Left Iliac Fossa Pain Flashcards by Francesca B

List the differential diagnosis for LIF pain.

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

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List some gynaecological causes of LIF pain.

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

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

Testicular torsion

Haemorrhage into testicular tumour

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Describe the pattern of pain in acute diverticulitis.

The pain will initially be midline and poorly localised

It will then migrate to the LIF and become constant

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Describe the pattern of pain in ureteric colic.

Loin to groin

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List some possible causes of sudden-onset LIF pain.

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

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Describe the character of the pain in ureteric colic.

It is extremely severe and colicky

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What alleviates pain caused by IBS?

Defecation

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Describe the time course of acute diverticulitis.

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

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

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

Ulcerative colitis
Colorectal carcinoma
Ischaemic colitis
Pseudomembranoud colitis

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List some gynaecological symptoms of pelvic inflammatory disease.

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

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

Steroids can dampen the inflammatory response and mask symptoms

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

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

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Describe the appearance of a patient with generalised peritonitis.

Lying totally still
Taking shallow breaths
Looking pale

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Describe the appearance of a patient with ureteric colic.

Writhing in pain and unable to stay still

What does enlargement of Virchow’s node suggest?

GI malignancy

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

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

Pelvic abscess

Rectal tumour

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

FBC
U&Es
CRP
VBG

Why is it important to do a VBG?

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

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

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

What is the imaging modality of choice for acute diverticulitis?

Abdominal CT with contrast

What other forms of imaging may be useful?

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

Describe the management of acute diverticulitis.

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

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

Gram-negatives | Anaerobes

Describe the presentation of perforated diverticulitis.

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

Describe the management of perforated diverticulitis.

Fluid resuscitation Oxygen (if low sats) Urinary output monitoring

What is Hartmann’s Procedure?

Proctosigmoidectomy with a rectal stump and end colostomy

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

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

Describe the typical presentation of IBS.

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

In what demographic is IBS most common?

Young women

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

Inflammatory bowel disease | Coeliac disease

What are the diagnostic tests for coeliac disease?

``` Anti-endomysial antibodies Tissue transglutaminase (TTG) ```

State the NICE criteria for clinical diagnosis of IBS.

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

Describe the typical presentation of an ectopic pregnancy.

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

Define pelvic inflammatory disease.

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.

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

Chlamydia trachomatis | Neisseria gonorrhoea

Describe the typical presentation of pelvic inflammatory disease.

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