Left Lower Quadrant Pain Research Articles

Primary epiploic appendagitis: reconciling CT and clinical challenges.

Our aim was to explain the spectrum of clinical and CT findings in 18 patients with acute epiploic appendagitis. We reviewed the clinical records and CT pictures of 18 consecutive patients seen in Nejran Armed Forces Hospital, Nejran, Kingdom of Saudi Arabia and Sohag University Hospital, Sohag, Egypt between July 2006 and June 2013 with a diagnosis of primary epiploic appendagitis. The age ranged between 22 and 64 years old with a mean of 44.3. Males were affected in 72 % of cases. Eleven patients had acute pain in left lower quadrant. Nausea and vomiting were encountered in four patients. No fever was recorded in all cases. Leukocytosis was found in four patients and C-reactive protein (CRP) was high in five. CT scan diagnosed primary epiploic appendagitis (PEA) in 15 patients, while 3 patients were diagnosed intraoperatively. The left colon was affected in 11 patients. All patients except one had a central fatty core surrounded by inflammation with size ranging between 1.5 and 3.5 cm in length. Fifteen patients were treated conservatively, and three cases underwent surgical exploration. Ten patients (55.5 %) completed the follow up schedule. Complete resolution was noted in three patients at 2 weeks, in six patients at 3 months, and only one patient had residual changes at 6 months. PEA is a challenging clinical diagnosis, and CT scan is extremely necessary in diagnosing this disease accurately. The awareness of the surgeons concerning this rare occasion will avoid unnecessary hospital admission and operative treatment.

A Case of an Infrarenal Mycotic Abdominal Aortic Aneurysm Caused by Bartonella henselae

Bartonella spp. is a highly unusual cause of mycotic aneurysms. We describe the first case of an infected aortic aneurysm secondary to Bartonella henselae endocarditis in an immunocompromised patient. A 72-year-old woman presented with severe left lower quadrant pain. Computed tomography angiography showed an infrarenal mycotic aneurysm, and transoesophageal echocardiogram revealed aortic valve vegetation. Serology confirmed the presence of B. henselae endocarditis. Given the patient's comorbidities, the aneurysm was successfully treated by endovascular repair and antibiotic therapy. Endovascular stent-grafting is an alternative treatment option for mycotic aneurysms in high-risk patients who are unsuitable for open repair.

A Case of an Infrarenal Mycotic Abdominal Aortic Aneurysm Caused by Bartonella henselae

Introduction: Bartonella spp. is a highly unusual cause of mycotic aneurysms. We describe the first case of an infected aortic aneurysm secondary to Bartonella henselae endocarditis in an immunocompromised patient. Report: A 72-year-old woman presented with severe left lower quadrant pain. Computed tomography angiography showed an infrarenal mycotic aneurysm, and transoesophageal echocardiogram revealed aortic valve vegetation. Serology confirmed the presence of B. henselae endocarditis. Given the patient's comorbidities, the aneurysm was successfully treated by endovascular repair and antibiotic therapy. Discussion: Endovascular stent-grafting is an alternative treatment option for mycotic aneurysms in high-risk patients who are unsuitable for open repair. A Case of an Infrarenal Mycotic Abdominal Aortic Aneurysm Caused by Bartonella henselaeEJVES ExtraVol. 27Issue 5PreviewBartonella spp. is a highly unusual cause of mycotic aneurysms. We describe the first case of an infected aortic aneurysm secondary to Bartonella henselae endocarditis in an immunocompromised patient. Full-Text PDF Open Access

171 Fecal Calprotectin in Predicting Recurrence After Attack of Colonic Diverticulitis

Backgorund: Colonic diverticulitis shows a high recurrence rate, but the role of fecal markers in predicting recurrence is unknown. The aim of this study was to investigate the role of fecal calprotectin (FC) in predicting recurrence of diverticulitis. Materials and methods: A prospective cohort study was performed on 54 patients suffering from Acute Uncomplicated Diverticulitis (AUD). After remission, patients underwent to clinical follow-up every 2 months. During the follow-up, C-reactive protein (CRP) and FC was analysed at each medical control visit starting 2 weeks after the end of the antibiotic therapy. Recurrence of diverticulitis was defined as return to our observation due to left lower quadrant pain with or without other symptoms (e.g. fever), associated with leucocytosis and/or increased CRP, and confirmed by means of CT. Results: The mean follow-up was 20 months (range 12-24 months). Fortyeight patients were available for the final evaluation, and 6 patients were lost to follow-up. During the follow-up, increased FC was detected in 17 (35.4%) patients. Diverticulitis recurred in 8 (16.7%) patients: 7 (87.5%) patients showed increased FC during the followup, and only 1 (12.5%) patient with recurrent diverticulitis didn't show increased FC. FC sensitivity, specificity, positive predictive value and negative predictive value were 87.5%, 75.0%, 41.2%, and 96.8%, respectively. Only higher FC values (>60 μg/g) correlated with CRP levels (rho=0.351, 95%CI 0.163 to 0.5267; p=0.001). Finally, extension of diverticulosis showed correlation with FC expression (rho=0.632, 95% CI 0.515 to 0.791; p=0.000). Conclusions: Increased FC was found to be predictive of diverticulitis recurrence. Accuracy of fecal calprotectin (FC) test for the diagnosis of recurrent diverticulitis.

173 The Fecal Microbiome in Diverticulitis and Uncomplicated Diverticulosis

Backgorund: Colonic diverticulitis shows a high recurrence rate, but the role of fecal markers in predicting recurrence is unknown. The aim of this study was to investigate the role of fecal calprotectin (FC) in predicting recurrence of diverticulitis. Materials and methods: A prospective cohort study was performed on 54 patients suffering from Acute Uncomplicated Diverticulitis (AUD). After remission, patients underwent to clinical follow-up every 2 months. During the follow-up, C-reactive protein (CRP) and FC was analysed at each medical control visit starting 2 weeks after the end of the antibiotic therapy. Recurrence of diverticulitis was defined as return to our observation due to left lower quadrant pain with or without other symptoms (e.g. fever), associated with leucocytosis and/or increased CRP, and confirmed by means of CT. Results: The mean follow-up was 20 months (range 12-24 months). Fortyeight patients were available for the final evaluation, and 6 patients were lost to follow-up. During the follow-up, increased FC was detected in 17 (35.4%) patients. Diverticulitis recurred in 8 (16.7%) patients: 7 (87.5%) patients showed increased FC during the followup, and only 1 (12.5%) patient with recurrent diverticulitis didn't show increased FC. FC sensitivity, specificity, positive predictive value and negative predictive value were 87.5%, 75.0%, 41.2%, and 96.8%, respectively. Only higher FC values (>60 μg/g) correlated with CRP levels (rho=0.351, 95%CI 0.163 to 0.5267; p=0.001). Finally, extension of diverticulosis showed correlation with FC expression (rho=0.632, 95% CI 0.515 to 0.791; p=0.000). Conclusions: Increased FC was found to be predictive of diverticulitis recurrence. Accuracy of fecal calprotectin (FC) test for the diagnosis of recurrent diverticulitis.

Acute urticaria as a side effect of the Mirena® (levonorgestrel-releasing intrauterine system): a case report

BackgroundThe levonorgestrel intrauterine system, Mirena®, is widely used for contraception and the treatment of idiopathic menorrhagia. Here, we reported one case of acute urticaria following Mirena® implantation to increase the awareness of possible adverse side effects associated with Mirena®.Case presentationThe case presented is a 27-year-old Chinese woman who received Mirena® implantation for her adenomyosis and menorrhagia. The operation was successful and the patient did not experience any discomfort during the operation. However, she developed acute urticaria on her entire body accompanied with pruritic, slight left lower quadrant pain, and slight dizziness two hours after the operation. The patient was recommended to have the Mirena® removed immediately, and she took 10 mg oral methylprednisolone and 5 mg desloratadine tablet daily for five days. Her urticaria resolved and did not recur.ConclusionThe patient’s acute urticaria seems to have been associated with the Mirena® levonorgestrel intrauterine system implantation, since she had no history of allergic reactions to materials used during the operation such as plastic, metal, alcohol, medications, and povidone-iodine.

Extragenital müllerian adenosarcoma in the pouch of douglas.

Extragenital Müllerian adenosarcomas are extremely rare tumours characterised by a stromal component of low-grade malignancy and by a benign glandular epithelial component. A 26-year-old woman was admitted to our clinic because of lower abdominal distension and left lower quadrant pain. Clinical and radiological examinations suggested an ovarian malignancy. Laparotomy revealed a cystic mass in the pouch of Douglas, originating from the left sacrouterine ligament. A total excision of the tumour was performed and showed low-grade adenosarcoma without sarcomatous overgrowth. Follow-up at 24 months after the surgery showed no evidence of recurrence. Mullerian adenosarcoma located in the pouch of Douglas is rare. For treatment, success may be achieved with only excision of the tumour if there is no sarcomatous overgrowth or spread to adjacent tissues.

Intra-abdominal Dalkon Shield IUD: Lost for Over 30 Years

A 64-year-old woman with a long history of intermittent left lower quadrant pain and ovarian cysts came for consultation. A computed tomography scan ordered by her referring physician revealed a retained Dalkon Shield intrauterine device (IUD) in the left mid-abdomen (Fig. 1 and Fig. 2). A 1.5 × 1.5 × 1.3-cm complex left ovarian cyst was also observed. The patient reported having a Dalkon Shield inserted greater than 30 years previously but presumed it had been expelled shortly after insertion. She underwent an uneventful laparoscopic removal of the Dalkon Shield, found embedded in the transverse colonic omentum, as well as a laparoscopic left-sided salpingo-oophorectomy.

Differential diagnosis in left lower quadrant pain: Acute appendicitis in patients with situs inversus

Karin agrisi acil servise basvurularda en sik gorulen sikayetlerden biridir. Abdominal agri ile basvuran hastalarda gorulen en sik cerrahi gerektiren hastalik apandisittir. Sol alt kadran agrisi ile basvuran hastalarda ayirici tanida akut apandisit ilk planda akla gelmemektedir. Bu durumun olusmasinda yetersiz muayene ve eksik anamnez alinmasinin yanlis negatif tani oranini yukselttigi kabul edilmektedir. Solda yerlesimli apandisit situs inversus totalis veya karin ici organlarin malrotasyonu ile birlikte gorulur. Sunumda sol tarafli akut apandisit tanisi almis bir situs inversus totalis olgusu degerlendirilecektir.

Nephrolithiasis in “Back-to-back” Kidneys

A 57-year-old woman presented with a 1-week history of left lower quadrant pain and nausea and vomiting. Computed tomography without contrast demonstrated a left 2.3-cm calculus at the ureteropelvic junction and a 6-mm lower pole calculus. The kidneys were in the pelvis and oriented "back-to-back," with the lateral portions of the kidneys fused in the midline. To our knowledge, this is the first description of this renal fusion anomaly. The patient underwent robotic pyelolithotomy of the ureteropelvic junction calculus and subsequent flexible ureteroscopic laser lithotripsy of the lower pole calculus and ureteral stent placement through the assistant working port.

Robotic Removal of an Ovarian Remnant for Chronic Pelvic Pain

Ovarian remnant syndrome is a rare condition in which functional ovarian tissue presents as a pelvic mass and/or pelvic pain after prior intended removal of one of both ovaries with or without hysterectomy. An ovarian remnant presents as not only a diagnostic challenge, but a surgical one as well. We present a case of a patient with chronic left lower quadrant pain after a C-hysterectomy and left salpingo-oophorectomy who was found to have a 3 x 2 x 4 cm residual ovarian tissue anterior to the psoas muscle.

Urolithiasis in adults with congenital megaureter

The primary presentation of congenital megaureter in adults is rare. Development of urolithiasis may lead to this unusual underlying diagnosis. Urinary tract stones can form either within the dilated ureteral segment or in a part of the upper urinary tract proximal to the abnormal ureteral segment. We report two cases of nephrolithiasis that occurred in adults found to have segmental megaureter. The first case is that of a 58-year-old man who presented with left lower quadrant pain. Computed tomography scan revealed a 2-cm stone in the distal left ureter within an area of isolated segmental distal ureteral dilation. The second case is a 48-year-old man who developed recurrent renal urolithiasis associated with isolated distal megaureter.Although a rare condition in adults, congenital megaureter may present when kidney stones develop as a result of the ureteral abnormality. Typically, stones will develop within the dilated segment of ureter. Atypically, stones may develop away from the site of the underlying abnormality. Congenital megaureter is a diagnosis that urologists and radiologists need to consider in the setting of isolated distal ureteral dilation, as the diagnosis of adult megaureter may require more involved surgical measures to prevent recurrence of adverse symptoms.

Classic signs of closed loop bowel obstruction

A 75-year-old man presented to this hospital with abdominal pain. The patient described the sudden onset of: left lower quadrant pain nine-out-of-ten in severity, associated with multiple episodes of bilious vomiting. The patient had not had a bowel movement in 4 days. Physical examination was notable for tenderness to palpation and guarding in the left lower quadrant. Computed tomography of the abdomen and pelvis without contrast material was completed, and demonstrated a closed-loop bowel obstruction involving an ileal loop (Figs. 1, 2). The patient underwent an exploratory laparotomy, which confirmed an ischemic closed-loop obstruction. A small bowel resection was performed (Fig. 3), and the patient recovered uneventfully.

Bilateral Inguinal Hernia with Uncommon Content

Ataturk University, Erzurum, Turkey Correspondence: Dr Hayri Ogul, Ataturk University, Erzurum 25240, Turkey. Telephone 90-442-2316751, e-mail drhogul@gmail.com Received for publication September 16, 2012. Accepted September 20, 2012 Case presentation A 56-year-old man was admitted to hospital with recurrent vomiting, left lower quadrant pain and bulges in both the left and right groin. The axial computed tomography (CT) scan (Figure 1) and threedimensional volume-rendering images (Figure 2) showed the antrum descended in the left inguinal canal together with a large amount of omental fat and small intestine, and herniation of the bladder toward the right inguinal canals.

Toothpick Perforation of the Intestines Presenting as Recurrent Abdominal Pain: Possible Roles of Abdominal Ultrasound and MRI

We report the case of a middle-aged man admitted for five months of unexplained left lower quadrant pain. He had been hospitalized on two prior occasions and treated with broad spectrum antibiotics. His clinical presentation was suggestive peritoneal irritation with severe, focal pain on abdominal palpation. Computed tomography scans showed non-specific inflammation in the left lower abdomen with adjacent small bowel wall thickening. Upper endoscopy and colonoscopy were unremarkable on prior admission. Given the severity and focality of the patient’s recurrent abdominal pain he underwent laparoscopy and was found to have a wooden toothpick perforation of the small bowel thirty centimeters from the ileocecal valve requiring partial small bowel resection. The patient did well post-operatively. On retrospective questioning he may have eaten a cabbage roll or bacon wrapped shrimp pierced with a toothpick weeks before the onset of symptoms. Toothpick perforation should be a consideration in edentulous persons with focal, severe abdominal pain and trans-abdominal ultrasound or MRI may be a better choice for detecting wooden foreign objects.

Intestinal Ischaemia Associated with Carcinoid Tumor: A Case Report with Review of the Pathogenesis

Carcinoid tumors are rare, slow-growing neuroendocrine neoplasms that are often indolent and may not become clinically apparent until there is a metastatic spread or evidence of carcinoid syndrome. A 44-year-old man presented to our clinic department with a history of previous left colon cancer operation, chronic crampy left lower quadrant pain, mass and severe anemia. A MR scan was obtained which demonstrated a calcified mesenteric mass 12×8×10 cm diameter with surrounding left colon mesenteric infiltration. The liver was normal. A case of ischaemic ileal necrosis is reported. It was associated with elastic vascular sclerosis produced by mesenteric metastases of an ileal carcinoid tumor. It is postulated that intestinal ischaemia may be of more importance in the production of abdominal pain by carcinoid tumors than has been generally accepted, and that it is the result of functional and structural changes in and around the mesenteric blood vessels, caused by substances secreted by the carcinoid tumor.

Unusual Source of Thromboembolism in a Patient with Atrial Fibrillation: Pulmonary Vein Thrombus due to Compressive Para‐Esophageal Hernia

A 68-year-old male presented to the arrhythmia clinic for evaluation of symptomatic episodes of atrial fibrillation (AF) and typical atrial flutter. Episodes of palpitations were brief and were associated with shortness of breath. He had symptoms suggestive of amarousis fugax that resolved spontaneously one week prior to presentation. His past medical history included hypertension, hyperlipidemia, gastro-esophageal reflux disease and left inguinal hernia repair. As he was complaining of left lower quadrant pain a 64-slice contrast enhanced CT scan of the chest and abdomen was obtained. A large para-esophageal hernia (type III) was noted in the thoracic cavity (Figure 1A,B) compressing the blood vessels of the left lower lobe. Wedge shaped renal infarcts were noted in the right kidney (Figure 1C). A filling defect suggestive of thrombus was found in the left inferior pulmonary vein (Figure 1D). He was started on oral anticoagulation with Warfarin. Transthoracic echocardiogram suggested normal left ventricular function, normal left atrial size and an echo density near the pulmonary veins. Work up for thrombophilia turned out to be negative for inherited hypercoagulable disorders.

Pulmonary Vein Thrombosis Associated with a Large Hiatal Hernia

BackgroundPulmonary vein thrombosis is a rare and potentially life-threatening condition. Reported cases of pulmonary vein thrombosis commonly occur as a complication of pulmonary surgery. There is a paucity of literature describing its clinical manifestations and non-operative causes. ObjectiveWe report the unique case of pulmonary vein thrombosis associated with a large hiatal hernia in a patient initially presenting with renal infarction. Case ReportA 68-year-old man initially presented with increasing intensity of left lower quadrant pain. Contrast-enhanced computed tomography of the abdomen revealed left renal infarctions. Searching for an embolic source, further investigation revealed left inferior pulmonary vein thrombosis in the setting of venous compression in the lung tissue adjacent to a large hiatal hernia. ConclusionLarge hiatal hernias may be a nidus for pulmonary vein thrombosis, a potential source of left-sided emboli.

Time for Remicade? An Unusual Cause of Recurrent Abdominal Pain

Purpose: A 54-year-old male presented to the outpatient clinic with 2 weeks of anorexia, malaise, and constant, sharp left lower abdominal pain. CT of abdomen and pelvis showed a small area of fat stranding in anterior midline of lower abdomen and adjacent small bowel wall thickening. He received empiric antibiotics with resolution of his pain at one week follow-up. He represented to the emergency room after 2 weeks with recurrent lower abdominal pain, nausea, vomiting, and non-bloody diarrhea. Repeat CT revealed a 5 cm fluid collection in the mid abdomen adjacent to the ileum and oral contrast seen within the extraluminal collection. Upper endoscopy revealed a small linear ulcer in the duodenum; colonoscopy showed a diminutive cecal polyp and normal terminal ileum. Histology of the ileum was normal. Antibiotics were administered. CT 3 days later showed improvement in extraluminal fluid collection. Two weeks later he complained of recurrent left sided abdominal pain. CT enterography was then done showing fat stranding at the previously affected loop of small bowel but no discrete extraluminal abscess or fluid collection. Recurrent nausea, left lower quadrant pain, subjective fevers and diarrhea without blood developed and he was admitted to the inpatient GI service. Physical exam revealed the patient to be afebrile with normal hemodynamic parameters. Oral examination revealed upper dentures. Abdomen was flat, with normal bowel sounds, but was markedly tender to palpation in his left lower quadrant with voluntary guarding. Rectal examination was normal. Labs now showed WBC 8.2, Hgb 9, MCV 84.5, platelets 418, albumin 3.1, Sed rate 58, Saccharomyces IgG was 34.7. Given the severity and focality of the patient's abdominal pain general surgery was consulted and performed a diagnostic laparoscopy. Approximately 30 cm from the ileocecal valve a segment of small bowel was noted to be matted and adherent to the sigmoid colon. A foreign body could be palpated in the lumen of the small bowel and a blue wooden toothpick was seen protruding through the ileal lumen. 15cm of distal ileum was resected and a side to side small bowel anastomosis was performed. The patient made an uneventful postoperative recovery and was discharged 9 days later.Figure: [904]

Sigmoid colon ureteral fistula presenting with urosepsis

This 72-year-old white male presented in the emergency room with symptoms of urosepsis. He had been sick for about ten days, reporting in-creasing malaise, temperature elevation, left flank pain, and “foul-smelling” urine. He had three prior episodes of left lower quadrant pain associated with diarrhea; which his physician had diagnosed as di-verticulitis and treated with antibiotics and dietary restrictions.At admission, vital signs of the cachec-tic patient were recorded as BP 160/78, pulse rate 92, respiration 22, and temperature of 38.4 Celsius. Physical exam demonstrated the lungs clear to aus-cultation and percussion; tenderness to percussion in the left back, and rebound tenderness in the left lower abdominal quadrant. Laboratory data were: RBC 3.8, Hb 9.4, HCT 36, WBC 24,000, BUN 28, Creatinine 2.6; K 4.2, and Na & Cl within normal limits. Urinanalysis and cytology demonstrated a murky appearance, specific gravity of 1.024, cellu-lar debris, WBC 120/hpf, RBC 80/hpf, gram negative bacteria, and vegetable fibers. An admission chest radiograph was negative.A three-phase contrast-enhanced CT (with intravenous contrast medium reduced to 60 mL, because of elevated creatinine) was performed with both coronal and sagittal reconstructions. An axial slice showed a hugely dilated left ureter with an air fluid level (Figure-1). A coronal reconstruction ( the area of interest enlarged to156%) demonstrates gas in the fistula to the thickwalled segment of the sig-moid colon as well as at the level of the UPJ (Fig-ure-2). Diverticula are shown in the third portion of the sigmoid colon. An aneurysm of the infra-renal segment of the aorta was noted. Another coronal re-construction (206% enlargement of area of interest) at a slightly more posterior level shows the entire left ureter dilated by gas (Figure-3). A sagittal re-construction shows the dilated gas-filled left ureter (Figure-4).Fistula from the GI tract to the ureter is un-common. Uretero-ileal fistulae as consequence of Crohn’s disease occur with higher frequency then uretero-colonic fistulae (1,2). Uretero-colonic fistu-lae may be secondary to inflammatory disease of the large bowel, such as diverticulitis, obstructing ureteral calculi, or neoplasm of the colon that con-tiguously involves the ureter (3,4). A non-function-ing kidney and ureter are often the consequence. CT is the modality of choice in working up uro-sepsis or renal colic, while antegrade or retrograde ureterogram is the most sensitive in the detection and characterization of a fistulous tract (5). In a like pathologic process, fistulization to the fallopian tubes can occur from diverticular abscesses. How-ever, the incidence of colo-vesical fistulae caused by diverticulitis is higher (6).