Lower abdominal pain

Lower quadrant abdominal (Pic. 1) pain is a common clinical occurrence, with a wide spectrum of aetiologies that can present a diagnostic challenge for clinicians. Appendicitis is invariably the first differential diagnosis and most common cause of right lower quadrant pain. However, other considerations include infective, inflammatory and malignant conditions involving the ileo-caecal region, right colon, mesentery and surrounding anatomical structures. Abdominal pain is one of the most common chief complaints of emergency department patients. Acute lower abdominal pain in young adult females is a diagnostic challenge for general surgeons, gynecologists, and emergency physicians.

During history it should be considered gender, current patient's age, age at beginning of symptoms and its duration. Pain should be characterized as to location, installation, irradiation, intensity, rhythm, periodicity, duration, interference with activities including sleep, ingestion of alcohol, spices, fatty food, fasting, defecation and use of drugs. It should be evaluated temporal relations, worsening and improving factors and circumstances generating its installation and maintenance. Also evaluate it is neccesary to evaluate pain relation with menstrual cycle, traumas or abdominal scars; evaluate triggering factors related to worsening of pain and/or improving pain factors such as cough, sneezing, elimination of flatus or feces, micturition, physical movements and efforts. 

Ultrasound (US) is the preferred imaging modality in children, pregnant women, and generally young patients, owing to the absence of ionising radiation. Advances in computed tomography (CT) with multiplanar reformations and 3D reconstruction have led to some clinicians considering multi-detector CT (MDCT) as the modality of choice when evaluating patients with right lower quadrant pain. CT is considered to be the first line imaging investigation for diffuse or peritonitic clinical pictures, and in elderly patients. 

Lower abdominal pain is associated with several diseases. For both gender there is Crohn's disease (a type of inflammatory bowel disease), diverticulitis, tuberculous enterocolitis, lymphoma, colonic carcinoma and pelvic inflammatory disease. Diseases which are accompanied with lower abdominal pain in women are endometriosis, ectopic pregnancy, fallopian and ovarian torsion, adenomyosis, pyosalpinx (blocked fallopian tube filled with pus), hematosalpinx (blocked fallopian tube filled with blood), endometrial cancer or ovarian cancer. Strong and acute abdominal pain in men is associated with testicular torsion.

Endometriosis

Endometriosis is a chronic gynaecological disorder characterised by growth of endometrial tissue outside the endometrial cavity – primarily in the pelvis, peritoneum and ovaries. This ectopic mucosa undergoes cyclical hormonal changes and also bleeds, forming haemorrhagic cysts.

Fallopian and ovarian torsion

Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting. 

In isolated tubal torsion acute severe lower abdominal pain is always present and often in the per ovulatory period probably because of pelvic congestion and increased tubal motility at mid cycle. The pain can be constant and dull or paroxysmal and sharp, radiating to the thigh or groin. Nausea and vomiting may accompany the pain. On clinical exam, findings include abdominal tenderness with or without peritoneal signs. On pelvic exam adnexa tenderness is present but a mass is not always palpable.

Ectopic pregnancy

The classic presentation for an ectopic pregnancy includes vaginal bleeding, abdominal and/or pelvic pain as well as a tender adnexal mass; however, only 50% of patients present with this triad of symptoms. Additional symptoms include nausea, fatigue, cramping and amenorrhea, which often mimic a normal early intrauterine pregnancy or miscarriage. It is important to explore the history of presenting illness fully as pain can progress from dull to sharp to no pain at all, as in tubal rupture, which decreases luminal distention but can also cause serious hemorrhage. The symptoms of hemoperitoneum (the presence of blood in the peritoneal cavity) may be even more difficult to localize and in severe cases, blood contact with the diaphragm can cause phrenic nerve irritation, thus shoulder pain.

Testicular torsion

Testicular torsion occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle's blood supply, a condition called ischemia. Testicular torsion usually presents with sudden, severe, testicular pain (in groin and lower abdomen) caused by chemical substances produced by ischemic tissue and tenderness. There is often associated nausea and vomiting.