acute left lower quadrant pain
TRANSCRIPT
ACUTE LEFT LOWER QUADRANT PAlN
Hisham AlKhatib, M.D.Consultant Radiologist
الحمد هلل والصالة والسالم على رسول هللا وعلى اله •
وصحبه وسلّم اجمعين
اللهم انفعني بما علمتني وعلمني بما ينفعني وزدني علما ، •
انك العليم الحكيم
• Praise be to Allah and prayers be upon the Messenger of Allah and his family and companions.
• Oh God, give me the benefit of what you have taught me and teach me what benefits me.
DIFFERENTIAL DIAGNOSIS
Common Causes
• Diverticulitis
• Colon Carcinoma
• Epiploic Appendagitis
• Pseudomembranous Colitis
• Infectious Colitis
• Ulcerative Colitis
Common Causes
• Gynecologic Causes
– Adnexal Torsion
– Endometriosis
– Salpingitis
– Tubo-Ovarian Abscess
– Uterine Fibroids
• Urolithiasis
• Post-Operative State, Bowel
Key Differential Diagnosis Issues
• Most etiologies are of bowel origin, but consider genitourinary; don't forget to check the mesentery & omentum
• CECT is the imaging modality of choice, after pregnancy is taken into account
Diverticulitis
• Most common cause in middle-aged and elderly
– Can affect patients as young as 25
• Usually long ( 10- 1 5 cm) segment of wall thickening, luminal narrowing, pericolonic infiltration
• Extraluminal collections of gas or fluid help confirm diagnosis
Colon Carcinoma
• Usually short segment without much pericolonic infiltration
• Regional lymphadenopathy has strong association with carcinoma, rarely seen in diverticulitis
• Acute symptoms may be due to colonic obstruction ± colitis proximal to the obstructing mass
Epiploic Appendagitis
• Small oval, fatty lesion (2-4 cm) with infiltration of omental fat
• Lies immediately adjacent to colonic surface
• Important to distinguish from diverticulitis, as epiploic appendagitis resolves without specific treatment
Pseudomembranous or Infectious Colitis
• Usually diffuse, pancolonic with impressive colonic wall thickening ("accordion sign")
• May be segmental, including distal colon
• Very common, especially in hospitalized patients, and those in nursing homes
Ulcerative Colitis
• Favors rectum and distal colon
• Colonic wall is usually not very thickened
• Look for loss of haustral pattern, infiltration of pericolonic fat
• Ask about history of prior episodes
Gynecologic Causes
• Many, including adnexal infection & masses, torsed ovary, endometriosis, etc.
• Look for evidence of mass &/or inflammation centered on adnexa, rather than bowel
• Uterine Fibroids
– May torse , undergo degeneration or infarction, lead to acute pain
– Heterogeneous soft tissue masses within enlarged uterus, ± focal calcifications within masses
Urolithiasis
• Distal left ureteral stone may cause left lower quadrant pain
• Diagnosis usually evident on CT
– Ureteral calculus, hydronephrosis, perinephric stranding
Post-Operative State, Bowel
• Following bowel (& other surgeries) ileus may result in bowel distention & pain
• May see just bowel distention on CT, but small amount of peritoneal fluid is common in immediate post-op state
• Anastomotic site narrowing & pericolonic infiltration are also expected in post-op period
Less Common Causes
• Ischemic Colitis
• Omental Infarct
• Uterine Fibroids
• Sclerosing Mesenteritis
• Crohn Disease
• Abdominal Abscess
• Sigmoid Volvulus
• Appendicitis
• Fecal Impaction
Less Common Causes
• Peritonitis
• Pyelonephritis
• Renal Cell Carcinoma
• Renal Infarction
• Coagulopathic ("Retroperitoneal") Hemorrhage
• Spigelian Hernia
• Inguinal Hernia
Rare but Important
• Bladder Fistulas
Helpful Clues for Less Common Diagnoses
Ischemic Colitis
• Sigmoid colon is 2nd most common site for hypoperfusion-induced ischemia
• Wall thickening & luminal narrowing
• Ask about prior hypotensive episode or cardiac disease
Omental Infarct
• Primary omental infarction occurs near the ascending colon
• Secondary form may occur anywhere near site of surgery, infection, radiation, etc.
• Heterogeneous fatty mass, larger than epiploic appendagitis
– Usually farther removed from surface of colon than for epiploic appendagitis
• Usually resolves without specific treatment
Sclerosing Mesenteritis
• Being diagnosed much more commonly as cause of recurrent abdominal pain, usually poorly localized
• "Misty mesentery" with cluster of jejunal mesentery nodes with surrounding thin capsule
• Often with history of prior similar episodes
• May respond to steroid therapy or resolve on its own
Abdominal Abscess
• Usually in post-operative patient, or following appendicitis, diverticulitis
Sigmoid Volvulus
• Very elongated & dilated sigmoid colon, folded back on itself ("coffee bean" or "football" signs)
• Colon proximal to sigmoid will be dilated, but not as much as sigmoid
• CT will show twisting of vessels in base of sigmoid mesocolon
Appendicitis
• Appendix may be very long or may arise from a malrotated colon, lead to left-sided symptoms
Fecal Impaction
• Common, but can lead to stercoral ulceration with erosion through colonic wall
THANK YOU