17. Left Iliac Fossa Pain

Question 1

List the differential diagnosis for LIF pain.

Answer 1

Acute diverticulitis
Constipation
Inflammatory bowel disease
Ischaemic colitis
Pseudomembranous colitis
Leaking AAA
Locally perforated sigmoid colon
UTI
Ureteric colic
Pyelonephritis
IBS

Question 2

List some gynaecological causes of LIF pain.

Answer 2

Ectopic pregnancy 
Torsion/rupture/haemorrhage of an ovarian cyst/tumour
Mittelschmerz
Pelvic inflammatory disease 
Salpingitis

Question 3

List some causes of LIF pain that are unique to males.

Answer 3

Testicular torsion

Haemorrhage into testicular tumour

Question 4

Describe the pattern of pain in acute diverticulitis.

Answer 4

The pain will initially be midline and poorly localised

It will then migrate to the LIF and become constant

Question 5

Describe the pattern of pain in ureteric colic.

Answer 5

Loin to groin

Question 6

List some possible causes of sudden-onset LIF pain.

Answer 6

Perforated viscus (e.g. locally perforated sigmoid colon)
Acute haemorrhage (e.g. ruptured AAA)
Torsion

Question 7

Describe the character of the pain in ureteric colic.

Answer 7

It is extremely severe and colicky

Question 8

What alleviates pain caused by IBS?

Answer 8

Defecation

Question 9

Describe the time course of acute diverticulitis.

Answer 9

2-3 day history of LIF pain with a possible history of similar previous episodes

Question 10

List some causes of LIF pain that are associated with a change in bowel habit.

Answer 10

IBS
IBD
Diverticular disease
Colorectal carcinoma

Question 11

List some causes of LIF pain that are associated with rectal bleeding.

Answer 11

Ulcerative colitis
Colorectal carcinoma
Ischaemic colitis
Pseudomembranoud colitis

Question 12

List some gynaecological symptoms of pelvic inflammatory disease.

Answer 12

New vaginal discharge
Dyspareunia
Cyclical pattern with the period (Mittelschmerz)

Question 13

Why is it important to note whether the patient is on steroids?

Answer 13

Steroids can dampen the inflammatory response and mask symptoms

Question 14

Why is it important to note whether the patient is on antibiotics?

Answer 14

Antibiotics are a risk factor for the development of pseudomembranous colitis (C. difficile colitis)

Question 15

Describe the appearance of a patient with generalised peritonitis.

Answer 15

Lying totally still
Taking shallow breaths
Looking pale

Question 16

Describe the appearance of a patient with ureteric colic.

Answer 16

Writhing in pain and unable to stay still

Question 17

What does enlargement of Virchow’s node suggest?

Answer 17

GI malignancy

NOTE: Virchow’s node enlargement is referred to as Troisier’s sign

Question 18

What causes of LIF pain may be palpable on rectal examination?

Answer 18

Pelvic abscess

Rectal tumour

Question 19

Which blood tests should be performed in patients with LIF pain?

Answer 19

FBC
U&Es
CRP
VBG

Question 20

Why is it important to do a VBG?

Answer 20

High lactate and metabolic acidosis would indicate ischaemia (e.g. ischaemic colitis)
It suggests that the patient is extremely unwell

Question 21

What form of imaging should not be performed in the acute phase of diverticulitis?

Answer 21

Colonoscopy
Barium enema
NOTE: this is because there is a risk of bowel perforation

Question 22

What is the imaging modality of choice for acute diverticulitis?

Answer 22

Abdominal CT with contrast

Question 23

What other forms of imaging may be useful?

Answer 23

Erect CXR
Abdominal X-ray
Transabdominal/Transvaginal ultrasound (if gynaecological cause suspected)

Question 24

Describe the management of acute diverticulitis.

Answer 24

Analgesia
Bowel rest (only clear fluids) 
IV fluids
Antibiotics 
DVT prophylaxis 
Monitor 
Follow-up (offer colonoscopy or barium enema, offer surgery if indicated)

Question 25

Which organisms need to be covered by the antibiotics used in acute diverticulitis?

Answer 25

Gram-negatives

Anaerobes

Question 26

Describe the presentation of perforated diverticulitis.

Answer 26

Sudden-onset severe LIF pain following around 2-3 days of milder LIF pain
The patient may subsequently become peritonitic

Question 27

Describe the management of perforated diverticulitis.

Answer 27

Fluid resuscitation
Oxygen (if low sats)
Urinary output monitoring

Question 28

What is Hartmann’s Procedure?

Answer 28

Proctosigmoidectomy with a rectal stump and end colostomy

Question 29

What is a primary anastomosis? What measure is taken to allow the anastomosis to heal?

Answer 29

Removal of the affected part of the bowel followed by the joining together of the two remaining ends
To allow the anastomosis to heal, a loop ileostomy may be created

Question 30

Describe the typical presentation of IBS.

Answer 30

Long history of chronic abdominal pain with cramping, bloating and altered bowel habit

Question 31

In what demographic is IBS most common?

Answer 31

Young women

Question 32

Which other diagnoses should be considered in young patients presenting with altered bowel habit and vague abdominal pain?

Answer 32

Inflammatory bowel disease

Coeliac disease

Question 33

What are the diagnostic tests for coeliac disease?

Answer 33

Anti-endomysial antibodies
Tissue transglutaminase (TTG)

Question 34

State the NICE criteria for clinical diagnosis of IBS.

Answer 34

More than 6 months of abdominal pain associated with bloating and altered bowel habit

Question 35

Describe the typical presentation of an ectopic pregnancy.

Answer 35

Sexually active young woman presenting with lower abdominal pain, vaginal bleeding and amenorrhoea/late period

Question 36

Define pelvic inflammatory disease.

Answer 36

An acute or chronic condition in which the uterus, Fallopian tubes and ovaries are infected. It usually results from an infection ascending from the vagina.

Question 37

What are the two main causative agents in pelvic inflammatory disease?

Answer 37

Chlamydia trachomatis

Neisseria gonorrhoea

Question 38

Describe the typical presentation of pelvic inflammatory disease.

Answer 38

A sexually active young woman (with a new partner), experiencing acute lower abdominal pain, new vaginal discharge, vomiting and fever combined with adnexal tenderness on vaginal exam