Left lower quadrant abdominal pain differential diagnosis

Overview

Acute abdomen is abdominal pain in the presence of tenderness and rigidity and is a surgical emergency. Abdominal pain can be considered in terms of surgical, Ob/Gyn and medical causes.

• The causes of abdominal pain are best dealt with according to the different regions of the abdomen. If pain is localised to a specific region of the abdomen, also consider nearby regions as the possible source of the pain.
• Don’t forget the abdominal wall as a source of the pain (e.g. haematomas, herpes zoster, etc) and that abdominal pain may originate from above the diaphragm!
• See also medical causes of abdominal pain.

Causes

Generalised abdominal pain with tenderness and rigidity

• perforated peptic ulcer
• perforation of other intra-abdominal organs
• AAA rupture
• aortic dissection
• pancreatitis
• ectopic pregnancy
• ischaemic gut

Central/ peri-umbilical pain without abdominal signs

• acute small bowel ischemia
• acute appendicitis
• acute small bowel obstruction
• acute pancreatitis
• testicular torsion
• medical causes of abdominal pain

Epigastric pain

Gastrointestinal

• gastritis
• peptic ulcer
• reflux oesophagitis
• pancreatitis
• cancer (gastric, pancreatic)
• Boerhaave syndrome (esophageal rupture)
• dyspepsia
• irritable bowel syndrome

Pain from nearby areas

• abdominal: central, RUQ pain
• cardiac: e.g. myocardial infarction, pleuritis
• pulmonary: e.g. pneumonia, pleurisy

Right hypochondrium/ upper quadrant pain

Gall bladder

• biliary colic
• cholecystitis
• cholangitis

Liver

• hepatitis
• hepatomegaly (e.g. liver congestion in right heart failure)
• hemorrhage into hepatic tumour
• trauma
• hepatic or subdiaphragmatic abscess
• Fitz-Hugh-Curtis syndrome (peri-hepatitis due to PID)
• Pre-eclampsia and HELLP

Other gastrointestinal

• appendicitis with high appendix (e.g. pregnancy)
• perforated or penetrating duodenal ulcer
• colon cancer

Pain from nearby areas

• abdominal: epigastric, central, RIF, loin, groin pain
• right lower lobe pneumonia, pleurisy or other lung disease
• subphrenic abscess
• acute pyelonephritis

Left hypochondrium/ upper quadrant pain

• pancreatitis
• subphrenic abscess
• diverticulitis
• ruptured spleen
• acute pyelonephritis
• leaking aneurysm of the splenic artery
• acute gastric distention

Right iliac fossa pain

Gastrointestinal

• appendicitis
• Crohn’s disease
• inflamed Meckel diverticulum
• cholecystitis with low gall bladder
• mesenteric adenitis
• epiploic appendagitis
• colon cancer
• constipation
• irritable bowel syndrome

Reproductive (female)

• ectopic pregnancy
• acute ovarian event (cyst rupture, hemorrhage, torsion)
• Mittelschmerz (ovulation pain mid-cycle)
• Pelvic inflammatory disease
• Endometriosis

Reproductive (male)

• seminal vesiculitis
• undescended testicle pathology

Urinary

• renal colic
• UTI

Pain from nearby areas

• abdominal: RUQ, central, groin pain
• hip pathology
• psoas abscess
• rectus sheath haematoma
• right lower lobe pneumonia

Left iliac fossa pain

Gastrointestinal

• diverticulitis
• colitis
• colon cancer
• constipation
• irritable bowel syndrome

Reproductive (female)

• ectopic pregnancy
• acute ovarian event (cyst rupture, hemorrhage, torsion)
• Mittelschmerz (ovulation pain mid-cycle)
• Pelvic inflammatory disease
• Endometriosis

Reproductive (male)

• seminal vesiculitis
• undescended testicle pathology

Urinary

• renal colic
• UTI

Pain from nearby areas

• abdominal: LUQ, central, groin pain
• hip pathology
• psoas abscess
• rectus sheath haematoma
• left lower lobe pneumonia

Suprapubic pain

• urinary retention
• cystitis
• uterine in origin (e.g. PID, fibroid, menstruation)
• origin from RIF and/ or LIF causes

Loin pain

Renal tract

• infection e.g. pyelonephritis
• obstruction, e.g. renal colic
• renal carcinoma
• renal vein thrombosis
• polycystic kidney disease
• adrenal hemorrhage

Other

• retroperitoneal hemorrhage
• retroperitoneal infection
• vertebral pathology

Groin pain

• renal calculi
• scrotal pain e.g. testicular torsion, epididymo-orchitis, trauma
• inguinal hernia
• hip pathology
• pelvic fracture

Chris Nickson

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC