How should I evaluate and manage a 32-year-old woman with acute migratory abdominal pain that began in the right lower quadrant yesterday and has now shifted to the suprapubic region, with moderate pain (6/10) and no evidence of urinary tract infection?

Evaluation and Management of Migratory Abdominal Pain in a 32-Year-Old Woman

This patient requires urgent pelvic ultrasound (transvaginal and transabdominal) as the initial imaging study to evaluate for gynecologic emergencies, particularly ovarian torsion or ruptured ovarian cyst, given the migratory pain pattern from RLQ to suprapubic region in a woman of reproductive age. 1

Critical First Steps

Immediate Assessment Priorities

• Obtain beta-hCG immediately before any imaging in all women of reproductive age with acute abdominal pain to rule out ectopic pregnancy, which is a life-threatening diagnosis that cannot be missed 2, 3
• Assess hemodynamic stability and peritoneal signs on physical examination, as these guide urgency of intervention 3
• The migratory pain pattern from RLQ to suprapubic is atypical for appendicitis but highly concerning for gynecologic pathology, particularly ovarian torsion or hemorrhagic/ruptured ovarian cyst 1, 4

Key Clinical Features to Elicit

• Gynecologic history: Last menstrual period, history of ovarian cysts, prior pelvic surgeries, sexual activity 3
• Pain characteristics: Sudden onset versus gradual, radiation patterns, exacerbating/relieving factors 3
• Associated symptoms: Fever (suggests infection/inflammation), nausea/vomiting (suggests obstruction or severe inflammation), vaginal bleeding or discharge (suggests gynecologic cause) 3
• Prior abdominal surgeries: Increases risk of adhesive small bowel obstruction 1

Imaging Strategy

First-Line Imaging: Pelvic Ultrasound

Combined transvaginal and transabdominal pelvic ultrasound should be performed first in this 32-year-old woman with migratory pain now localized to the suprapubic region 1, 4. This approach:

• Achieves 97.3% sensitivity and 91% specificity for gynecologic pathology in adult women when performed by experienced operators 1
• Avoids radiation exposure in a woman of reproductive age 1, 3
• Can rapidly diagnose ovarian torsion, ruptured ovarian cyst, tubo-ovarian abscess, or ectopic pregnancy 2, 3
• Can also visualize the appendix if gynecologic structures are normal 1

When to Escalate to CT

If pelvic ultrasound is non-diagnostic or shows no gynecologic pathology, proceed immediately to CT abdomen and pelvis with IV contrast rather than repeating ultrasound 1. CT is indicated because:

• The initial RLQ pain raises concern for appendicitis, which CT diagnoses with 95% sensitivity and 94% specificity 2, 1
• CT identifies alternative diagnoses in 23-45% of cases, including diverticulitis, bowel obstruction, epiploic appendagitis, or mesenteric pathology 1, 5
• Migratory pain patterns can occur with atypical appendicitis presentations 2

Differential Diagnosis by Pain Migration Pattern

RLQ to Suprapubic Migration Suggests:

Gynecologic causes (most likely given demographics and pain pattern):

• Ovarian torsion with intermittent detorsion (explains improving pain) 2, 3
• Hemorrhagic or ruptured ovarian cyst with blood tracking to pelvis 4, 3
• Pelvic inflammatory disease with peritonitis 3

Gastrointestinal causes:

• Appendicitis with atypical presentation (though pain typically doesn't migrate away from RLQ once localized) 2, 1
• Epiploic appendagitis (presents with sharp, localized pain without systemic symptoms, can occur in RLQ) 6
• Right-sided colonic pathology 5

Urologic causes (though UTI ruled out):

• Urolithiasis with passed stone (explains improving pain) 3
• Ureteropelvic junction obstruction 3

Critical Pitfalls to Avoid

• Do not assume normal labs exclude serious pathology: Many serious conditions present with normal inflammatory markers, especially in early presentations 1
• Do not skip pregnancy testing: Ectopic pregnancy can present with atypical pain patterns and is life-threatening 2, 3
• Do not rely on ultrasound appendix visualization alone: Non-visualization occurs in 20-81% of cases and creates diagnostic uncertainty 1
• Do not delay imaging if ovarian torsion is suspected: Time to diagnosis directly impacts ovarian salvage rates 3
• Do not assume improving pain means benign pathology: Intermittent torsion, passed stone, or contained perforation can all show temporary improvement 1, 6

Management Algorithm

1. Obtain beta-hCG stat 2, 3
2. Order pelvic ultrasound (transvaginal + transabdominal) as first imaging 1
3. If ultrasound shows gynecologic pathology: Obtain urgent gynecology consultation 3
4. If ultrasound is negative or equivocal: Proceed immediately to CT abdomen/pelvis with IV contrast 1
5. If CT shows appendicitis or surgical pathology: Obtain urgent surgical consultation 1
6. If all imaging is negative: Consider epiploic appendagitis, early inflammatory process, or functional pain; close outpatient follow-up with return precautions 6

Conservative Management Considerations

Given the spontaneously improving pain (though still 6/10), do not adopt a "wait and see" approach without imaging in this scenario because:

• Ovarian torsion can have intermittent symptoms with detorsion 3
• Appendicitis can have variable pain patterns, especially in women where gynecologic anatomy can alter presentation 2
• The migratory pattern itself is concerning and warrants definitive diagnosis 1, 3