Right iliac fossa pain (oxford clin cases) Flashcards
What are some differentials that come to mind when someone presents with acute right iliac fossa pain?
Appendicitis Inguinal hernia (that has undergone strangulation) Ureteric colic Gastroenteritis Pancreatitis Cholecystitis Pyelonephritis
What diagnoses are more likely in patients with right iliac fossa pain who are children?
Intussecption
Mesenteric adenitis
What diagnoses are more likely in patients with right iliac fossa pain who are of older age?
Tumors
Volvulus
Diverticular disease
AAA
What must you do if a women presents with right iliac fossa pain and why?
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
What are some things you can you do to establish the degree of a patients abdominal tenderness and pain?
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
What conditions is hard to differentiate from appendicitis especially in young patients?
Mesenteric adenitis
What is mesenteric adenitis?
Inflammation and enlargement of the mesenteric lymph nodes
How do you differentiate mesenteric adenitis from appendicitis?
Look for lymphadenopathy- the mesenteric lymph nodes on the abdomen and cervical too
What often causes mesenteric adenitis?
Upper resp tract infection
What would you look for on examination if someone presents with right iliac fossa pain?
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
What blood tests would you do for someone with right iliac fossa pain and why?
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
What imaging might you do for someone with right iliac fossa pain
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
When should you do an abdo x ray?
Only if you suspect bowel obstruction, toxic megacolon or IBD
For what 3 conditions is an abdo x ray useful?
IBD
Bowel obstruction
Toxic megacolon
What symptoms will someone with appendicitis classically present with?
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
What are some differentials when you suspect appendicitis and how can they be ruled out?
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
How is appendicitis mananged?
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
What is an appendix mass?
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
What is an appendix abcess?
An inflamed appendix with a collection of puss
What is the difference between an appendix mass and abcess?
Mass= omentum wrapped around appendix Abcess= contains puss
What is the difference in treatment for appendix mass vs abcess?
Mass= conservative management until mass reduces and then appendicectomy Abcess= needs to be immediately drained
What must you always do if a male patient presents with abdominal pain and why?
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
What is the classical history of someone with mesenteric adenitis?
Upper resp tract infection in the past few weeks
What is mittelschmerz?
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)
What is the difference between SIRS and sepsis?
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)
What is severe sepsis and septic shock?
Severe sepsis= hypotension
Septic shock= severe sepsis that does not respond to fluid resus and requires high dose vasopressors
