RIF pain

Question 1

What are the ddx for someone presenting with RIF pain

Answer 1

Appendicitis*
Gastroenteritis
Ureteric colic
Inguinal hernia (incarcerated / strangulated = emergency)

Question 2

On examination, what are you looking for?

Answer 2

1. Febrile/tachycardiac, etc.
2. Scars - previous abdominal surgery makes small bowel obstruction more likely
3. Abdominal distension - sign of small bowel obstruction
4. Cervical lymphadenopathy - ?mesenteric adenitis (often succeeds URTI). Often misdiagnosed as appendicitis
5. Masses
6. Bowel sounds - absent in ileus (functional bowel obstruction) or tinkling if small bowel obstruction
7. Hernias - can cause small bowel obstruction
8. Rectal exam - blood indicates (IBD/caecal diverticulum bleed).
9. External genitalia - torsion/epididymitis and orchitis can present to abdomen. 6 hours window of rescue for testicular torsion

Question 3

Which blood tests would you do in someone with RIF pain

Answer 3

1. FBC
2. CRP
3. VBG - metabolic acidosis are signs of ischaemia or severe sepsis
4. U&Es - urea is a prognostic indicator for pancreatitis (as per Glasgow scale)
5. Serum amylase/lipase - pancreatitis
6. Glucose - ?DKA. Glucose also part of Glasgow score pancreatitis criteria
7. Liver enzymes

Question 4

What should you look for in urinalysis

Answer 4

Haematuria = infection, renal/ureteric calculi, inflamed pelvic appendix that irritates bladder.

UTI if high leucocyte esterase and nitrites.

Question 5

What imaging investigations should be done in someone with RIF pain

Answer 5

1. USS abdomen
2. CXR - ?perforated viscus
3. Abdominal CT
4. ECG
5. AXR - only if bowel obstruction suspected, toxic megacolon or foreign body.

Question 6

When should mesenteric adenitis be suspected?

Answer 6

Following URTI or sore throat - cervical lymphadenopathy often present.
More common in children.

Question 7

When should constipation be suspected

Answer 7

Constipation basically never results in tachycardia or fever. Also no migration of pain to RIF.

Question 8

When should acute onset Crohns disease be suspected

Answer 8

Hx of diarrhoea and weight loss for weeks/months leading unto acute presentation

Question 9

When should gastroenteritis be suspected

Answer 9

Vomiting and diarrhoea predominantly.

Question 10

When should renal/ureteric colic be suspected

Answer 10

Patient writhing in pain, not sitting/lying still. Pain doesn’t migrate from central abdomen and urinalysis may show haematuria.

Question 11

When should pancreatitis be suspected?

Answer 11

High amylase

Question 12

How should acute appendicitis be managed

Answer 12

Appendicectomy

Perioperative broad spectrum Abx and DVT prophylaxis

Question 13

How to differentiate between epididymitis and torsion

Answer 13

Elevating affected scrotum relives the pain in epididmyitis but not torsion (positive Prehn’s sign)

Question 14

If a patient has a chronic history of disturbed bowel habit, what should you suspect?

Answer 14

Crohns disease