Right Iliac Fossa Pain

Question 1

What are the surgical emergencies in a male with RIF pain?

Answer 1

Appendicitis
Acute pancreatitis
Testicular torsion
Meckel's diverticulitis
SBO
Caecal volvulus
Perforated peptic ulcer
Pyenephritis
Diabetic ketoacidosis
Cholecystitis

Question 2

Mesenteric adenitis vs appendicitis?

Answer 2

Typically follow an UTRI or sore throat (thus cervical lymphadenopathy)

Most common in children less than 15

Pain often more diffuse than adendicitis, and signs of peritonitis are often present

Doesn’t result in rectal tenderness

Question 3

Acute onset Crohn’s vs appendicitis?

Answer 3

Acute signs and symptoms would mimic appendicitis

There is often a history of diarrhoea and weight loss for weeks/months leading up to the acute presentation

Question 4

What may occur if presentation of appendicitis to A&E is delayed?

Answer 4

Appendix mass

The greater omentum, caecum, and/or adherent loops of SB wrap themselves around the inflammmed

Question 5

What is mittelschmerz?

Answer 5

A relatively common condition (affecting one in five menstruating women) characterised by pain mid cycle

Can appear suddenly and usually subsides within hours

Sometimes localised enough that women can tell which ovary is providing the egg

Question 6

What are the main causes of appendicitis?

Answer 6

Obstruction by faecolith or foriegn body in the lumen of the appendix

Lymphoid hyperplasia of Peyer’s patches

Fibrous strictures at the base of the appendix following previous inflammation

Rare cause is carcinoid tumour (most commonly found in the appendix)

Question 7

Which two incisions are commonly used for appendectomy?

Answer 7

Gridiron incision - Perpendicular to the imaginary line between the umbilicus and the ASIS, and centred over McBurney’s point (rarely used)

Lanz incision - Placed slightly lower in the RIF, starting about 2cm medial to the ASIS, and follow a more horizontal course (follows skin creases)

Question 8

In the presence of a normal appendix during the operation what does the surgeon do? Why?

Answer 8

One of the differential of appendicitis is an inflamed/ruptured Meckel’s diverticulum, so the surgeon inspects the distal 2 feet of the terminal ileum

They remove it anyway usually

(inflamed appendix is lily white)

Question 9

What is the relationship between appendicectomy and IBD?

Answer 9

Appendicectomy appears to protect against the development of UC

Patients who do develop UC post-appendectomy are less likely to develop recurrent symptoms and less likely to require colectomy

Risk of Crohns is increased during the first few years after appendicectomy (but may be due to misdiagnosis of appendicitis though)