Left Iliac Fossa Pain Flashcards by Adele Schiff

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

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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

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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

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What are the non-gastro differentials for LIF pain in men?

Testicular torsion

2. Haemorrhage into a testicular tumour

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What would pain initially poorly localised, midline and colicky then migrates to LIF suggest?

acute diverticulitis

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What would pain that migrates down the left flank and iliac fossa suggest?

ureteric stone

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What would sudden onset LIF pain suggest?

perforation of viscus
acute haemorrhage (e.g. into ovarian cyst or from ruptured AAA)
torsion (ovary, testes)

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What would initially colicky midline pain to LIF pain suggest?

acute diverticulitis

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What would colicky LIF pain suggest?

ureteric calculi

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What would constant LIF pain suggest?

established diverticulitis and other

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What would sharp LIF pain suggest?

haemorrhage
perforation
torsion

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What would LIF pain that radiates to groin suggest?

ureteric pain

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What would LIF pain that feels better with defecation suggest?

IBS

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What would LIF pain that feels better when lying still?

peritonitis

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What would LT abdominal discomfort for months and years with LIF pain suggest?

IBS

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What would a 2-3 day history of LIF pain and pervious episodes suggest?

acute diverticulitis

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What would LIF pain with nay movement being painful?

peritonitis (e.g. due to colonic perforation)

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What would excruciating LIF pain suggest?

ureteric colic

2. colonic perforation secondary to diverticulitis or a sigmoid carcinoma

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What would LIF pain with nausea and vomiting suggest?

acute diverticulitis

2. pelvic inflammatory disease

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What would LIF pain with fever suggest?

acute diverticulitis

2. infection

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What would LIF pain with a prolonged change in bowel habit suggest?

IBS
diverticular disease
IBD
colorectal carcinoma

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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?

1. 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?

1. How unwell? 2. Does she appear to have generalised peritonitis? 3. Withering in pain unable to keep still? 4. 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?

1. Focal tenderness 2. Generalised peritonitis 3. Massess 4. 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?

1. Acute diverticulitis 2. Sigmoid carcinoma may also be palpable 3. 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?

1. VBG 2. FBC 3. U+Es 4. CRP

Why do you do a VBG with LIF pain?

1. 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?

1. Abdominal CT with contrast 2. CXR: if any clinical suspicion of perforated viscus 3. 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?

1. Analgesia 2. Bowel rest: by clear fluids only 3. IV fluids: if unable to maintain sufficient oral intake 4. Antibiotics: cover Gram neg bacteria and anaerobes 5. Venous thromboembolism prophylaxis 6. 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