16. Right Iliac Fossa Pain

Question 1

List the differential diagnosis for RIF pain.

Answer 1

Appendicitis
Gastroenteritis
Ureteric colic 
Inguinal hernia (especially if strangulated)
Mesenteric adenitis 
Acute pancreatitis 
Testicular torsion
Meckel’s diverticulitis

Question 2

State two causes of RIF pain that are more common in children.

Answer 2

Intussusception

Mesenteric adenitis

Question 3

What causes of RIF pain are more common in the elderly?

Answer 3

Caecal pathology (e.g. tumours, volvulus, diverticuli)
AAA

Question 4

List some gynaecological causes of RIF and LIF pain.

Answer 4

Ectopic pregnancy 
Pelvic inflammatory disease
 Mittelschmerz
Torsion/rupture/haemorrhage of an ovarian cyst or tumour 
Salpingitis 
Threatened abortion 
Fibroid degeneration 
Uterine dehiscence

Question 5

What is pelvic inflammatory disease?

Answer 5

Acute or chronic infection of the ovaries, fallopian tubes and uterus, usually resulting from an infection ascending from the vagina
Chlamydia trachomatis and Neisseria gonorrhoeae are causative agents

Question 6

What is Mittelschmerz?

Answer 6

Mid-cycle RIF/LIF pain caused by rupture of the ovarian follicle

Question 7

List some causes of RIF/LIF pain that are exclusive to males.

Answer 7

Testicular torsion

Haemorrhage into a testicular tumour

Question 8

Before laying a hand on the patient, it is important to ascertain how much pain they are already in. State two ways in which you can assess how much pain they are in without touching them.

Answer 8

Ask them to cough

Ask them to suck their tummy in as far as possible and then puff it out again

Question 9

List some features of examination that would suggest that the patient is acutely unwell.

Answer 9

Tachypnoea
Tachycardia
Fever
Hypotension

Question 10

Why is it important to take note of any surgical scars the patient may have on their abdomen?

Answer 10

Previous surgery increases the risk of post-surgical adhesion
Adhesions can lead to bowel obstruction

Question 11

Why is it important to check for cervical lymphadenopathy in a patient with RIF pain?

Answer 11

Mesenteric adenitis is often preceded by an upper respiratory tract viral infection
This viral infection can cause cervical lymphadenopathy
NOTE: mesenteric adenitis is very difficult to distinguish clinically from appendicitis

Question 12

What can cause absent bowel sounds?

Answer 12

Occurs if there is a functional bowel obstruction (e.g. paralytic ileus)

Question 13

What can cause tinkling bowel sounds?

Answer 13

Small bowel obstruction

Question 14

Why is it important to check for hernias in a patient with RIF pain?

Answer 14

Hernias can become strangulated and cause small bowel obstruction

Question 15

What useful clues may be gained from performing a DRE?

Answer 15

Constipation
Masses
Blood (suggests inflammatory bowel disease, Meckel’s diverticulum bleed or caecal diverticular bleed)

Question 16

Why is it particularly important to examine the external genitalia of men with RIF/LIF pain?

Answer 16

Testicular torsion and strangulated inguinal hernias can cause RIF/LIF pain

Question 17

Where is pain caused by testicular torsion, epididymitis and orchitis referred?

Answer 17

It is referred to the abdomen via T10 innervation

Question 18

What is Prehn’s sign?

Answer 18

Elevation of the testes relieves pain in epididymitis but does NOT relieve pain in testicular torsion

Question 19

Describe how the cremasteric reflex is used to narrow the differential in a male patient with RIF/LIF pain.

Answer 19

The absence of the cremasteric is NOT diagnostic of testicular torsion
However, the presence of a cremasteric reflex strongly suggests that testicular torsion is not the cause of the pain

Question 20

What is the time limit within which surgery should be performed in a patient with testicular torsion?

Answer 20

6 hours

Question 21

What form of imaging is sometimes used to aid diagnosis of testicular torsion?

Answer 21

Doppler ultrasound

Question 22

List some blood tests that may be performed in a patient with RIF/LIF pain.

Answer 22

FBC
CRP
VBG
Serum amylase 
U&Es
Blood glucose 
Liver enzymes

Question 23

Why is a VBG important in patients with RIF pain?

Answer 23

High lactate and metabolic acidosis may indicate that there is ischaemia or severe sepsis

Question 24

Why is blood glucose important to check in a patient with RIF pain?

Answer 24

DKA can present with acute abdomen

Question 25

List potential findings of urinalysis in a patient with RIF pain.

Answer 25

Haematuria – could result from infection, renal/ureteric colic and inflamed pelvic or retrocaecal appendix
Glycosuria and ketonuria – indicates DKA
Positive leucocyte esterase and nitrites – indicates UTI
Proteinuria – can result from UTI or appendiceal irritation of the bladder

Question 26

List some forms of imaging that may be used in a patient with RIF pain.

Answer 26

Ultrasound – allows visualization of appendicitis and it is good for detecting free fluid 
Erect CXR – check for perforated viscus 
Abdominal CT 
ECG – useful if patient is tachycardic 
Abdominal X-ray

Question 27

List some indications for performing an abdominal X-ray.

Answer 27

Foreign body
Toxic megacolon
Bowel obstruction

Question 28

Describe the typical presentation of mesenteric adenitis.

Answer 28

Usually occurs in children < 15 years
Typically follows an upper respiratory tract viral infection
Cervical lymphadenopathy often present
Clinically difficult to distinguish from appendicitis

Question 29

What is Meckel’s diverticulum?

Answer 29

It is a remnant of the omphalomesenteric duct that is found in the ileum. This congenital abnormality could become inflamed and mimic appendicitis. It may also contain embryonic remnants of stomach mucosa, which can form a peptic ulcer that could bleed.

Question 30

Describe a presentation of acute-onset Crohn’s disease that causes RIF pain.

Answer 30

Inflammation of the terminal ileum can cause RIF pain

This symptom is often accompanied by a history of diarrhoea and weight loss

Question 31

RIF pain can also be caused by gastroenteritis. What other symptoms would help identify gastroenteritis as the cause of the RIF pain?

Answer 31

Vomiting
Diarrhoea
Symptoms seen in close contacts

Question 32

Describe the typical presentation of renal/ureteric colic.

Answer 32

Waxing and waning loin to groin pain
Often described as being ‘worse than child birth’
Urinalysis often shows microscopic haematuria

Question 33

Describe the pattern of pain caused by appendicitis.

Answer 33

Initially, the patient will experience low-grade central abdominal pain
This pain will gradually migrate to the RIF over 12-24 hours
It will become more intense

Question 34

What other clinical feature is strongly associated with appendicitis?

Answer 34

Anorexia – most patients with appendicitis lose their appetite

Question 35

List some other signs of appendicitis.

Answer 35

Rovsing’s Sign – palpation of the LIF causes more pain in the RIF than the LIF
McBurney’ point tenderness – percussion tenderness at McBurney’s point (1/3 of the way between the right ASIS and the umbilicus)
Psoas Sign – extension of the hip causes pain (suggests that the appendix is retrocaecal)
Cope’s Sign – flexion and internal rotation of the hip causes pain (suggests that the appendix is close to the obturator internus)

Question 36

Describe the management of appendicitis.

Answer 36

IV fluids
Analgesia
Appendicectomy preparation

Question 37

Describe the pre-operative preparation for appendicectomy.

Answer 37

NBM for food and non-clear fluids for 6 hours pre-op
NBM for clear fluids for 2 hours pre-op
Peri-operative broad-spectrum antibiotics
DVT prophylaxis

Question 38

List the criteria for SIRS.

Answer 38

Heart Rate > 90 bpm
Temperature < 36 or > 38
Breathing Rate > 20 or PaCO2 < 32 mm Hg
WCC < 4000/mm3 or > 12,000/mm3

Question 39

What is sepsis?

Answer 39

SIRS with a confirmed or presumed infectious process

Question 40

State the Sepsis Six.

Answer 40

High flow oxygen
Blood cultures 
Broad-spectrum antibiotics
IV fluid challenge
Measure serum lactate and haemoglobin
Measure hourly urine output

Question 41

What is an appendix mass?

Answer 41

This is a complication of acute appendicitis
It if formed when the greater omentum, caecum and/or adherent loops of small bowel wrap themselves around an inflamed/perforated appendix forming a localised mass