MEDICINE

cme: The Differential Diagnosis of

Right Lower Quadrant Pain
Martin E. Kreis, Franz Edler v. Koch, Karl-Walter Jauch, Klaus Friese

SUMMARY
Introduction: There are numerous differential diagnoses for right lower quadrant pain, which
can present in a variety of ways. Methods: Selective literature review. Results/Discussion:
The most frequent differential diagnoses are acute appendicitis and diseases of the female
genital tract. However, a variety of rarer diseases involving several medical subspecialties
can also underlie this symptom. While acute appendicitis may be diagnosed relatively simply,
sophisticated diagnostic tests may be needed to identify other disorders, particularly
where the clinical presentation is atypical. Close interdisciplinary cooperation with other
specialties is of major importance for the optimal management of right sided lower
abdominal pain. Dtsch Arztebl 2007; 104(45): A 3114–21
Key words: acute abdomen, appendicitis, differential diagnosis, pelvic inflammatory disease,
right lower quadrant pain

A cute right lower quadrant pain is the most common type of acute abdomen (e1). This
symptom has many different causes, particularly in female patients; the most
common cause requiring surgery is acute appendicitis (e1, e2). The diagnostic assessment
of right lower quadrant pain presents a challenge, not just because of the variety of causes,
but also because the leading entities in the differential diagnosis are very different
depending on the patient's age and sex (1, 2, e3). Immune-suppressed patients with an acute
abdomen are often oligosymptomatic even when seriously ill (1, 3).
Patients with right lower quadrant pain often come to medical attention during off hours
and therefore require an efficient and goal-directed diagnostic assessment to receive the
proper treatment as soon as possible. The assessment must often be carried out at times
when the availability of ancillary testing is limited. The importance of speed should not be
underestimated: patients with a perforated hollow viscus, for example, can be seriously
endangered by delays in treatment (e4).
In this article, we will discuss the most important clinical entities causing right lower
quadrant pain, and we will propose an algorithm for its rapid and efficient diagnostic
assessment, taking into consideration the often limited access to ancillary testing. Previous
articles in this journal about the acute abdomen have dealt with the problem from a single
specialty's point of view (e5) and have considered the differential diagnosis of upper
abdominal pain (e6). Here, we consider the diagnostic assessment and management of right
lower quadrant pain. Treatment will not be discussed in detail. This article is based on a
selective review of published reports that were retrieved by a PubMed search on the following
terms: "acute abdomen," "appendicitis," "right-sided lower abdominal pain," "right lower
quadrant pain," and "pelvic inflammatory disease."

Chirurgische Klinik und Poliklinik, Klinikum Großhadern, München: PD Dr. med. Kreis, Prof. Dr. med. Dr. h. c. Jauch; Klinik und
Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum Großhadern, München: PD Dr. med. Edler von Koch, Prof. Dr. med. Friese

Right lower quadrant pain

Its diagnostic assessment presents a challenge
because the leading entities in the differential
diagnosis are different depending on the
patient's age and sex.

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History and physical examination: the key elements of case stratification

The history and physical examination are the key elements leading to the determination of
the diagnosis and of the further management of the patient (4, e7). The physician should
inquire in general about the onset, duration, nature, and intensity of the pain, as well as
about the following specific features:
> Defecation: has the patient noticed any abnormalities?
> Is the patient suffering from nausea, vomiting, or alguria/dysuria (painful or otherwise
abnormal micturition)?
In female patients, a gynecological history is obligatory and often points to the diagnosis.
In taking the history, the physician should always try to gain information of differential
diagnostic value in order to determine which further tests should be performed. The physical
examination serves the same purpose. The physician should inspect, auscult, and palpate
the abdomen, look for guarding and peritoneal signs, check the renal beds and potential hernia
sites, and perform a digital rectal examination. Female patients should have an intravaginal
examination as well, as a component of the acute gynecological consultation (e8).

Diagnostic testing as an adjunct to clinical examination

Testing with diagnostic apparatus should be performed only after the history and physical
examination have been completed. Its purpose is to confirm the diagnosis that seems most
likely among the possible differential diagnoses and to exclude all of the competing
diagnoses (box). If appendicitis is suspected, a blood draw for laboratory testing (e9, 5) and
an ultrasonographic examination of the abdomen are indicated (e10, 6). These tests can be
performed quickly and with negligible distress to the patient.
It should be borne in mind, however, that these tests are not very sensitive or specific.
Conditions affecting the female reproductive tract, such as adnexitis, symptomatic ovarian
cysts, or extrauterine pregnancy, are common causes of right lower quadrant pain; thus, a
properly performed gynecological examination is recommended, combined with an
endovaginal ultrasonographic examination, as long as it can be performed in an acceptably
short time frame (7, 8). If a woman with right lower quadrant pain is first seen by a
gynecologist and the cause of the trouble is not definitively found to be gynecological, then
a general surgeon should be consulted next.
The same procedure applies to patients who present with additional symptoms or findings
in the urological area, e.g., renal percussion tenderness, alguria/dysuria, or macrohematuria,
or in the orthopedic/neurological area, e.g., movement-related pain, radicular or pseudo-
radicular symptoms, and percussion tenderness of the spine.
The specialists that are consulted to evaluate symptoms of these types will then determine
the indication for further tests such as
> Extended urinalysis
> Voiding urography
> Plain x-rays of the pelvis and spine
> Spinal CT.
If there are right lower quadrant symptoms suggesting perforation (e.g., due to right-sided
diverticulitis) or ileus, then plain abdominal and chest x-rays should be obtained to determine
the possible presence of free intraperitoneal air or adynamic intestinal loops (figure 1).
Plain films of the abdomen should not be obtained routinely in the diagnostic assessment
of right lower quadrant pain. Unless these are ordered to answer a specific question, their
diagnostic value is limited (9, e11). If the initial diagnostic evaluation has not revealed any
definitive or suspected diagnosis, it would seem more reasonable either to observe the

History Systematic history-taking

In women with right lower quadrant pain,
a gynecological examination often leads
to the diagnosis.
If the patient has been examined by a
gynecologist and her symptoms do not
appear to be due to a gynecological
problem, a general surgeon should be
consulted.

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BOX

The most common causes of right lower

quadrant pain
> Surgery/Gastroenterology
– Acute appendicitis
– Gastroenteritis (bacterial/viral)
– Mesenteric lymphadenitis (Yersinia enterocolitica infection)
– Perforated or infected cecal pole diverticulum
– Sigmoid diverticulitis or perforation
– Crohn's disease, ulcerative colitis
– Carcinoma of the colon
– Ileus
– Meckel's diverticulum
> Gynecology
– Adnexitis/tubo-ovarian abscess
– Extrauterine pregnancy
– Torsion of an ovarian cyst
> Urology
– Cystitis/pyelonephritis
– Urolithiasis
– Tumors of the urinary tract
> Neurology/orthopedics
– Radicular/pseudoradicular symptoms of disc prolapse or protrusion
– Coxarthrosis
– Sacroileitis
– Herpes zoster

patient further and reassess at close intervals or to proceed right away to computerized
tomography, depending on the severity of the symptoms ([10, 11]; see also the diagnostic
algorithm shown in diagram 1).

Differential diagnosis: the typical causes of right lower quadrant pain

Up to this point, we have discussed the initial steps in the evaluation of all cases of right
lower quadrant pain. We will now describe its various typical and common causes, classified
according to the relevant medical specialties. It should be borne in mind that patients'
complaints are highly variable and often atypical. This factor complicates the diagnostic
process still further. Moreover, in each specialty area there are rarer causes of right lower
quadrant pain, not all of which can be listed here.

Surgery/gastroenterology
Appendicitis is probably the most common cause of right lower quadrant pain. The abdominal
pain is typically diffuse and poorly localizable at first, until it becomes concentrated in the
right lower quadrant (e9). Classic symptoms are nausea, vomiting, and cessation of defecation.

Plain abdominal x-ray Diagnostic assessment

Plain films of the abdomen should not be Appendicitis is the most common cause
obtained routinely in the diagnostic of right lower quadrant symptoms.
assessment of right lower quadrant pain.
Unless they are ordered to answer a specific
question, their diagnostic value is limited.

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Patients generally present to medical attention after having suffered abdominal pain for
1 or 2 days.
Examination usually discloses localized lower abdominal pain and peritoneal signs at
McBurney's or Lanz's point, including percussion tenderness, rebound pain, and local
guarding (diagram 2). Patients with appendicitis may also have the following:
> Blumberg's sign: contralateral rebound pain (e9, 5)
> The psoas sign: pain on lifting of the straightened right leg against resistance. This is a
classic finding of retrocecal appendicitis.
> Rovsing's sign: pain when manual pressure is applied to the ascending colon in a
retrograde direction.
Figure 1:
Plain abdominal x-ray of a 53-
year-old woman presenting with
an acute abdomen. The typical
findings of ileus are present:
adynamic loops of small bowel,
with fluid levels.

Fever may or may not be present. Studies have not confirmed the hypothesis that the
difference between the axillary and rectal temperatures is of diagnostic significance (12,
e12). The same holds for the digital rectal examination (e12, 13), though it is in any case an
integral part of a thorough physical examination of the abdomen.
Further information can be obtained by ultrasonography (concentric ring sign, free fluid)
and by laboratory testing (leukocytosis) (e10, 6, 12). Modern computerized tomography
enables appendicitis to be diagnosed with high sensitivity and specificity (11, 14, e13).
Nonetheless, because of its cost and the radiation exposure associated with it, the use of CT
as a routine investigation in all patients with acute right lower quadrant pain cannot be
justified. If the typical symptoms and signs of appendicitis are present, the correct diagnosis
can be established and a decision to operate can be made on clinical grounds alone.
The protean manifestations of appendicitis make it impossible to state universally
applicable rules about when to operate. In general, however, whenever appendicitis is
strongly suspected, the patient should be taken to surgery. The suspicion of appendicitis is
usually based on the clinical findings (local peritoneal signs and guarding) but can also be
derived from ancillary tests. To the best of the authors' knowledge, it is common practice in
most hospitals to rely more on the clinical findings than on ancillary tests in cases of doubt.
Appendicitis can usually be distinguished from bacterial or viral gastroenteritis on
clinical grounds (the latter is associated with recent consumption of possibly tainted food,
vomiting, diarrhea, absence of peritoneal signs and guarding, and hyperperistaltic bowel
sounds [12]). Chronic inflammatory bowel diseases such as Crohn's disease and ulcerative
colitis can produce symptoms and signs resembling those of acute gastroenteritis; these
entities should be suspected in patients with chronically recurring diarrhea, weight loss, a
history of perianal fistulae, and a prior appendectomy. Right lower quadrant pain is an

The three steps in the diagnostic Appendicitis

assessment of right lower If the clinical assessment reveals
quadrandt pain entirely typical findings of appendicitis,
> History the diagnosis and the indication for
> Physical examination surgery can be established on clinical
> Is appendicitis suspected? grounds alone.

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DIAGRAM 1

Algorithm for the differential diagnostic assessment of right lower quadrant pain
*1 Female patients with right lower quadrant pain should always consult a gynecologist if the gynecological
examination can be performed in an acceptably short time frame.

especially typical feature of terminal ileitis (e14). Gastroenteritis, Crohn's disease, and
ulcerative colitis generally do not produce peritoneal signs or guarding unless a perforation
has occurred. Often, these diseases can be distinguished from appendicitis by ultrasonography
or CT (e10, 6, e13). Colonoscopy may be used for the definitive diagnosis of chronic
inflammatory bowel disease but is not useful as an emergency diagnostic test because it
requires prior bowel preparation with appropriate rinsing solutions.
Further ancillary tests, such as plain x-ray of the abdomen with an emptied gastrointestinal
tract and computerized tomography, should be performed in atypical cases and when yet
other possible diagnoses are suspected (e13). In the surgical-gastroenterological area,
another possible cause of right lower quadrant pain is diverticulitis (e15), which is particularly
likely to arise in the right hemicolon in patients of Asian extraction (15). Even sigmoid
diverticulitis can present in the right lower quadrant if a large sigmoid loop is present.
Infection of a Meckel's diverticulum is a special type of diverticulitis that is only rarely
correctly diagnosed preoperatively (e16). Other diseases causing right lower quadrant pain
usually have further accompanying symptoms that can aid in the differential diagnosis.
Tumors of the right hemicolon, for example, usually cause right lower quadrant pain only

Further diagnostic testing

Right lower quadrant pain is a typical
manifestation of diseases affecting the terminal
ileum. A CT or plain film of the abdomen should
be obtained if the constellation of clinical
findings is atypical.

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The three pressure

DIAGRAM 2
points of Blumberg,
McBurney, and
Lanz.

after a long, chronic course; the affected patients may also complain of weight loss, altered
bowel habits, and blood in the stool. Some other conditions causing pain in the right lower
quadrant without peritoneal signs are:
> Mesenteric lymphadenitis due to infection with Yersinia enterocolitica (16)
> Inguinal hernia (palpable, pain often exacerbated by the Valsalva maneuver)
> Adhesion ileus (symptoms of ileus, lack of flatus or defecation)
> Adhesion-related pain, classically occurring in a patient who has previously had an
appendectomy (17).
If the clinical examination and ancillary tests do not provide a clear answer and the
abdominal symptoms and signs are so severe that the presence of a life-threatening condition
cannot be ruled out with certainty, diagnostic laparoscopy should be performed (e17).
Diagnostic laparoscopy can also be used instead of laparotomy when an acute disease
process in the abdomen has already been successfully diagnosed on the basis of the clinical
examination, laboratory tests, and imaging studies. Laparoscopy often enables immediate
treatment of the problem, e.g., by laparoscopic appendectomy. The known contraindications
to laparoscopy should be borne in mind, however, including a history of extensive abdominal
surgery (18).

Gynecology
Appendicitis is suspected and then not confirmed at surgery more often in women than in
men (14, e18). This fact indicates the major importance of gynecological conditions in the
differential diagnosis of appendicitis (7). Among the various types of infectious/inflammatory
change coming under the heading of "pelvic inflammatory disease" (PID), the most important
differential diagnoses of appendicitis are acute adnexitis/salpingitis, abscesses in the
adnexal region, and parametritis (e19). Like appendicitis, acute adnexitis often presents in
atypical fashion and can then be definitively diagnosed only by laparoscopy. It characteristically
arises in sexually active women, is often bilateral, and is sometimes accompanied by
abnormal vaginal bleeding or discharge.
In many cases, acute adnexitis arises in connection with the use of an intrauterine
contraceptive device (IUD or spiral) (19). Palpation generally yields no definitive findings.
Unless an abscess has formed, the oviducts are often not especially thickened and therefore

Diagnostic laparoscopy
Diagnostic laparoscopy can be performed
when the foregoing clinical, laboratory,
and imaging tests all point to an acute
intra-abdominal process.

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With permission from K. Jundt

Figure 2: Extrauterine pregnancy

usually not palpable. There may be lower abdominal guarding, pain on passive movement
of the cervix, and/or uterine tenderness to palpation. Laboratory testing only reveals elevated
inflammatory parameters. Vaginal ultrasound can reveal the diagnosis if the oviducts are
markedly distended by pus or blood (pyosalpinx or hematosalpinx) (e20). Another gynecological
disease that can cause acute right lower quadrant pain is ectopic pregnancy (figure 2). Its
manifestations include
> Secondary amenorrhea
> A positive pregnancy test
> Normal inflammatory parameters
> Abnormal vaginal bleeding.
Extrauterine pregnancy often becomes symptomatic when it perforates, causing a
potentially life-threatening intra-abdominal hemorrhage (e21). Patients may have a history
of bouts of adnexitis or a prior extrauterine pregnancy. The diagnosis can often be made
with endovaginal ultrasonography (20). An adnexal mass is seen; sometimes the fetal
heartbeat can be seen as well. The uterine cavity is usually empty even though the endometrium
is greatly thickened. The "pseudogestational sac" that is sometimes found in the uterine
cavity by ultrasonography makes an intrauterine pregnancy more difficult to rule out.
Extrauterine pregnancies are often found in the oviducts but can also be located in an ovary
or in the peritoneal cavity. Torsion of an ovarian tumor or cyst, or cyst rupture, can also
cause acute right lower quadrant pain. In cases of torsion, ultrasonography usually reveals
a fairly large ovarian cyst (> 5 cm). In many cases, Doppler ultrasonography reveals
diminished or absent blood flow in the affected ovary (21). This entity causes very severe
pain that generally arises quite suddenly, e.g., in connection with intense physical activity
such as sport or dancing.
In premenopausal women, ovulation itself can sometimes cause acute lower abdominal
pain, even if the menstrual cycles are regular. A carefully obtained history (last menstrual
period, previous episodes of mid-cycle pain) can yield important diagnostic clues (2).
Whenever the clinical findings lead to no clear diagnosis, and particularly in young women
who may be suffering either from appendicitis or from adnexitis, laparoscopy is a good
option (e19) that should be considered if the patient wishes to avoid the radiation exposure
associated with CT.

Urological causes
Lower abdominal pain can also be due
to urological causes such as macro-
or microhematuria, renal tenderness,
and dys- or alguria.

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Urology
Right lower quadrant pain is rarely the major clinical finding of an acute urological illness,
but it can nevertheless be the presenting symptom of pyelonephritis, urinary colic, cystitis,
or a tumor of the urinary tract. In all of these cases, it is usually accompanied by other
symptoms or signs pointing to the urological origin of the problem (22), including macro-
or microhematuria, renal percussion tenderness, and dys- or alguria. Obstructions to the
flow of urine can often be seen when ultrasonography is performed as part of the emergency
diagnostic evaluation. If any of the above manifestations are present in a patient with acute
right lower quadrant pain, urological consultation should be obtained. If the urologist also
suspects a urological condition, contrast-enhanced CT or micturition urography can be
performed to complete the diagnostic evaluation (e22).

Orthopedics/neurology
Orthopedic and neurological conditions, like urological conditions, generally do not cause
isolated right lower quadrant pain; rather, the pain is typically accompanied by other symptoms
and signs. Leukocytosis is absent, and abdominal ultrasonography is unremarkable. The
pain is classically associated with movement and can be deliberately manually provoked at
its site of origin (e8) when it is due to conditions such as
> Coxarthrosis
> Sacroileitis
> Intervertebral disc prolapse
> Lumbago.
The absence of fever and laboratory changes indicating inflammation is a further criterion
by which these processes can be distinguished from an acute infectious/inflammatory
disease in the abdomen.

Rare causes of right lower quadrant pain

There are a large number of rarer causes of right lower quadrant pain, including common
iliac artery aneurysm (23), infarction of the cecal pole (24), cecal volvulus (25), and
intussusception (19). These entities can usually be recognized by CT or by laparoscopy.
Abdominal pain is only rarely caused by a systemic metabolic disease or temporary
metabolic derangement. Diabetic ketoacidosis is easily distinguished from an infectious or
inflammatory process in the abdomen by the history and by simple laboratory tests. Acute
intermittent porphyria is exceedingly rare and often hard to diagnose because its abdominal
manifestations are combined with mental changes and variable neurological manifestations.
A change of the color of the urine to dark red on exposure to light is the classic diagnostic
criterion. Even if the patient is known to suffer from a systemic metabolic disease, this
disease is not necessarily the cause of the abdominal pain, because an intra-abdominal cause
may be present as well. Thus, the treating physician should always take care to exclude
other causes. Further systemic diseases that can mimic a local abdominal disturbance
include heavy metal poisoning (lead, thallium, arsenic) and familial hyperlipoproteinemias
with hypertriglyceridemia. When poisoning is suspected, the physician should attempt to
determine the nature of the exposure; in lipid metabolic disorders, further manifestations of
the disease should be sought, e.g., xanthomatoses or lipemic retinitis (e23).

Overview
Right lower quadrant pain can be due to a large variety of diseases whose causes must be
diagnosed and treated by physicians from a number of different specialties. If the clinical

Rare causes
Abdominal pain is only rarely due to
a metabolic disturbance or systemic
metabolic disease.

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manifestations are sufficiently typical, extensive ancillary diagnostic testing can often be
dispensed with. If the findings are unclear, however, modern radiological studies should be
performed as soon as possible, as these will make an important contribution to the diagnostic
process. When the cause of acute right lower quadrant pain is not immediately evident, a
rapid and interdisciplinary evaluation is essential, because delays in treatment lead to
excess morbidity and mortality.

Conflict of Interest Statement

The authors state that they have no conflict of interest as defined by the guidelines of the International Committee of Medical
Journal Editors.

Manuscript received on 23 February 2007; final version accepted on 4 September 2007.

Translated from the original German by Ethan Taub, M.D.

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Corresponding author
PD Dr. med. Martin E. Kreis
Ludwig-Maximilians Universität München
Chirurgische Klinik Großhadern
Marchioninistr. 15
81377 München, Germany
martin.kreis@med.uni-muenchen.de

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Wojtecki L, Südmeyer M, Schnitzler A: Current Treatment of Parkinson’s Disease: 1/d, 2/b, 3/b, 4/c, 5/a,
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MEDICINE

Please answer the following questions to participate in our certified

Continuing Medical Education program. Only one answer is possible
per question. Please select the answer that is most appropriate.

Question 1
Which of the following statements is correct?
(a) Right lower quadrant pain is rare in patients presenting with abdominal symptoms.
(b) Nausea and vomiting are atypical manifestations of appendicitis.
(c) The absence of leukocytosis rules out appendicitis.
(d) When the appendix is retrocecal, appendicitis usually causes a positive psoas sign.
(e) Rebound tenderness in the left lower quadrant is not consistent with appendicitis.

Question 2
Which of the following statements is correct?
(a) Lanz's point is defined as the pressure point located 2 handbreadths above the navel.
(b) Blumberg's sign is elicited by retrograde pressing on the colon.
(c) Rovsing's sign of the left hemicolon is positive when there is contralateral rebound tenderness.
(d) In acute appendicitis, tenderness and peritoneal signs are typically found at McBurney's point.
(e) Appendicitis is always heralded by severe constipation.

Question 3
In which of the following conditions are peritoneal signs usually found in the right lower
quadrant?
(a) Inguinal hernia
(b) Adhesion-related ileus
(c) Acute appendicitis
(d) Mesenteric lymphadenitis
(e) Adhesions after appendectomy

Question 4
Which of the following statements about ruptured tubal pregnancy is correct?
(a) The accompanying acute hemorrhage is often life-threatening.
(b) It occurs so early in pregnancy that a pregnancy test is usually negative.
(c) The pain is always only on the right side.
(d) This disorder cannot be diagnosed by vaginal ultrasonography, because the oviducts are too far
away from the head of the ultrasound device.
(e) If this diagnosis is suspected, initial conservative management is a viable option.

Question No. 5
Acute adnexitis
(a) occurs only in sexually inactive women.
(b) is always found bilaterally in the lower abdomen.
(c) often causes pain on passive movement of the cervix.
(d) is an important element of the differential diagnosis of appendicitis in men.
(e) is usually accompanied by extreme weight loss.

Question 6
Which of the following suggests that an attack of right lower quadrant pain is due to
Crohn's disease?
(a) Constipation
(b) Weight gain
(c) A history of perianal fistulae or abscesses
(d) Increased hunger
(e) Guarding in the right lower quadrant

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MEDICINE

Question 7
Gastroenteritis is characterized by:
(a) Abdominal symptoms limited to the right lower quadrant
(b) Constipation
(c) Diffuse peritoneal signs
(d) Hyperperistaltic bowel sounds
(e) No generalized sense of feeling unwell

Question 8
Urological diseases that cause right lower quadrant pain can also cause
(a) Dysuria/alguria
(b) Macro- or microhematuria
(c) Renal percussion tenderness
(d) Urinary obstruction that can be seen by ultrasonography
(e) All of the above

Question 9
Orthopedic/neurological diseases causing right lower quadrant symptoms are
characterized by
(a) Movement-related pain
(b) High fever
(c) Reproducibility of the pain with manual maneuvers
(d) Leukocytosis
(e) Abnormal abdominal ultrasonography

Question 10
Which of the following statements is correct?
Right lower quadrant pain due to systemic metabolic diseases or transient metabolic derangements
(a) is common.
(b) always occurs after the patient touches heavy metals.
(c) can arise in diabetic ketoacidosis.
(d) is never accompanied by neurological manifestations when the cause is acute intermittent
porphyria.
(e) may arise through an allergic reaction.

CASE ILLUSTRATION: SEE NEXT PAGE

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MEDICINE

Case Illustration
The Differential Diagnosis of Right Lower Quadrant Pain

O ne morning after breakfast, this 24-year-old college German major felt

mildly nauseated and unwell. At first she thought this was the effect of the
previous day's lunch in the student cafeteria. By afternoon, she also had a diffuse
abdominal ache, which she interpreted as an ordinary upset stomach.
After the afternoon's lectures, she went to her general practitioner, who found
tenderness to palpation in the epigastrium and in the right lower quadrant. To be on
the safe side, he advised her to be examined in the university surgical clinic, because
he could not rule out an incipient appendicitis. She considered this excessive and
could not imagine at that point that she might need surgery. Later that night, however,
her pain worsened, and she vomited some bilious material. She was now sufficiently
worried to present to the surgical clinic and undergo an examination.
When she was seen in the surgical outpatient department, the pain was already
clearly localized to the right lower quadrant. Her nausea persisted, and she had not
had a bowel movement all day. The examining physician documented the presence
of local peritoneal signs, contralateral rebound tenderness, and a body temperature
of 37.5°C. The bowel sounds were hypoactive.
Laboratory tests disclosed a mild leukocytosis, and abdominal ultrasonography
showed a concentric ring sign in the right lower quadrant.
A gynecological consultation was obtained. No abnormalities were found by
palpation or by endovaginal ultrasonography, but adnexitis could not be ruled out
with certainty. Because of the local peritoneal signs and the difficulty of determining
whether the symptoms were due to appendicitis or to a problem in the reproductive
tract, the general surgeon on call recommended a diagnostic laparoscopy. At
laparoscopy, phlegmonous appendicitis was found, and a laparoscopic appendectomy
was performed. There were no further complications. The patient was discharged
from the hospital two days later.

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