Left Iliac Fossa Pain Flashcards
What are the gastro differentials for LIF pain in post-menopausal women?
- Acute diverticulitis
- Constipation
- IBD
- Ischaemic colitis
- Pneudomembranous colitis
- Locally perforated sigmoid carcinoma
- IBS
What are the non-gastro differentials for LIF pain in post-menopausal women?
- Leaking AA
- UTI
- Uteric coli
- Pyelonephritis
- Shingles
- Rectus Sheath haematoma
- Diabetic ketoacidosis
What are the non-gastro differentials for LIF pain in premenopausal women?
- Ectopic pregnancy
- Mittelschmeriz
- Haemorrhage into a functional ovarian cyst
- Pelvic inflammtory disease
- Torsion/rupture of an ovarian cyst
What are the non-gastro differentials for LIF pain in men?
- Testicular torsion
2. Haemorrhage into a testicular tumour
What would pain initially poorly localised, midline and colicky then migrates to LIF suggest?
acute diverticulitis
What would pain that migrates down the left flank and iliac fossa suggest?
ureteric stone
What would sudden onset LIF pain suggest?
- perforation of viscus
- acute haemorrhage (e.g. into ovarian cyst or from ruptured AAA)
- torsion (ovary, testes)
What would initially colicky midline pain to LIF pain suggest?
acute diverticulitis
What would colicky LIF pain suggest?
ureteric calculi
What would constant LIF pain suggest?
established diverticulitis and other
What would sharp LIF pain suggest?
- haemorrhage
- perforation
- torsion
What would LIF pain that radiates to groin suggest?
ureteric pain
What would LIF pain that feels better with defecation suggest?
IBS
What would LIF pain that feels better when lying still?
peritonitis
What would LT abdominal discomfort for months and years with LIF pain suggest?
IBS
What would a 2-3 day history of LIF pain and pervious episodes suggest?
acute diverticulitis
What would LIF pain with nay movement being painful?
peritonitis (e.g. due to colonic perforation)
What would excruciating LIF pain suggest?
- ureteric colic
2. colonic perforation secondary to diverticulitis or a sigmoid carcinoma
What would LIF pain with nausea and vomiting suggest?
- acute diverticulitis
2. pelvic inflammatory disease
What would LIF pain with fever suggest?
- acute diverticulitis
2. infection
What would LIF pain with a prolonged change in bowel habit suggest?
- IBS
- diverticular disease
- IBD
- colorectal carcinoma
What would LIF pain with rectal bleeding suggest?
- acute diverticulitis
- bloody diarrhoea with UC
- psedomembranous colitis
- ischaemic colitis
- colorectal carcinoma
What would LIF pain with bloating suggest?
IBS
What would LIF pain with weight loss suggest?
colorectal carcinoma
What gyancological symptoms do you check with LIF pain and why?
- new vaginal discharge and or dyspareunia consistent with pelvic inflammatory disease
- check any chance of pregnancy
What MHx do you ask about with LIF pain?
- Steroids
2. Recent use of antibiotics, PPIs
Why do you check if patient is taken steroids?
can dampen inflammatory response, masking signs and symptoms
Why do we check if patient with LIF pain has recent use of antibiotics and PPIs?
potentially pseudomembranous colitis (c.diff colitis) in patient with LIF pain and diarrhoea
What do you look for in general examination of patient with LIF pain?
- How unwell?
- Does she appear to have generalised peritonitis?
- Withering in pain unable to keep still?
- Signs of GI malignancy
How do you check how unwell a patient is?
check obs: HR, BP, temp, repsiration + sats
What are signs of generalised peritonitis?
Is she lying very still, taking shallow breaths and looking pale?
What would a patient with LIF pain writhing in pain, unable to keep still suggest?
ureteric colic
What are signs of GI malignancy in general examination?
cachetic, jaundiced
What do you look for in the abdominal exam for someone with LIF pain?
- Focal tenderness
- Generalised peritonitis
- Massess
- Left supraclavicular lymphadenopathy (Troisier’s sign)
What would focal tenderness with LIF pain suggest?
uncomplicated acute diverticulitis
What would generalised peritonitis (guarding, rigid abdo, absent bowel sounds) with LIF pain suggest?
suspect perforation of colonic diverticulum, sigmoid carcinoma or AAA
What would palpable masses in LIF suggest?
- Acute diverticulitis
- Sigmoid carcinoma may also be palpable
- Centrally laterally pulsatile mass is AAA until proven otherwise
What would left supraclavicular lympathdenopathy (Troisier’s sign) with LIF pain suggest?
GI malignancy
Why do you carry out a rectal exam in LIF pain patient?
detect a pelvic abcess in patients with acute diverticluitis or detect a rectal malignancy
When do you do a vaginal exam with LIF pain?
if also new vaginal discharge
What may you find on a vaginal exam with LIF pain?
cervical motion tenderness - pelvic inflammatory disease
What blood tests do you use for LIF pain?
- VBG
- FBC
- U+Es
- CRP
Why do you do a VBG with LIF pain?
- High lactate and/or metabolic acidosis: ischaemic bowel
2. Glucose: check if diabetic ketoacidosis
What are you looking for in FBC with LIF pain?
WCC elevated in inflammtory conditions e.g. acute diverticulitis + pseudomembranous colitis
Why do you do U+Es in LIF pain?
- Establish baseline before IV fluids / surgery
- check no AKI
Why do you do CRP in LIF pain?
useful for UC and c.diff colitis
What imaging do you use if you suspect diverticulitis and why?
- Abdominal CT with contrast
- CXR: if any clinical suspicion of perforated viscus
- AXR: to rule out bowel obstruction
What other imaging would you do if a woman is premenopausal?
transabdominal ± transvaginal US
What imaging can you not use in acute phase of illness/acute diverticulitis?
colonscopy or double contast barium enema
What is the management of acute diverticulitis in the acute phase?
- Analgesia
- Bowel rest: by clear fluids only
- IV fluids: if unable to maintain sufficient oral intake
- Antibiotics: cover Gram neg bacteria and anaerobes
- Venous thromboembolism prophylaxis
- Monitor: if symptoms do not improve within 48-72hrs further investigation
When is a patient with acute diverticulitis offered a colonoscopy (or barium enema)?
2-6 weeks after resolution of this episode to confirm diagnosis
Why do you do a colonsocpy in acute diver?
- assess extent of diverticulosis and the degree of stricturing secondary to inflammation
- can exclude other diagnoses e.g. carcinoma or colitis
What is the conservative management for acute diver?
maintain high intake dietary fibre to reduce future episodes
When is patient with acute diver offered colonic resection?
if two future acute diverticulitis episodes also lead to hospital admission
