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Oxford Clinical Cases > Left Iliac Fossa Pain > Flashcards

Left Iliac Fossa Pain Flashcards

1
Q

List the differential diagnosis for LIF pain.

A 
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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2
Q

List some gynaecological causes of LIF pain.

A 
Ectopic pregnancy 
Torsion/rupture/haemorrhage of an ovarian cyst/tumour
Mittelschmerz
Pelvic inflammatory disease 
Salpingitis
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3
Q

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

A

Testicular torsion

Haemorrhage into testicular tumour

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4
Q

Describe the pattern of pain in acute diverticulitis.

A

The pain will initially be midline and poorly localised

It will then migrate to the LIF and become constant

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5
Q

Describe the pattern of pain in ureteric colic.

A

Loin to groin

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6
Q

List some possible causes of sudden-onset LIF pain.

A 
Perforated viscus (e.g. locally perforated sigmoid colon)
Acute haemorrhage (e.g. ruptured AAA)
Torsion
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7
Q

Describe the character of the pain in ureteric colic.

A

It is extremely severe and colicky

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8
Q

What alleviates pain caused by IBS?

A

Defecation

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9
Q

Describe the time course of acute diverticulitis.

A

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

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10
Q

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

A

Most colonic diseases in the differential:
IBS, diverticula disease, IBD, colorectal carcinoma
(Result in prolonged changes in bowel habit)

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11
Q

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

A

Ulcerative colitis
Colorectal carcinoma
Ischaemic colitis
Pseudomembranoud colitis

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12
Q

List some gynaecological symptoms of pelvic inflammatory disease.

A

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

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13
Q

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

A

Steroids can dampen the inflammatory response and mask symptoms

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14
Q

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

A

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

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15
Q

Describe the appearance of a patient with generalised peritonitis.

A

Lying totally still
Taking shallow breaths
Looking pale

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16
Q

Describe the appearance of a patient with ureteric colic.

A

Writhing in pain and unable to stay still

17
Q

What does enlargement of Virchow’s node suggest?

A

GI malignancy

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

18
Q

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

A

Pelvic abscess

Rectal tumour

19
Q

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

A

FBC
U&Es
CRP
VBG

20
Q

Why is it important to do a VBG?

A

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

21
Q

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

A

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

22
Q

What is the imaging modality of choice for acute diverticulitis?

A

Abdominal CT with contrast

23
Q

What other forms of imaging may be useful?

A

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

24
Q

Describe the management of acute diverticulitis.

A 
Analgesia
Bowel rest (only clear fluids) 
IV fluids
Antibiotics 
DVT prophylaxis 
Monitor 
Follow-up (offer colonoscopy or barium enema, offer surgery if indicated)
25
Q

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

A

Gram-negatives

Anaerobes

26
Q

Describe the presentation of perforated diverticulitis.

A

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

27
Q

Describe the management of perforated diverticulitis.

A

Fluid resuscitation
Oxygen (if low sats)
Urinary output monitoring

28
Q

What is Hartmann’s Procedure?

A

Proctosigmoidectomy with a rectal stump and end colostomy

29
Q

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

A

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

30
Q

Describe the typical presentation of IBS.

A

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

31
Q

In what demographic is IBS most common?

A

Young women

32
Q

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

A

Inflammatory bowel disease

Coeliac disease

33
Q

What are the diagnostic tests for coeliac disease?

A 
Anti-endomysial antibodies
Tissue transglutaminase (TTG)
34
Q

State the NICE criteria for clinical diagnosis of IBS.

A

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

35
Q

Describe the typical presentation of an ectopic pregnancy.

A

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

36
Q

Define pelvic inflammatory disease.

A

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.

37
Q

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

A

Chlamydia trachomatis

Neisseria gonorrhoea

38
Q

Describe the typical presentation of pelvic inflammatory disease.

A

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

Oxford Clinical Cases (29 decks)

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