8.RIF MASS CASE PRESENTATION.pptx general

Surgery

1. RIGHT ILIAC FOSSA MASS J.VIGNESH MANI SANKAR Guide: Dr .Mohammed Arsath

2. CASE HISTORY A 67 year gentleman Mr. Ashok , a farmer from irungalur came to the OPD with chief complaints of mass in lower abdomen on the right side for three months

3. History of presenting illness The patient was apparently normal before 3 months after which he noticed a swelling in lower abdomen on the right side which was spontaneous in onset, progressive in nature and gradually increasing to attain the present size. It was not associated with pain . H/o easy fatiguability is present H/o loss of weight present   H/o loss of appetite present

4. No H/o fever No H/o vomiting No H/o loose stools No H/o chronic cough No H/o evening rise of temperature No h/o abdominal distension No h/o hemoptysis No h/o low back pain

5. Past history No H/o of Diabetes mellitus, Hypertension, Tuberculosis, Bronchial Asthma, epilepsy and cardiovascular disorders No H/o of previous surgeries in past Personal history Patient consumes mixed diet He is not an alcoholic and not a smoker Normal bowel and bladder habits and No sleep disturbances Family history No relevant family history

6. General Examination With informed consent , the patient was examined in a well lit room with proper exposure Conscious ,oriented P oorly built and nourished Pallor is present No c yanosis , I cterus , Clubbing , Generalised lymphadenopathy, bilateral pitting pedal edema ,

7. Vitals Pulse rate : 76 beats/min, regular in rhythm ,normal in volume,no specific character,no radioradial and radiofemoral delay Blood pressure : 126/80 mmhg  measured in Rt. Upperlimb in sitting posture Respiratory rate : 20 breaths /min , abdominothoracic Temperature : 98.6 F

8. Examination of Abdomen Patient examined in supine position Exposed from nipple areolar complex to midthigh Inspection Contour of the abdomen -scaphoid Umbilicus is normal in position, inverted All quadrants move with respiration Skin over the abdomen is normal - no dilated veins or scars There is no visible intestinal peristalsis No visible pulsations Hernial orifices- free External genitalia-normal 

9. Palpation There is no warmth or tenderness. A mass of size 4x5cm in right iliac fossa with ill defined margins other than lower margin, hard in consistency , lower margin is 2 cm from ASIS, surface is not smooth,and not mobile C arnett test – swelling is not prominent suggestive of intra abdominal swelling All other quadrants are normal Hernial orifices are free External genitalia is normal No enlargement of left supraclavicular node Percussion Liver span - 14cm  Mass is dull No shifting dullness

10. Auscultation Bowel sounds are heard Digital Rectal examination Not done Other system examination Cvs - S1 and S2 heard Rs-normal breath sounds are heard Spine and cranium-normal

11. SUMMARY A 67 yr gentleman Mr. Ashok with chief complaints of mass for 3 months ,H/o of easy fatiguability and loss of weight and appetite , with signs of pallor, a irregular mass of 4 X 5 cm in right iliac fossa , with ill defined borders other than lower margin ,hard in consistency, surface is not smooth and the swelling is not prominent in carnett test Provisional diagnosis – a case of Right iliac fossa mass probably due to carcinoma caecum

12. Questions Why carcinoma caecum ? What are the differential diagnosis ?

13. DIFFERENTIAL DIAGNOSIS Appendicular mass Ileocaecal tuberculosis Amoeboma Iliac adenitis Actinomycosis Iliopsoas abscess Retroperitoneal tumors Undescended testis Undescended kidney

14. Investigations 1.Complete blood count 2.Stool for occult blood 3.colonoscopy 4 .CECT abdomen 5 .USG 6 .Chest X-ray PA view   

15. Questions 1 .Stool for occult blood- why ? 2 .Colonoscopy – why ? What is the advantage ? 3 .CECT abdomen – role ? 4.Mode of spread ? 5.Signs of advanced malignancy – clinically and radiological ? 6.Tumour marker ?

16. Treatment Right hemicolectomy with side to end ileotransverse anastomosis 

17. Questions What are the structures removed in right hemicolectomy ? Reconstruction ? What is Turn Bull Technique ? Adjuvant Therapy ? Advanced lesion with intestinal obstruction ?

18. CARCINOMA CAECUM 3 RD Most common site after RECTUM AND SIGMOID SPORADIC CRC--- High Calorie Diet, Red Meat, Alcohol and Smoking, Sedentary lifestyle FAMILIAL CRC– FAP , HNPCC, Cowden syndrome, Peutz Jeghr Syndrome NON FAMILIAL– Previous History of Adenomatous Polyps, Inflammatory Bowel Disease– Ulcerative Colitis

19. CARCINOMA CAECUM—INVESTIGATIONS BLOOD INVESTIGATIONS Complete Blood count--- Anemia LFT --- Sr. CEA levels—(Not Diagnostic).. Helpful in Follow up COLONOSCOPY 1. For Visualisation and the extent of the lesion (5 % are synchronous) 2. For the biopsy RADIOLOGICAL Initially Non invasive USG ABDOMEN AND PELVIS– CECT ABDOMEN(contrast enhanced)— To look for extent of the lesion, Posterior infiltration (to muscles or the ureter), lymph node status, liver secondaries , and pelvic deposits CHEST X RAY /CT CHEST– TO rule out Lung Secondaries

20. TREATMENT PRINCIPLES Assessment of Local and Distant Tumor spread Synchronous tumors occurs in 5 percent of patients Surgery -  to remove the primary tumor and its draining regional lymph nodes Histological examination of resected tumors decision for the need for adjuvant therapy

21. SURGERY If Resectable Right Hemicolectomy Structures removed are 1.Terminal ileum of about 20 cm, Caecum, Appendix, Ascending colon, Hepatic flexure, Transverse colon medial 1/3 rd And RECONSTRUCTION OF EITHER End To End or End To Side Ileo Transverse Anastomosis

22. If Not Resectable in Advanced cases, 1.if patient presents with obstruction- Palliative Side to side Ileo Transverse Anastomosis and Palliative Chemotherapy 2.If without obstruction-- Palliative Chemotherapy

23. Questions What is appendicular Mass ? Treatment ? What is the treatment for appendicular abscess

24. TREATMENT Only Conservative Treatment 2.” OCHSNER SHERREN REGIMEN” Nil Per Oral (NPO)---for bowel rest Continuous Ryle’s Tube Aspiration I V Fluids Antibiotics Analgesics and Anti Inflammatory drugs 3.Monitor Pulse Rate Temperature Size of the mass

25. If the patient’s condition improves, continue the conservative management for 5 to 7 days, followed by Interval Appendicectomy 6 to 12 weeks after the initial presentation If the patient’s condition worsens Rising pulse Rate and Temperature Increasing abdominal pain Persistent vomiting Increase in size of mass Repeat the investigations USG , and CT if needed---- APPENDICULAR ABSCESS-- Emergency Surgery

26. APPENDICULAR ABSCESS TREATMENT-  Extraperitoneal Drainage of Abscess Why No Intraperitoneal Approach? Should not convert Localised Perionitis to Generalised Peritonitis

27. What are the Other Appendicular Masses ?

28. Other Appendicular Masses Carcinoid Tumor Mucocele of the Appendix Adenocarcinoma Lymphomas

29. Questions Types of Intestinal TB ? Which type produces mass lesion ? How you confirm the diagnosis ? Treatment ?

30. ILEOCAECAL TUBERCULOSIS Most common site of Abdominal Tuberculosis TYPES; ULCERATIVE HYPERPLASTIC STRICTURE FORMATION LEADS TO ACUTE/SUBAUTE INTESTINAL OBSTRUCTION MASS FORMATION

31. INVESTIGATIONS Complete Blood Count -  lymphocytosis Elevated ESR Radiological initially non invasive USG ABDOMEN THEN TO CECT ABDOMEN COLONOSCOPIC BIOPSY Langhans giant cells, granulomatous lesion

32. TREATMENT ANTITUBERCULAR THERAPY 2.If patient presents with Intestinal Obstruction ( in ulcerative type) Stricturoplasty - -  for short segment strictures Limited Intestinal Resection and Anastomosis--- for long segment strictures under the cover of ATT

33. Thank you i