cases, making imaging essential rather than optional in this high-severity presentation. 2
• The patient's extensive surgical history (appendectomy, cholecystectomy, hysterectomy, oophorectomy) significantly narrows the differential but also increases risk for adhesive disease, bowel obstruction, and post-surgical complications. 1
• CT identifies alternative diagnoses in 23-45% of patients presenting with RLQ pain, fundamentally changing management in nearly half of cases. 1, 2

Critical Differential Diagnoses to Evaluate

Right Lower Quadrant Pain with Groin Radiation

The groin radiation pattern is a critical distinguishing feature that suggests specific pathologies:

• Ureteral stone disease – The most common cause of RLQ pain radiating to the groin; CT will identify stones with near 100% sensitivity. 1
• Right colonic diverticulitis – Occurs in 8% of patients presenting with RLQ pain and can mimic appendicitis despite prior appendectomy. 1
• Psoas abscess or retroperitoneal pathology – Groin radiation with severe pain suggests possible psoas involvement, which CT will definitively identify. 3
• Adhesive small bowel obstruction – Given multiple prior surgeries, this is a high-probability diagnosis that requires urgent identification. 1
• Incarcerated hernia (femoral or inguinal) – Can present with groin radiation and requires surgical intervention. 1

Left Upper Quadrant Pain

Despite prior cholecystectomy, several important diagnoses remain:

• Splenic pathology (infarct, abscess, rupture) – Requires immediate identification. 1
• Gastric or duodenal perforation – Life-threatening and requires emergency surgery. 1
• Pancreatic pathology (pancreatitis, pseudocyst) – CT is the gold standard for diagnosis. 1
• Left-sided colonic pathology (diverticulitis, colitis) – Common in adults and well-visualized on CT. 1

Optimal CT Protocol

Order CT abdomen and pelvis with IV contrast without oral contrast for the following reasons: 1, 2

• Rapid acquisition without delays from oral contrast administration, critical in severe pain (9/10). 1
• Maintains 90-100% sensitivity and 94.8-100% specificity for acute abdominal pathology without oral contrast. 1, 2
• Evaluates both solid organs and hollow viscus with excellent accuracy. 1
• Identifies vascular complications including mesenteric ischemia, which can present with severe pain. 1

Critical Pitfalls to Avoid

• Do not rely on absence of fever or normal white blood cell count to exclude serious pathology – Fever is absent in approximately 50% of acute abdominal conditions, and laboratory values have limited diagnostic power (positive likelihood ratio of only 2.47). 2
• Do not delay imaging for prolonged clinical observation – Pain severity of 9/10 with groin radiation demands urgent evaluation, as delays can lead to perforation, ischemia, or other complications. 2
• Do not assume the pain is musculoskeletal or chronic – While the patient has extensive surgical history, new-onset severe pain requires exclusion of acute surgical emergencies. 2
• Do not order ultrasound as the initial study – While ultrasound is appropriate for RUQ pain or in pregnant patients, it has limited sensitivity for the broad differential in this case and will likely require subsequent CT anyway. 1

Management Algorithm Based on CT Findings

If Ureteral Stone is Identified

• Initiate aggressive pain control with IV opioids and NSAIDs (if not contraindicated). 4
• Consult urology for stones >5mm or with evidence of obstruction. 1
• Admit for observation if pain is uncontrolled or patient cannot tolerate oral intake. 1

If Bowel Obstruction is Identified

• Make patient NPO immediately and place nasogastric tube if high-grade obstruction. 1
• Obtain immediate surgical consultation as adhesive obstruction may require operative intervention. 1
• Initiate IV fluid resuscitation and correct electrolyte abnormalities. 1

If Diverticulitis or Colitis is Identified

• Initiate broad-spectrum antibiotics covering gram-negative and anaerobic organisms. 1
• Admit for IV antibiotics if complicated diverticulitis (abscess, perforation) is present. 1
• Consider percutaneous drainage for abscesses >3cm. 2

If Splenic or Pancreatic Pathology is Identified

• Obtain immediate surgical consultation for splenic rupture or infarct. 1
• Admit to ICU if hemodynamically unstable or evidence of ongoing bleeding. 1
• Initiate supportive care for pancreatitis with aggressive IV hydration and pain control. 1

If CT is Negative

• Reassess clinical examination for peritoneal signs that may have evolved. 2
• Consider MRI if CT is truly negative but clinical suspicion remains high, particularly for early ischemia or gynecologic pathology. 1, 2
• Provide close follow-up within 24 hours with strict return precautions for worsening pain, fever, vomiting, or inability to tolerate oral intake. 2

Additional Immediate Management

While awaiting imaging:

• Establish IV access and initiate fluid resuscitation if patient appears dehydrated or hemodynamically compromised. 1
• Obtain complete blood count, comprehensive metabolic panel, lipase, and urinalysis to help narrow the differential. 1
• Provide cautious pain control with IV morphine 0.1-0.2 mg/kg, administered slowly to avoid masking evolving peritoneal signs. 4
• Ensure patient is NPO until surgical pathology is excluded. 1