Left Iliac Fossa Pain Flashcards
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
List some gynaecological causes of LIF pain.
Ectopic pregnancy Torsion/rupture/haemorrhage of an ovarian cyst/tumour Mittelschmerz Pelvic inflammatory disease Salpingitis
List some causes of LIF pain that are unique to males.
Testicular torsion
Haemorrhage into testicular tumour
Describe the pattern of pain in acute diverticulitis.
The pain will initially be midline colicky and poorly localised
It will then migrate to the LIF and become constant
Describe the character and pattern of pain in ureteric colic.
severe colicky loin to groin pain
List some possible causes of sudden-onset LIF pain.
Perforated viscus (e.g. locally perforated sigmoid colon) Acute haemorrhage (e.g. ruptured AAA) Torsion
What alleviates pain caused by IBS?
Defecation
Describe the time course of acute diverticulitis.
2-3 day history of LIF pain with a possible history of similar previous episodes
List some causes of LIF pain that are associated with a change in bowel habit.
dicerticuli
IBS
IBD
Colorectal cancer
List some causes of LIF pain that are associated with rectal bleeding.
Ulcerative colitis
Colorectal carcinoma
Ischaemic colitis
Pseudomembranous colitis
List some gynaecological symptoms of pelvic inflammatory disease.
New vaginal discharge
Dyspareunia
Cyclical pattern with the period (Mittelschmerz)
Why is it important to note whether the patient is on steroids?
Steroids can dampen the inflammatory response and mask symptoms
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)
Describe the appearance and signs of a patient with generalised peritonitis.
Lying totally still Taking shallow breaths Looking pale tender, rigid abdomen No bowel sounds
Describe the appearance of a patient with ureteric colic.
Writhing in pain and unable to stay still
What is Troisier’s sign and what does it suggest?
GI malignancy
NOTE: Virchow’s node enlargement
What causes of LIF pain may be palpable on rectal examination?
Pelvic abscess- post acute diverticulitis
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- for pneumoperitoneum post perforated viscus
Abdominal X-ray- for bowel obstruction
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 = severe, sharp diffuse pain, worse on movement
Describe the management of perforated diverticulitis.
Fluid resuscitation Oxygen (if low sats) Urinary output monitoring Analgesia Antibiotics Bloods (VBG, FBC, U+Es, CRP, Cross-match) CT
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
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 fever adnexal tenderness on vaginal exam
Which patients are offered an elective bowel resection after diverticulitis?
if they’ve had:
- 2 proven episodes of diverticular disease requiring hospital admission or had obstructive symptoms of contrast leak on CT abdo
List some of the potential complications of diverticulosis
- perforation
- haemorrhage
- abscess formation
- fitulation
- stricture formation => bowel obstruction
What’s the most common type of fistula in patients with diverticulosis and which sex is it more common in?
Colovesical fistulas
more common in med
List some of the main risk factors for ectopic pregnancy
- previous ectopic pregnancy
- Pelvic inflammatory disease
- tubular procedures (sterilisation)
- endometriosis
- pelvic surgery
- IVF
- IUD
Which classification system is used to classify peritoneal contamination in the context of acute diverticulitis?
Hinchey’s classification
What are the different stages of Hinchey’s classification
- Pericolic or mesenteric abscess
- Walled-off pelvic abscess
- Generalised purulent peritonitis
- Generalised faecal peritonitis
