The document discusses the differential diagnosis for acute left lower quadrant pain, highlighting common and less common causes, including diverticulitis, colon carcinoma, and gynecologic issues. It emphasizes the importance of imaging, specifically CECT, and provides detailed descriptions of conditions like epiploic appendagitis and pseudomembranous colitis. Additionally, the document covers less common causes such as ischemic colitis and abdominal abscess, offering clues for diagnosis.

1. ACUTE LEFT LOWER QUADRANT
PAlN
Hisham AlKhatib, M.D.
Consultant Radiologist

2. •‫اله‬ ‫وعلى‬ ‫هللا‬ ‫رسول‬ ‫على‬ ‫والسالم‬ ‫والصالة‬ ‫هلل‬ ‫الحمد‬
‫اجمعين‬ ‫م‬ّ‫ل‬‫وس‬ ‫وصحبه‬
•، ‫علما‬ ‫وزدني‬ ‫ينفعني‬ ‫بما‬ ‫وعلمني‬ ‫علمتني‬ ‫بما‬ ‫انفعني‬ ‫اللهم‬
‫الحكيم‬ ‫العليم‬ ‫انك‬
• 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.

3. DIFFERENTIAL DIAGNOSIS

4. Common Causes
• Diverticulitis
• Colon Carcinoma
• Epiploic Appendagitis
• Pseudomembranous Colitis
• Infectious Colitis
• Ulcerative Colitis

5. Common Causes
• Gynecologic Causes
– Adnexal Torsion
– Endometriosis
– Salpingitis
– Tubo-Ovarian Abscess
– Uterine Fibroids
• Urolithiasis
• Post-Operative State, Bowel

6. 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

7. 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

10. 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

13. 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

15. 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

18. 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

20. 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

24. Urolithiasis
• Distal left ureteral stone may cause left lower
quadrant pain
• Diagnosis usually evident on CT
– Ureteral calculus, hydronephrosis, perinephric
stranding

26. 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

27. Less Common Causes
• Ischemic Colitis
• Omental Infarct
• Uterine Fibroids
• Sclerosing Mesenteritis
• Crohn Disease
• Abdominal Abscess
• Sigmoid Volvulus
• Appendicitis
• Fecal Impaction

28. Less Common Causes
• Peritonitis
• Pyelonephritis
• Renal Cell Carcinoma
• Renal Infarction
• Coagulopathic ("Retroperitoneal")
Hemorrhage
• Spigelian Hernia
• Inguinal Hernia

29. Rare but Important
• Bladder Fistulas

30. Helpful Clues for Less Common
Diagnoses

31. 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

33. 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

35. 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

37. Abdominal Abscess
• Usually in post-operative patient, or following
appendicitis, diverticulitis

39. 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

41. Appendicitis
• Appendix may be very long or may arise from
a malrotated colon, lead to left-sided
symptoms

42. Fecal Impaction
• Common, but can lead to stercoral ulceration
with erosion through colonic wall

49. THANK YOU