Evaluating the Patient with Left Lower Quadrant Abdominal Pain

As the coronavirus disease 2019 (COVID-19) pandemic is still underway, a range of clinical presentations and pathologies continue to present themselves in unexpected ways. One such pathology is that of epiploic appendagitis, an uncommon and underdiagnosed cause of acute abdominal pain. We present the case of a 50-something-year-old male who presented with left lower quadrant abdominal pain in the setting of acute COVID-19 infection, found to have acute epiploic appendagitis. After persistent moderate to severe abdominal pain, epiploic appendagitis was diagnosed by computed tomography (CT) imaging findings. The patient was managed for his COVID-19 pneumonia over the course of his hospitalization, as well as conservatively managed with pain control measures for his epiploic appendagitis. This is the second reported case in the literature to the best of our knowledge that shares the case of acute epiploic appendagitis in a patient presenting with acute abdominal pain, who is also found to be COVID-19-positive. Procoagulant changes in coagulation pathways are found in patients with severe COVID-19, and contribute to venous thromboembolism in this patient population. Diagnosing and conservatively managing epiploic appendagitis will lead to decreasing misdiagnosis, preventing invasive or inappropriate treatments that may increase harm to patients, and more adequately understanding the complications associated with COVID-19.

Acute diverticulitis is a prevalent surgical condition that typically presents with lower abdominal pain and tenderness. However, the clinical and laboratory findings of diverticulitis are non-specific and other conditions may give similar manifestations. We present the case of a middle-aged woman with a left lower quadrant abdominal pain and fever of three days duration. On examination, she had tachycardia and localized tenderness in the left iliac fossa with rebound tenderness. There were no signs of peritonitis, including the rigid abdomen and decreased bowel sounds. The laboratory findings were suggestive of an inflammatory or infectious process. A computed tomography scan of the abdomen demonstrated a fat-density lesion anterior to the descending colon representing epiploic appendagitis. The patient was managed conservatively with non-steroidal anti-inflammatory drugs (lornoxicam 8 mg). The patient experienced gradual improvement and was discharged after four days of hospitalization. No surgical intervention was needed. The case highlighted the importance of considering epiploic appendagitis in the differential diagnosis of acute diverticulitis. An accurate diagnosis will prevent the patient from having unnecessary surgeries as conservative management is often sufficient in patients with epiploic appendagitis.

In patients presenting with abdominal pain, appendicitis is the most common surgical disorder. Appendicitis causing pain in the left lower quadrant is extremely rare and can occur with congenital abnormalities...

A previously healthy 17-year-old girl is seen in the emergency department with complaints of left lower quadrant abdominal pain, vomiting, and fevers for the last 2 days. She does not have a prior history of urinary tract infections. Her appendix was removed when she was 6 years old. She states that she is sexually active and has had three male partners over the past 3 months, with intermittent condom use. Her temperature is 38 °C, with normal vital signs otherwise. On physical examination, she has tenderness of the left lower quadrant of her abdomen, without rebound or guarding. On pelvic exam, her cervix is friable with motion tenderness. On bimanual exam, she has moderate left adnexal tenderness. Results of laboratory studies include a total white blood cell count of 26,000 cells/μL with 85% neutrophils and 15% lymphocytes, an elevated erythrocyte sedimentation rate, and an elevated C-reactive protein. Swabs of the cervix, taken during the pelvic exam, were sent to the laboratory for a wet mount, KOH prep, and nucleotide acid amplification testing for gonorrhea, chlamydia, and trichomonas. The laboratory calls with positive results for both gonorrhea and chlamydia. A screening blood test for syphilis and a fourth-generation HIV test are negative. The girl is hospitalized for treatment of pelvic inflammatory disease. After 4 days of treatment with intravenous cefoxitin and oral doxycycline, her pain is well-controlled, and she is fever free for 48 hours. Results of a repeat erythrocyte sedimentation rate and C-reactive protein are improved. The girl is discharged home to complete a 14-day course of doxycycline. Her sexual partners are contacted by the local health department and advised to seek medical attention and treatment for chlamydia and gonorrhea.

Primary abscess of the omentum: report of a case and review of the literature.

Diverticulitis is an infection of the diverticular sacs protruding from the intestinal wall. It typically presents as elevated inflammatory markers and left lower quadrant abdominal pain. Although clinical symptoms and biomarkers are essential for diagnosis, imaging methods, particularly computed tomography (CT), are critical due to the inability to perform endoscopic procedures in the acute phase because of the risk of perforation. Various classification systems that include imaging findings have been developed. The most recent and widely accepted system is the Sartelli classification, which is endorsed by the World Society of Emergency Surgery. This classification describes stages of diverticulitis ranging from edematous bowel wall thickening and phlegmon in the adjacent mesentery to microperforation, localized or distant abscess formation, and generalized peritonitis with free fluid and air. Imaging findings are also pivotal in diagnosing and managing complications such as abscesses, pylephlebitis, fistulas, and gastrointestinal bleeding. Moreover, imaging can differentiate diverticulitis from infectious colitis, epiploic appendagitis, ischemic colitis, colorectal carcinoma, and inflammatory bowel disease. This review focuses on the radiological findings of diverticulitis. We specifically discuss CT imaging and emphasize its clinical manifestations, significant complications, and differential diagnosis.

Acute appendicitis is one of the most common reasons for presentation to the emergency department that requires an emergency appendectomy. Clinical presentation with abdominal pain in the left lower quadrant is very uncommon but can occur with a congenital left-sided appendix or right-sided long appendix. We report a rare case of a 65-year-old man with incidental finding of situs inversus totalis who presented with left lower quadrant abdominal pain. A CT scan of the abdomen confirmed the diagnosis of left-sided acute appendicitis, and the patient underwent laparoscopic appendectomy with an uneventful postoperative course.

A 49-year-old Caucasian female underwent a second kidney–pancreas transplant in May 2002 for end-stage diabetic nephropathy. Her postoperative course was complicated by intra-abdominal sepsis and the development of bilateral deep venous thrombosis (DVT). The patient was treated conservatively, with a 6-month course of oral anticoagulation. One month after discontinuation of oral anticoagulation, the patient noted a 7-day history of a painful and swollen left lower extremity. Three days prior to admission she noted paresthesia, pain and pallor of her left lower extremity. The next day she noticed left lower quadrant abdominal pain over her renal allograft associated with anuria. On the day of admission, initial creatinine at her referring physician’s office was 1.7mg/dl. Seven hours later, her creatinine had climbed to 4.7mg/dl with persistent anuria. On examination, her left leg was oedematous and swollen. Her renal allograft was tender to palpation in the left lower quadrant. Duplex examination revealed venous thrombosis arising in the post-tibial veins and extending to the iliac veins, an enlarged renal allograft (>1 cm in increase in length compared with previous ultrasound) and a patent renal artery with absence of diastolic flow consistent with venous outflow obstruction. The patient was systemically anticoagulated with unfractionated heparin. A decisionwasmade to attempt graft salvage by performing a venous thrombectomy. Via local cut down to the femoral vein, venography of the vena cava and the left common iliac veins was completed using <30 cc of half strength Visipaque contrast. This confirmed the extension of thrombus distal to the renal allograft venovenostomy and the absence of flow within the left iliac vein. A standard venous thrombectomy was performed via a common femoral vein venotomy. A Fogarty thromboembolectomy catheter (Edwards Lifesciences, Irvine, CA) and Esmarch compression were used proximally and distally, respectively, for thrombus removal. Repeat venography (30 cc of half strength Visipaque) demonstrated a widely patent left iliac vein with dye washout at the level of the renal allograft venostomy. Repeat duplex of the renal allograft on postoperative day 1 demonstrated normal arterial and venous flow to the transplanted kidney with appropriate diastolic flow. Her creatinine steadily declined to baseline (1.0mg/dl) postoperatively and she was discharged on postoperative day 5 with lifelong anticoagulation. At 6 months postoperative, her creatinine is normal (0.8 mg/dl) with venous duplex examination demonstrating absence of residual thrombus.

Teratoma is a type of extracranial germ cell tumor that often occurs and correlates with age and anatomical location. Mature Cystic Teratoma (MCT) is the most common ovarian tumor in children and adolescents. The most common sites for teratomas are the sacrococcygeal region and the ovaries. Laparoscopy is by far the surgical treatment of choice for teratomas. We report a case of a 9-year-old girl with a chief complaint of left lower quadrant abdominal pain 1 week before hospital admission. The patient appears weak and has decreased appetite, accompanied by weight loss, and painful urination. Physical examination of abdominal distension (+), tenderness, and release in the left lower quadrant (+). The patient had not menstruated, and a history of vaginal discharge was denied. On MSCT-scan examination of the abdomen with contrast, a cystic mass was found that adhered to and pushed the surrounding bowel structures in the lower abdominal region. On histopathological examination taken from the left ovary preparation, a macroscopic examination found cyst tissue of 9.5 x 6.5 x 5 cm. The cyst is gray-black, filled with blood and a white pulp mass with hair. On microscopic examination found cysts with fibrous connective tissue stroma containing vascular. The treatment is in the form of laparoscopy and after surgery, currently, the patient is in good condition and will be followed up again every 3 months.

Colon cancer is the fourth most common cancer in the United States, effecting more men than women. With the adoption of colonoscopy for colon cancer screening, the rates of incidence and mortality have been downtrending due to early detection. The common age range at diagnosis is 65-74 and the risk increases after age 50. Other risk factors include personal history and family history of colon cancer (especially before age 55). A 39 year old white male with type 2 diabetes presented to the hospital complaining of four days of yellow bilious emesis and left lower quadrant abdominal pain. The pain worsened over time to 9/10 on the pain scale, was colicky and radiated to his back. He denied fever, weight loss, change in stool quality or color, melena, hematochezia and hematemesis. He denied tobacco use, drug use and alcohol use. His mother had type 2 diabetes and his father died of an unknown cancer in his 50s. Vital signs were within normal limits. Physical exam was significant for tenderness to palpation in the left lower quadrant, negative for rebound or guarding and he had pale conjunctiva. Labs were significant for normocytic anemia. He was given Maalox and Pepcid and an abdominal/pelvic CT with contrast was done. It showed an inflamed and thickened colon wall at the splenic flexure with several large, necrotic lymph nodes adjacent to it. He was admitted and Gastroenterology was called. A barium enema showed obstruction of the retrograde flow of contrast in the splenic flexure. Colonoscopy showed a circumferential/obstructing mass in the descending colon 70cm from the anal verge. It was ulcerated, fungating and friable; they were unable to traverse the mass, but it was tattooed and biopsied. CEA level was 3.8ng/mL. CT chest with contrast showed no metastatic disease. Surgery performed a left hemicolectomy. The tumor was 6x6.5x2cm. Pathology showed poorly differentiated high grade adenocarcinoma with invasion of the pericolic adipose tissue and lymph/vascular invasion with two positive lymph nodes. He was started on FOLFOX chemotherapy and has had no recurrence for 5 months. This case highlights the importance of age and risk appropriate screening. Given the atypical presentation of colon cancer in a young patient, he is fortunate the CT abdomen/pelvis was obtained, which led to the rest of the workup. This also illustrates the importance of educating patients on knowing their own family history, which would have been of utmost importance in this case.Figure: CT Scan of Abdomen and Pelvis with Contrast showing inflamed and thickened colon wall at the splenic flexure with several large, necrotic lymph nodes adjacent to it.Figure: Barium enema showing obstruction of the retrograde flow of contrast in the splenic flexure.Figure: Colonoscopy showing a circumferential/obstructing mass in the descending colon 70cm from the anal verge.

Epiploic appendagitis (EA) is a rare cause of focal abdominal pain in otherwise healthy patients. It may mimic diverticulitis, appendicitis or mesenteric infarction on clinical manifestation. The diagnosis of EA is very infrequent due in part to low awareness by clinical physicians. The aim of this study was to review and describe the clinical presentation and computed tomography (CT) findings of EA. Twenty-one patients (6 women and 15 men, average age 40 years [range 27-65 years]) were diagnosed with EA by CT between January 2006 and October 2009. The patients' medical records were retrospectively reviewed with regard to their socioeconomic data, characteristics of abdominal pain, associated symptoms, laboratory results, radiological findings and treatment. Abdominal pain was the leading symptom. The pain was localized in the left lower quadrant (17 patients, 81.0%), left middle abdomen (2 patients, 9.5%) and right lower quadrant (2 patients, 9.5%), respectively. Leukocytosis (white blood cell > 10 × 10(9) /L) without left shift was found in 6 patients but all patients were afebrile. Characteristic CT findings of paracolonic oval hypodense fat tissue with thickened peritoneal ring and periappendageal fat stranding were all presented in 21 patients, but the central dot sign was presented in only 7 patients. They were all treated was conservative therapy. Epiploic appendagitis is the inflammatory response of an appendage to infarction or spontaneous venous thrombosis. A CT scan provides a definite diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention and antibiotics.

INTRODUCTION: Colonoscopy is used as a diagnostic and therapeutic tool to treat a wide range of gastrointestinal disorders. Acute diverticulitis after colonoscopy is a rare but potentially serious complication. The incidence of acute diverticulitis after colonoscopy is reported to be 0.084%. Since this is a rare entity, there is limited data regarding the risk, prevention and management of acute diverticulitis after colonoscopy. CASE DESCRIPTION/METHODS: A 50 year old woman with a history of adenomatous polyp with villous component detected 4 years prior presented for surveillance colonoscopy. She did not have any abdominal pain. Her labs from a year prior showed WBC 6.86 k/uL. Colonoscopy was notable for pan-colonic diverticulitis (Figure 1), most prominent in sigmoid colon. There was a 2 mm sessile polyp in recto-sigmoid colon that was removed with cold biopsy forceps. The procedure was otherwise uncomplicated. She presented to the emergency department (ED) 3 days later with left lower quadrant pain (LLQ) and fever up to 101 Fahrenheit. The pain started 2 days after she underwent colonoscopy. She did not have nausea, vomiting or rectal bleeding. In the ED, she was afebrile with moderate LLQ tenderness without rebound or guarding. Labs showed WBC 15.41 k/uL (72.5% segmented neutrophils), BUN 11 mg/dL, Cr 1.0 mg/dL. CT of the abdomen and pelvis had findings concerning for acute sigmoid colon diverticulitis without abscess (Figure 2). The patient was discharged from the ED on moxifloxacin and metronidazole. DISCUSSION: The American Society for Gastrointestinal Endoscopy (ASGE) lists diverticulitis as a miscellaneous complication, however, there is limited data regarding the risk of developing diverticulitis after colonoscopy. In a retrospective cohort of 236, 377 patients who underwent colonoscopy, 68 patients (0.029%) developed post-colonoscopy diverticulitis. The mean time to develop diverticulitis after colonoscopy was 12 ± 8 days. 34 patients (50%) had a history of diverticulitis prior to colonoscopy and 30 patients (44%) required hospitalization. Prospective studies are now needed to evaluate the risk, mechanism and prevention of colonoscopy induced diverticulitis. If significant diverticula are noted on colonoscopy, post-colonoscopy diverticulitis should be discussed as a potential complication, and it should be considered in a patient who presents with fever and abdominal pain after undergoing colonoscopy.

A 74-year-old man presented to the emergency department with lower back pain and left lower quadrant pain. His medical history included Parkinson’s disease and left inguinal hernia repair. He was...

Since Kambin experimentally induced arthroscopy to treat herniated nucleus pulposus, percutaneous endoscopic lumbar discectomy (PELD) has been developed. The branch of the segmental artery around the neural foramen may be damaged during PELD using the transforaminal approach. We report 2 rare cases in which segmental artery injury that occurred during PELD was treated with emergency embolization. In case 1, a 31-year-old man was transferred to our emergency department with left lower quadrant abdominal pain after PELD at a local hospital. Lumbar spine magnetic resonance imaging after the surgery showed a hematoma of the left retroperitoneal area and the psoas muscle area. Under suspicion of vascular injury, arteriography was performed. Pseudoaneurysm and blood leakage from the left 4th lumbar segmental artery into the abdominal cavity were identified. Emergency transarterial embolization was performed using fibered microcoils for bleeding of the segmental artery. In case 2, a 75-year-old woman was transferred to our emergency department with low blood pressure, right flank pain, and drowsy mental status after PELD at a local hospital. When the patient arrived at the emergency room, the blood pressure decreased from 107/55 mmHg to 72/47 mmHg. Low blood pressure persisted. Under suspicion of vessel injury, arteriography was performed, and the right 4th lumbar segmental artery rupture was confirmed. Emergency transarterial embolization was performed for bleeding of segmental artery. We were able to find the bleeding focus by angiography and treat the injury of the segmental artery successfully through emergency transarterial embolization.

Rupture of Ectopic Pelvic Dysplastic Kidney after Blunt Abdominal Trauma Presenting as Left Lower Quadrant Pain