Right iliac fossa pain (oxford clin cases)

Question 1

What are some differentials that come to mind when someone presents with acute right iliac fossa pain?

Answer 1

Appendicitis
Inguinal hernia (that has undergone strangulation) 
Ureteric colic
Gastroenteritis 
Pancreatitis
Cholecystitis
Pyelonephritis

Question 2

What diagnoses are more likely in patients with right iliac fossa pain who are children?

Answer 2

Intussecption

Mesenteric adenitis

Question 3

What diagnoses are more likely in patients with right iliac fossa pain who are of older age?

Answer 3

Tumors
Volvulus
Diverticular disease
AAA

Question 4

What must you do if a women presents with right iliac fossa pain and why?

Answer 4

Pregnancy test
Done to rule out conditions like ectopic pregnancy but also to help balance risk of radiation in investigations with benefit if there is a foetus

Question 5

What are some things you can you do to establish the degree of a patients abdominal tenderness and pain?

Answer 5

Ask them to suck their tummy in as much as they can and then puff it out- intense pain will stop them from doing this

Ask them to cough- patients in a lot of pain will be reluctant to cough properly

Palpate starting in the area of the abdomen that they say the pain is and observe their face for pain

Question 6

What conditions is hard to differentiate from appendicitis especially in young patients?

Answer 6

Mesenteric adenitis

Question 7

What is mesenteric adenitis?

Answer 7

Inflammation and enlargement of the mesenteric lymph nodes

Question 8

How do you differentiate mesenteric adenitis from appendicitis?

Answer 8

Look for lymphadenopathy- the mesenteric lymph nodes on the abdomen and cervical too

Question 9

What often causes mesenteric adenitis?

Answer 9

Upper resp tract infection

Question 10

What would you look for on examination if someone presents with right iliac fossa pain?

Answer 10

Does the patient look unwell?- fever, tachycardia, sweating etc
PR exam
Abdominal masses- greater omentum can wrap around inflamed organs making a mass
Hernias- hiatus, inguinal etc
External genitalia- especially if male, you have to check for testicular torsion
Scars
Abdominal distention
Bowel sounds

Question 11

What blood tests would you do for someone with right iliac fossa pain and why?

Answer 11

FBC- look for anaemia, look for infection (raised WCC or neutrophilia)
CRP/ESR- to look for signs of inflammation
Glucose- diabetic ketoacidosis may present w abdo signs
LFTs- look for liver and pancreas pathology
Amylase/lipase- check for possible pancreatitis
U&Es- for baseline, raised urea may be pancreatitis
VBG- lactate or acidosis indicates ischaemia or sepsis

Question 12

What imaging might you do for someone with right iliac fossa pain

Answer 12

Ultrasound- to check the biliary tree, check for abdo fluid
Chest x ray- to look for air under diaphragm if you suspect perforation (of ulcer, viscus etc)
Abdominal CT- note this is a high dose of radiation but may be useful for determining extent of masses
Abdo x ray- do not do unless you suspect bowel perforation, IBD or toxic megacolon

Question 13

When should you do an abdo x ray?

Answer 13

Only if you suspect bowel obstruction, toxic megacolon or IBD

Question 14

For what 3 conditions is an abdo x ray useful?

Answer 14

IBD
Bowel obstruction
Toxic megacolon

Question 15

What symptoms will someone with appendicitis classically present with?

Answer 15

Abdominal pain and tenderness that started in the epigastrium or umbilical region and radiates to localise in the right iliac fossa over a couple hours
Anorexia
Lack of bowel movements
Fever, tachycardia

Question 16

What are some differentials when you suspect appendicitis and how can they be ruled out?

Answer 16

Pancreatitis- pain should be in the epigastrium not just the RIF, amylase and lipase may be very high

Mesenteric adenitis- lymph nodes in the abdomen and cervix will usually be palpable, more common in young children

Ureteric colic- the patient will be writhing in pain and not lying still

Acute onset crohns- there will usually be a past history of weeks of abdo pain and weight loss

Gastroenteritis- pain will not shift and localise, nausea and vomitting will be the main symptoms

Question 17

How is appendicitis mananged?

Answer 17

First line is surgical removal (appendicectomy)
The patient should be nil by mouth and on clear fluids before surgery
Perioperative abx and dvt prophylaxis should be given
Analgesia should also be given

Question 18

What is an appendix mass?

Answer 18

When the appendicitis results in a milder inflammation with more tolerable pain so people may wait for a few days until presenting to the hospital. In the meantime the omentum wraps around the inflammed appendix creating a mass

Question 19

What is an appendix abcess?

Answer 19

An inflamed appendix with a collection of puss

Question 20

What is the difference between an appendix mass and abcess?

Answer 20

Mass= omentum wrapped around appendix
Abcess= contains puss

Question 21

What is the difference in treatment for appendix mass vs abcess?

Answer 21

Mass= conservative management until mass reduces and then appendicectomy 
Abcess= needs to be immediately drained

Question 22

What must you always do if a male patient presents with abdominal pain and why?

Answer 22

Examine their external genitalia to check for testicular torsion as it is a surgical emergency and needs to be fixed within 6 hours for good outcomes

Question 23

What is the classical history of someone with mesenteric adenitis?

Answer 23

Upper resp tract infection in the past few weeks

Question 24

What is mittelschmerz?

Answer 24

A condition wherein theres abdominal pain in the middle of the menstrual cycle (around ovulation day, some women can actually tell which ovary is releasing an egg), it is relatively common (1 in 5 women)

Question 25

What is the difference between SIRS and sepsis?

Answer 25

SIRS= systemic inflammatory response syndrome where the body responds to proinflammatory processes that are not just infection eg pancreatitis, PE etc

Sepsis= SIRS due to infection (suspected or proven)

Question 26

What is severe sepsis and septic shock?

Answer 26

Severe sepsis= hypotension

Septic shock= severe sepsis that does not respond to fluid resus and requires high dose vasopressors