The Major Players in the LLQ

• Left ureter
• Left ovary in women
• Left fallopian tube in women
• Descending colon, sigmoid colon, and rectum (large intestines)
• Small intestines

 

Ureter

The paired ureters, using peristalsis, drain urine from their respective kidneys and travel under the floor of the abdomen to the pelvis where they empty into the bladder. Drain is not the right word, because peristalsis is an undulating musculature that “milks” the urine down the line and spits urine into the bladder every few moments.

Like all structures covered with the lining of the abdomen (peritoneum), the sensitivity of each ureter to distension can cause pain. Two things can cause painful distending sensations in the ureter:

• URETERAL SPASM: This can be caused by a urinary tract infection, but more typically is produced by a stone.
• OBSTRUCTION: from a stuck stone trying to pass.

This LLQ pain so evoked is

• colicky,
• sharp,
• severe, and
• intermittent.

It is painful enough to cause collapse and it will be obvious to you that the ER is needed. The pain originates on the one side (here, the left) and radiates upward due to above-obstruction back-up of urine, and downward--more dramatically when the stone is traveling. The urine is often blood-tinged.

 

Ovary

OVARIAN CYST: the ovary on the left is the counterpart to the one on the right. In a normal monthly cycle, a follicle ripens in preparation for the release of an egg (ovulation) from one of them. If that follicle becomes enlarged (by definition, > 2 cm has then deemed a cyst), and it can distend the sensitive covering over the ovary (made of peritoneum).

The pain from an ovarian cyst is

• sharp,
• one sided ("unilateral"--here, on the left), specifically isolated enough such that a woman can point to it with one finger.

When it ruptures, the pinpoint pain suddenly stops, but this relief is soon replaced with a vague, spreading, dull and burning ache across the pelvis. This represents the sudden release of the distension with cyst rupture, but the beginning of pain from the leaking bloody fluid into the pelvis that is irritating. Such bleeding is usually self-resolving and not an emergency (after the fact!--YOU will not be able to tell, so any abdominal signs require transport.)

 

Other Female-Specific Considerations

ENDOMETRIOSIS: another source of pain on or around the ovary and other parts of the pelvis--even the bowel--is endometriosis, an unfortunate implantation of menstrual-like tissue which can cause sharp, burning or aching where it resides. Its flares are timed with the menstrual cycles, giving a crucial clue to the source of the pain and the diagnosis.

FALLOPIAN TUBE: each fallopian tube can transport an unfertilized egg (or one that’s fertilized) from the ovary to travel into the uterus, which is midline in the pelvis. Two sources of fallopian tube pain are:

• ECTOPIC PREGNANCY

If a fertilized egg gets stuck in the tube on its journey to the uterus, an embryo will begin developing there, leading to distension and rupture, with possible life-threatening bleeding into the abdomen. Such a hemorrhage is a surgical emergency. Immediate transport is mandatory for suspected ectopic pregnancy. The most common cause of ectopic pregnancy is a previous infection in the tube (salpingitis).

• SALPINGITIS. This is due to infection. The most common culprits are gonorrhea and chlamydia.

NOTEWORTHY: Ectopic pregnancy is unilateral and salpingitis is usually bilateral.

 

Large Bowel

CONSTIPATION: in an otherwise healthy person, the most common cause for LLQ pain is constipation, which can progress to obstruction via fecal impaction. Although the most common causes of constipation are diet and dehydration, one must always suspect that fecal impactions may be due to the use or abuse of narcotics, the absence of which is a pertinent negative to include in the history.

DIVERTICULOSIS: the LLQ is the usual home for diverticulosis, making it an important consideration with any LLQ pain.

It is a weakness in the bowel wall causing a sac-like protrusion (diverticulum) which can get infected (diverticulitis) and create pain. Of the four abdominal quadrants the large bowl occupies (ascending → transverse → descending colon), diverticulosis and diverticulitis occur most frequently in the LLQ. If hard fecal pieces (fecaliths) cause blockage, the dynamic processes of the infection can weaken the bowel wall and the diverticulum can rupture. 15% will require surgical removal of the diseased colon segment.

Small Bowel

SMALL BOWEL OBSTRUCTION: infections in the abdomen, adhesions, or cancer can cause partial or complete obstructions, and the LLQ is no exception because the small intestines, all twenty feet, are primarily in the lower abdomen. [See "ADHESIONS" below.]

CROHN DISEASE: an inflammatory condition through the wall of the intestines that can lead to strictures and obstruction. It can happen anywhere in the gastrointestinal tract--most frequently in the ileum of the RLQ--so the abdominal pain is not limited to the LLQ but should be included in any LLQ pain differential diagnosis.

ADHESIONS: abnormal connections between tissues in the abdomen. The abdomen is very vigilant to infection and inflammation, stimulating bowel and bowel fat to migrate toward such an area to wall it off from the rest of the body. When it heals, unfortunately, the two areas are stuck together, sometimes creating a kink in the bowel that can make passage of bowel contents more difficult than when this area was free. This can distend the bowel to create a colicky, sharp pain.

OBSTRUCTION: Usually fleeting in its painful presentation, adhesions can occasionally cause an obstruction that becomes a surgical emergency. Adhesions are not exclusive to the LLQ and can occur in both large and small bowel anywhere in the abdomen. Previous abdominal surgery, Crohn's disease, previous infectious processes, abdominal surgery, or internal bleeding in the abdomen are risk factors for adhesions and obstruction.

NOTEWORTHY:

• When triaging LLQ pain in women, your first consideration is a disease in the reproductive organs and then diverticulitis secondarily.
• In triaging men, LLQ pain should prompt primary consideration of diverticulitis in the colon. 

Otherwise,

• kidney stones are likely to be the culprit.

• GI symptoms such as diarrhea may suggest an inflammatory bowel disease, such as Crohn's disease. Many of these also can occur on the right side.