Left lower quadrant abdominal pain

Background

• This page outlines the general approach to adult left lower quadrant (LLQ) pain
• LLQ contains: sigmoid colon, descending colon, left ureter, left ovary/fallopian tube (females), left spermatic cord (males)
• Key EM considerations: diverticulitis (most common surgical cause in adults >40), ovarian torsion, ectopic pregnancy, renal colic
• Always consider pregnancy-related emergencies in women of reproductive age

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

RUQ pain	Epigastric pain	LUQ pain
Flank pain	Diffuse abdominal pain	Flank pain
RLQ pain	Pelvic pain	LLQ pain

Clinical Features

History

• Onset, character, location, radiation, aggravating/alleviating factors
• Prior episodes of similar pain (recurrent diverticulitis)
• Change in bowel habits, blood in stool (colitis, diverticulitis, malignancy)
• Urinary symptoms (UTI, nephrolithiasis)
• Menstrual/gynecologic history: LMP, vaginal bleeding/discharge, sexual activity
• Fever (infectious/inflammatory cause)
• Diet: low fiber (diverticular disease)
• Age: diverticulitis more common >40 years

Physical Exam

• LLQ tenderness, guarding, rebound (peritonitis)
• Palpable mass (abscess, tumor)
• CVA tenderness (pyelonephritis, nephrolithiasis)
• Pelvic exam: cervical motion tenderness, adnexal mass/tenderness (ectopic, torsion, PID)
• Rectal exam: stool guaiac, rectal mass
• Testicular exam in males (referred pain from hernia or testicular pathology)

Red Flags

• Hemodynamic instability with LLQ pain + positive pregnancy test (ectopic pregnancy)
• Acute onset severe pain with no prior history (torsion, mesenteric ischemia, perforation)
• Fever + peritoneal signs (perforation, abscess)
• Free air on imaging (perforated diverticulitis or other hollow viscus)

Differential Diagnosis

Must Not Miss

• Ectopic pregnancy in reproductive-age women
• Ovarian torsion
• Perforated diverticulitis
• Mesenteric ischemia (especially elderly with atrial fibrillation)
• Large bowel obstruction / volvulus (sigmoid volvulus)

Evaluation

Laboratory

• CBC, BMP
• Urinalysis
• Urine pregnancy test (mandatory in reproductive-age women)
• LFTs, lipase
• Lactate if concern for ischemia or sepsis
• CRP/ESR may support diverticulitis diagnosis
• GC/CT NAAT if PID suspected

Imaging

• CT abdomen pelvis with IV contrast: gold standard for diverticulitis, abscess, volvulus, mesenteric ischemia
• Pelvic ultrasound (transvaginal): first-line for suspected ovarian torsion, ectopic pregnancy
• POCUS: free fluid, hydronephrosis, IUP identification
• Abdominal X-ray: useful for obstruction or volvulus (coffee bean sign in sigmoid volvulus)

Management

• Treat underlying disease process
• IV fluids, analgesia
• Diverticulitis: uncomplicated — outpatient antibiotics or observation without antibiotics per recent guidelines; complicated (abscess, perforation, obstruction) — IV antibiotics, surgical consultation
• Ectopic pregnancy: emergent OB/GYN consultation
• Ovarian torsion: emergent GYN consultation for surgical detorsion
• Sigmoid volvulus: GI consultation for endoscopic decompression; surgery if peritonitis
• Nephrolithiasis: analgesia (NSAIDs first-line), hydration

Disposition

• Admit: complicated diverticulitis, ectopic pregnancy requiring intervention, ovarian torsion, bowel obstruction/volvulus, mesenteric ischemia
• Discharge: uncomplicated diverticulitis, stable renal colic, benign ovarian cyst, with appropriate follow-up and return precautions

See Also

• Abdominal Pain
• Diverticulitis
• Ectopic pregnancy
• Ovarian torsion