LEFT LOWER QUADRANT MASS

LEFT LOWER QUADRANT MASS: Excerpt from Differential Diagnosis in Primary Care

To quickly develop a list of etiologies of a left lower quadrant (LLQ) mass, visualize the anatomy of the area. Compared to the RUQ, the number of organs there is few. Beneath the skin, subcutaneous tissue, fascia, and muscle are the sigmoid colon, the iliac artery and veins, the aorta, and the ileum. In the female, one must remember the fallopian tube and ovary. Occasionally, the kidney drops into this region (nephroptosis) and the omentum may cause adhesion. Now apply the mnemonic MINT to each organ and the list of possibilities in Table 4 is completed without any difficulty.

ABDOMINAL MASS, LLQ

Lesions of the skin and fascia are similar to those in upper quadrants with one exception: Because of the inguinal and femoral canals, hernias (especially indirect inguinal hernias) are much more frequent. In the sigmoid colon the following conditions should be considered:

1. M—Malformations include diverticula and volvulus.
2. I—Inflammatory conditions include diverticulitis, abscesses, and granulomatous and ulcerative colitis.
3. N—Neoplasms such as polyps and carcinomas may be present.
4. T—Trauma to this area may involve perforations and contusions.

This list excludes an important consideration, that of fecal impaction. If the patient is given an enema, the mass will often disappear. Less common causes of masses in the sigmoid colon are tuberculosis and amebiasis and other parasites.

There may be aneurysms of the iliac artery or aorta and thrombosis of the iliac vein, although the latter is not usually palpable. The iliac lymph nodes may enlarge from Hodgkin disease, metastatic carcinoma, or tuberculosis. Tubal and ovarian lesions that should come to mind are malignant and benign ovarian cysts, tubo-ovarian abscesses, ectopic pregnancy, and endometriosis. A sarcoma or other tumor of the ileum may be palpable, but abscesses of the sacroiliac joint are rarely palpable.

Approach to the Diagnosis

The approach to this diagnosis includes a careful pelvic and rectal examination, a search for the presence of blood in the stool, a history of weight loss, tenderness of the mass, fever and other symptoms, and a laboratory workup. As mentioned above, an enema may diagnose and treat a fecal impaction. A surgical consult is wise at this point. Stool examination (for blood, ova, and parasites), sigmoidoscopy, and barium enemas are the most useful diagnostic procedures other than a colonoscopy. Arteriography and gallium scans (for diverticular and other abscesses) and the CT scan have become useful additions to the diagnostic armamentarium. Peritoneoscopy and exploratory laparotomy are still necessary in many cases.

Other Useful Tests

1. Sonogram (ovarian cyst, ectopic pregnancy)
2. Peritoneal tap (ruptured ectopic, peritoneal abscess)
3. IVP (pelvic kidney)
4. Pregnancy test (ectopic pregnancy)
5. CBC (infection, anemia)
6. Sedimentation rate (abscess, pelvic inflammatory disease)
7. Gastroenterology consult

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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