Right Iliac Fossa Pain Flashcards
List the differential diagnosis for RIF pain.
Appendicitis Gastroenteritis Ureteric colic Inguinal hernia (especially if strangulated) Mesenteric adenitis Acute pancreatitis Testicular torsion Meckel’s diverticulitis
State two causes of RIF pain that are more common in children.
Intussusception
Mesenteric adenitis
What causes of RIF pain are more common in the elderly?
Caecal pathology (e.g. tumours, volvulus, diverticuli) AAA
List some gynaecological causes of RIF and LIF pain.
Ectopic pregnancy Pelvic inflammatory disease Mittelschmerz Torsion/rupture/haemorrhage of an ovarian cyst or tumour Salpingitis Threatened abortion Fibroid degeneration Uterine dehiscence
What is pelvic inflammatory disease?
Acute or chronic infection of the ovaries, fallopian tubes and uterus, usually resulting from an infection ascending from the vagina
Chlamydia trachomatis and Neisseria gonorrhoeae are causative agents
What is Mittelschmerz?
Mid-cycle RIF/LIF pain caused by rupture of the ovarian follicle
List some causes of RIF/LIF pain that are exclusive to males.
Testicular torsion
Haemorrhage into a testicular tumour
Before laying a hand on the patient, it is important to ascertain how much pain they are already in. State two ways in which you can assess how much pain they are in without touching them.
Ask them to cough
Ask them to suck their tummy in as far as possible and then puff it out again
(Ask them to look at their toes when lying down)
List some features of examination that would suggest that the patient is acutely unwell.
Tachypnoea
Tachycardia
Fever
Hypotension
Why is it important to take note of any surgical scars the patient may have on their abdomen?
Previous surgery increases the risk of post-surgical adhesion
Adhesions can lead to bowel obstruction
Why is it important to check for cervical lymphadenopathy in a patient with RIF pain?
Mesenteric adenitis is often preceded by an upper respiratory tract viral infection
This viral infection can cause cervical lymphadenopathy
NOTE: mesenteric adenitis is very difficult to distinguish clinically from appendicitis
What can cause absent bowel sounds?
Occurs if there is a functional bowel obstruction (e.g. paralytic ileus)
What can cause tinkling bowel sounds?
Small bowel obstruction
Why is it important to check for hernias in a patient with RIF pain?
Hernias can become strangulated and cause small bowel obstruction
What useful clues may be gained from performing a DRE?
Constipation
Masses
Blood (suggests inflammatory bowel disease, Meckel’s diverticulum bleed or caecal diverticular bleed)
Why is it particularly important to examine the external genitalia of men with RIF/LIF pain?
Testicular torsion and strangulated inguinal hernias can cause RIF/LIF pain
Where is pain caused by testicular torsion, epididymitis and orchitis referred?
It is referred to the abdomen via T10 innervation
What is Prehn’s sign?
Elevation of the testes relieves pain in epididymitis but does NOT relieve pain in testicular torsion
Describe how the cremasteric reflex is used to narrow the differential in a male patient with RIF/LIF pain.
The absence of the cremasteric is NOT diagnostic of testicular torsion
However, the presence of a cremasteric reflex strongly suggests that testicular torsion is not the cause of the pain
What is the time limit within which surgery should be performed in a patient with testicular torsion?
6 hours
What form of imaging is sometimes used to aid diagnosis of testicular torsion?
Doppler ultrasound
List some blood tests that may be performed in a patient with RIF/LIF pain.
FBC CRP VBG Serum amylase U&Es Blood glucose Liver enzymes
Why is a VBG important in patients with RIF pain?
High lactate and metabolic acidosis may indicate that there is ischaemia or severe sepsis
Why is blood glucose important to check in a patient with RIF pain?
DKA can present with acute abdomen
DKA can present with acute abdomen
Haematuria – could result from infection, renal/ureteric colic and inflamed pelvic or retrocaecal appendix
Glycosuria and ketonuria – indicates DKA
Positive leucocyte esterase and nitrites – indicates UTI
Proteinuria – can result from UTI or appendiceal irritation of the bladder
List some forms of imaging that may be used in a patient with RIF pain.
Ultrasound – allows visualization of appendicitis and it is good for detecting free fluid Erect CXR – check for perforated viscus Abdominal CT ECG – useful if patient is tachycardic Abdominal X-ray
List some indications for performing an abdominal X-ray.
Foreign body
Toxic megacolon
Bowel obstruction
Describe the typical presentation of mesenteric adenitis.
Usually occurs in children < 15 years
Typically follows an upper respiratory tract viral infection
Cervical lymphadenopathy often present
Clinically difficult to distinguish from appendicitis
What is Meckel’s diverticulum?
It is a remnant of the omphalomesenteric duct that is found in the ileum. This congenital abnormality could become inflamed and mimic appendicitis. It may also contain embryonic remnants of stomach mucosa, which can form a peptic ulcer that could bleed.
Describe a presentation of acute-onset Crohn’s disease that causes RIF pain.
Inflammation of the terminal ileum can cause RIF pain
This symptom is often accompanied by a history of diarrhoea and weight loss
RIF pain can also be caused by gastroenteritis. What other symptoms would help identify gastroenteritis as the cause of the RIF pain?
Vomiting
Diarrhoea
Symptoms seen in close contacts
Describe the typical presentation of renal/ureteric colic.
Waxing and waning loin to groin pain
Often described as being ‘worse than child birth’
Urinalysis often shows microscopic haematuria
Describe the pattern of pain caused by appendicitis.
Initially, the patient will experience low-grade central abdominal pain
This pain will gradually migrate to the RIF over 12-24 hours
It will become more intense
What other clinical feature is strongly associated with appendicitis?
Anorexia – most patients with appendicitis lose their appetite
List some other signs of appendicitis.
Rovsing’s Sign – palpation of the LIF causes more pain in the RIF than the LIF
McBurney’ point tenderness – percussion tenderness at McBurney’s point (1/3 of the way between the right ASIS and the umbilicus)
Psoas Sign – extension of the hip causes pain (suggests that the appendix is retrocaecal)
Cope’s Sign – flexion and internal rotation of the hip causes pain (suggests that the appendix is close to the obturator internus)
Describe the management of appendicitis.
IV fluids
Analgesia
Appendicectomy preparation
Describe the pre-operative preparation for appendicectomy.
NBM for food and non-clear fluids for 6 hours pre-op
NBM for clear fluids for 2 hours pre-op
Peri-operative broad-spectrum antibiotics
DVT prophylaxis
List the criteria for SIRS.
Heart Rate > 90 bpm
Temperature < 36 or > 38
Breathing Rate > 20 or PaCO2 < 32 mm Hg
WCC < 4000/mm3 or > 12,000/mm3
What is sepsis?
SIRS with a confirmed or presumed infectious process
State the Sepsis Six.
High flow oxygen Blood cultures Broad-spectrum antibiotics IV fluid challenge Measure serum lactate and haemoglobin Measure hourly urine output
What is an appendix mass?
This is a complication of acute appendicitis
It if formed when the greater omentum, caecum and/or adherent loops of small bowel wrap themselves around an inflamed/perforated appendix forming a localised mass
