Acute right iliac fossa pain- the commonest surgical emergency

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ACUTE RIGHT ILIAC FOSSA PAIN A PROBLEM ORIENTED APPROACH


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www.themegallery.com


Dr.B.SELVARAJ MS;Mch;FICS;

NEONATAL & PEDIATRIC SURGEON

PIMS

PONDICHERRY INDIA

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Recognise various conditions

Clinch the correct diagnosis

Appropriate early treatment

Appropriate surgical referral 4

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OBJECTIVES

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ACUTE RIGHT ILIAC FOSSA PAIN

CAUSES

CAUSES Mesenteric

Lymphadenitis

Acute Appendicitis

Ectopic pregnancy

Mittelschmerz

Meckel’s Diverticulitis

Twisted ovarian cyst

PID

UTI

Right ureteric calculus P

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ACUTE APPENDICITIS

PATHOPHYSIOLOGY

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ACUTE APPENDICITIS- “Murphy’s Triad”

Anorexia

Nausea

Vomiting

Fever

Pain in RIF

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ACUTE APPENDICITIS- Physical Examination

1.RIF Tenderness

2. RIF Rebound Tenderness

Blumberg’s sign

3. Guarding/Rigidity

4.Cope’s Psoas Test

5.Cope’s Obturator Test

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ACUTE APPENDICITIS

Alvarado’s Scoring

●Migration of pain from periumbilical to

RIF region 1

●Anorexia 1

●Nausea/ Vomiting 1

● Tenderness RIF 2

●Rebound Tenderness 1

●Elevated temperature >37.5* C 1

●Leukocytosis 2

●Shift to left polymorphs > 75% 1

(MANTRELS)

Total Score 10

Alvarado’s

Scoring

Symptoms

Signs

Labs

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ACUTE APPENDICITIS

Imaging Studies

AXR

USG Abdomen

CT Abdomen

●Graded

compression

technique

●Non compressible

tubular structure

>6mm diameter

●Periappendicularc

ollection

●Dilated hypodense

appendix > 6mms

●Periappendicular

fat stranding

●Collection in RIF P

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●Fecolith

●Focal Ileus


ACUTE APPENDICITIS

AXR&USG Abdomen

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ACUTE APPENDICITIS

CT Abdomen

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RIGHT ILIAC FOSSA PAIN

Algorithm

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ACUTE APPENDICITIS

Algorithm

Appendicitis

Investigations: TWBC;DC;U R/E;Alvarado’s

scoring; USG Abd; CT Abd

>36 hrs of Illness

CT Scan

<36 hrs of illness

Children with

typical

presentation

Surgery

Children with

typical

presentation

Surgery

Treatment

Abscess

Percutaneous

Drainage

Interval

Appendicectomy

Abscess

Percutaneous

Drainage

Interval

Appendicectomy

History&Physical Exam

Women in

child bearing

age group

Imaging

Diagnostic��S

urgery

Women in

child bearing

age group

Imaging

Diagnostic��S

urgery

Men

Surgery

Men

Surgery

Elderly

Early CT

Surgery

Elderly

Early CT

Surgery

Phlegmon

Antibiotics

Bowel rest

Interval

Appendicectomy

Phlegmon

Antibiotics

Bowel rest

Interval

Appendicectomy

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ACUTE APPENDICITIS- Perforation Rate

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ACUTE APPENDICITIS- Negative Appendicectomies

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ACUTE APPENDICITIS

Open Appendicectomy

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ACUTE APPENDICITIS

Laparoscopic Appendicectomy

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ACUTE APPENDICITIS

Laparoscopic Appendicectomy

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ACUTE APPENDICITIS

Complications

Complications

Abscesses�Local,

Pelvic,Subdiaphragmatic

Post op adhesive intestinal

obstruction

Perforation

General Peritonitis

Wound infection

Wound Dehiscence

Incisonal Hernia

Hemorrhage P

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Stump Blowout

Fecal Fistula


ACUTE APPENDICITIS

“ Mindmaps”

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• Remnant of V.I. Duct

• Mimic Ac Appendicitis

• Present as pain abdomen,Hematochezia

Melena,umbilical discharge or intestinal

obstruction.

• Pre op diagnosis by Tch 99 Scintigraphy

• Treatment: Excision&EEA

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Meckel’s Diverticulitis- Rule of 2

• Occur in 2% of the population

• Peak age of presentation 2 yrs

• 2 feet from ileocecal junction

• 2 Cms in diameter

• 2 inches in length

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Meckel’s Diverticulm

Various Presentations

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Meckel’s Diverticulm

Timing of various presentations

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Perforated Meckel’s Diverticulum

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Meckel’s Diverticulitis-Tch99 Scintigraphy

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Mesenteric Adenitis

• Common in children

• Secondary to upper respiratory viral infection

• Pain is less severe but more generalised

• Tenderness is not fixed to RIF � “ Shifting

Tenderness”

• Non Progressive and Self Limiting

• In doubtful cases exploration, Biopsy of nodes

and Appendicectomy

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L/O/G/O

P I M S


Health & Medicine

Acute right iliac fossa pain- the commonest surgical emergency