Right Iliac Fossa Pain Flashcards
What are the gastro differentials of a right iliac fossa pain in a 38yo male?
- Appendicitis
- Gastroentertitis
- Mesenteric adenitis
- Acute pancreatitis
- Meckel’s diverticulitis
- Cholecystits
- SBO
- Acute onset ileitis (bacterial or Chrons)
- Perforated peptic ulcer
What are the non-gastro differentials of a right iliac fossa pain in a 38yo male?
- Ureteric colic
- Inguinal hernia (especially if encarcerated or strangulated)
- Epididymitis and/or orchitis
- Testicular Torsion
- Pyelonephritis
- Psoas abscess
- Diabetic ketoacidosis
- UTI
- Constipation
- Caecel volvus
- Caecel diverticulitis
- Shingles
- Rectus sheath haematoma
- Femoral hernia
In a female with right iliac fossa pain what differentials can you consider?
- Ectopic pregnancy
- Pelvic inflammatory disease/salpingitis
- Torsion/haemorrhage ruptrue of an ovarian tumour or cyst
- Mittelschmerz
- Threatened abortion
- Fibroid degeneration
- Uterine dehiscence
Is tenderness and pain and sign or symptom?
Tenderness is a sign
Pain is a symptom
How can you check for peritonitis quickly?
- Suck patient tummy in as far as possible then puff out again (esp in children)
- If board-like abdominal rigidity secondary to generalised peritoinism will only make minor movements
- Ask patient to cough
- Patients with inflammation of parietal peritoneum will be reluctant to cough deeply and may place their hands over area of tenderness
How do you palpate a patient in pain?
start in opposite side to where pain is
What other things must you look for in examination for a patient with right iliac fossa pain?
- Acutely unwell
- Scars
- Abdominal distension
- Cervical lymphadenopathy
- Masses
- Bowel sounds
- Hernias
- Rectal exam
- External genitalia
How can you tell if a patient is acutely unwell?
- febrile
- tachycardic
- hypotensive
- tachypnoeic
What scars do you look for?
abdominal e.g. if still have appendix and previous abdominal surgery make SBO more likely as postsurgical adhesion
Why do you look for abdominal distention?
see if SBO
Why do you look for cervical lymphaedopathy with right iliac fossa pain?
rule out mesenteric adenitis - usually follows an upper respiratory tract viral infection - most difficult condition to differentiate from appendicitis in young people
What sort of masses may cause RIF pain?
- greater omentum can wrap around inflamed organs, and create a localised mass
- tumour
- rectus sheath haematoma
What condition causes bowel sounds to be absent?
ileus
What would tinkling bowel sounds suggest?
SBO
Why do you check for hernias?
cause of SBO
What are you looking for on a rectal exam in RIF pain?
- constipation to see if due to rectal mass
2. see if blood due to IBD, bleeding Meckel’s or ceacal diverticulum
Why must you examine external genitalia with RIF pain?
- torsion
- epididymitis
- orchitis
- can present with referred pain to abdomen due to T10 symapthetic
What blood tests would you order for RIF pain?
- FBC
- CRP
- VBG
- U+Es
- Serum amylase or lipase levels
- Glucose
- Liver enzymes
Why would WCC be elevated with RIF pain?
inflammatory conditions:
- appendicitis
- cholecystitis
- basal pnuemonia
What are the signs of ischaemia or severe sepsis on a VBG?
- Raised lactate and/or metabolic acidosis
1. pH <7.35
2. low/normal CO2
3. BE
Why do you measure U+Es in RIF pain?
- establish baseline electrolytes
2. urea used as a prognostic factor for pancreatitis (glasgow criteria)
When is serum amylase or lipase very high?
pancreatitis (3x)
When is there a slight rise in serum amylase or lipase levels?
- bowel obstruction
- mesenteric ischaemia
- posteriorly perforated duodenal ulcer
- mumps
- pancreatic carcinoma
- opiate medications
Why do you measure gluocse in RIF pain?
- Check for diabetic ketoacidosis
2. part of glasgow score for pacreatitis
When do you measure liver enzymes in RIF pain?
- Prognostic info for pancreatitis
2. Essential if clinical suspicion of biliary pathology
What urine tests do you do for RIF pain?
urinanalysis
When could you have haematuria in RIF pain?
- infection
- renal/ureteric calculi
- rarely inflamed pelvic appendix
What would glucose and ketones in urine with RIF pain suggest?
diabetic ketoacidosis
What a combo of positive leucoytes esterase and nitrates with RIF pain suggest?
UTI
What would proteinuria and RIF pain suggest?
UTI and appendicial irritation of bladder can result in proteinuria (distinguished by performing urine microscopy looking for bacteria, which could confirm UTI)
What imaging is used for RIF pain?
abdominal US
Why do you carry out an abdominal US in RIF pain?
- biliary pathology
- appendicitis
- can also detect free fluid in abdomen
- female gynaecological pathology
What other investigations would you use for RIF pain?
- Erect CXR
- Abdominal CT
- ECG
- ABX
When do you perform a erect CXR in RIF pain?
any suspicion of perforated viscus
What would air under diaphragm in erect CXR suggest?
- perforated peptic ulcer
- Meckel’s diverticulum
- caecal diverticulum
- appendix
When would you use a abdominal CT in RIF pain?
- balance time and risk of radiation
2. useful for determining extent of intra-abdominal collections and masses
When do you peform an ECG in RIF pain?
if tachycardia to confirm they have standard sinus tachycardia
When is a ABX every useful?
- Bowel obstruction (look for dilated loops of bowel)
- Known IBD to rule out toxic megacolon
- Look for foreign body
What are the key features of mesenteric adenitis?
- Follows upper respiratory tract infection or sore throat (cervical lympathednopathy may be present)
- Pain more diffuse and signs of peritonitis often absent (unlike in appendicitis)
- Often settles quickly
- Occassionaly raised temp
What is the management of acute appendictis?
- IV fluids to manage tachycardia
- Analgesia
- 1st Line: appendectomy (open or laprascopic)
- Nil by mouth prior to surgery
- Perioperative broad-spectrum antibiotics to reduce wound infection and abcess formation
- DVT prophylaxis
What is DVT prophylaxis?
- daily injection of LMW heparin
2. elastic compression stockings in calves
What is management of septic shock?
- Call for help
2. Sepsis Six
What is the sepsis six?
- Administer high flow oxygen
- Take blood cultures
- Give broad-spectrum antibiotics
- Give IV fluid challenges
- Measure serum lactate and haemoglobin
- Measure accurate hourly urine output
