Chronic Right Lower Quadrant Pain Research Articles

Role of elective laparoscopic appendicectomy in chronic right lower quadrant pain: a prospective and interventional study

Background: Chronic pain occurring in the Right Lower Quadrant (RLQ) region is a common clinical entity and has many differential diagnoses. Chronic/Recurrent appendicitis is an important cause. We evaluate here whether undiagnosed chronic RLQ pain can be relieved after elective laparoscopic appendectomy. Methods: 30 patients, 5-65 years of age, with undiagnosed chronic RLQ pain underwent laparoscopic appendectomy between 2012 and 2014. Inclusion criteria was pain of more than 3 months’ duration. Exclusion criteria was patients who had previously been treated conservatively for appendicitis or appendicular lump, previous abdominal surgery, diagnosed cases of specific urological, gynecological or gastrointestinal diseases. Patients were followed up for 6 months and their pain was graded in the following manner - grade 1 (pain worse than before), grade 2 (pain decreased, but not completely gone) and grade 3 (completely pain free). The histopathology of the appendices was also compared with the grades of pain. Results: Out of 30 patients, 26 were completely pain free at the end of 6 months. 4 patients had a pain grading of 2. Most of the patients had appendicular adhesions. There was 1 patient who had disseminated abdominal tuberculosis. Other intra-operative findings were ascites, free fluid in cul-de-sac, mesenteric lymphadenopathy and intussusception. There was no significant co-relation between pain relief and histopathology of the appendix. Conclusions: Laparoscopy is an invaluable tool in diagnosing other conditions existing concurrently. There is no correlation between the relief of chronic right lower quadrant pain and histopathology of the appendix. Chronic right lower quadrant pain is relieved by performing laparoscopic appendicectomy.

Acute on Chronic Appendicitis

Purpose: Introduction: Chronic appendicitis is characterized by the pathologic findings of chronic inflammation or fibrosis of the appendix. Clinically, the patients have prolonged right lower quadrant pain with relief of symptoms following appendectomy. We herein present a case of chronic appendicitis that posed a significant diagnostic challenge. Case Presentation: A 60-year-old male with a history of DM/HTN/alcoholic liver cirrhosis presented with diffuse abdominal pain for 3 days. The pain was associated with nausea, vomiting, and subjective fever. He also noticed worsening distended abdomen since the onset of abdominal pain. He admits chronic constipation and right lower quadrant (RLQ) pain for several years which were thought to be attributed to diverticulosis demonstrated by colonoscopy. His vital signs were T 101.3 F, HR 110/min, RR 20/min, BP 145/97 mmHg, SpO2 97% on room air. In general, he was alert and oriented but in distress due to abdominal pain. His conjunctivae were icteric. His abdomen was distended, bowel sounds were diminished, but there was no tenderness. There was trace edema in his lower extremities. His labs revealed WBC 1400/μl, band 41.0%, HGB 14.9 g/dl, PLT 102 K/μl, Na 136 mEq/l, K 4.4 mEq/l, Cl 103 mEq/l, CO2 24 mmol/l, BUN 14.0 mg/dl, Cr 1.4 mg/dl, T-Bil 2.3 mg/dl, D-Bil 1.7 mg/dl, ALP 397 U/l, AST 54 U/l, ALT 33 U/l, Amy 41 U/l, Lipase 22 U/l, TP 6.1 mg/dl, Alb 2.1 mg/dl, PT-INR 1.7, PTT 36.7 sec. Abdominal/pelvic CT showed partial small bowel obstruction, macronodular liver, perihepatic ascites, and splenic varices. Appendix was not visualized. Emergent exploratory laparotomy revealed ruptured appendix surrounded by adhesions. Histologically, there was significant fibrosis of the appendiceal wall as well as periappendicitis and periappendiceal abscess. These findings demonstrated acute infection superimposed on chronic inflammatory process. The patient fully recovered after appendectomy. Discussion: RLQ pain is one of the most common complaints and differential diagnoses are broad. In this case, chronic RLQ pain was probably due to chronic appendicitis confirmed by pathology. The clinical manifestations and histopathological findings of chronic appendicitis are different from those of acute appendicitis. They are characterized by symptoms lasting longer than 4 weeks, confirmation of chronic inflammation through histopathological examination, improvement of symptoms after appendectomy. The imaging studies might show appendicolith but appendices are not always visualized, which poses a significant diagnostic challenge. Therefore, it is prudent to consider chronic appendicitis as a differential diagnosis when approaching to chronic RLQ pain.