Approach to right iliac fossa(RIF) pain

Approach to right iliac fossa(RIF) pain.FULL DISCUSSION ON APPENDICITIS WITH OTHER DIFFERENTIAL DIAGNOSIS OF IT. AS WELL AS CLINICAL REASONING DIAGNOSIS AND TREATMENT.

1. Approach to RIF pain Dr Ilavarasan Kannaiyan

2. “Patient is the centre of medical universe around which all our works revolve and towards which all our efforts trend” - J.B Murphy Professor of Surgery, USA

3. RIF PAIN Common condition is our practice Difficult to diagnose

4. Pain Site Duration onset Severity Character Continuous or intermittent Migration radiation

5. Associated symptoms Vomiting Nausea Loss of appetite Loose stools Constipation Hematochezhia , malena Fever Dysuria, hematuria, calcaluria , pyuria Missed periods Difficulty to walk/move Skin rash on back

6. Symptoms of other systems cough Throat pain Chest pain

7. Past history Similar episodes Surgery done Travel to abroad TB, HIV, Crohn’s disease,Malignancy Relevant medical history

8. Family history Incidence of appendicitis, ureteric colic in family

9. Clinical examination Vitals- general condition Look for jaundice and pallor Cynosis . Generalised lymphadenopathy , pedal edema.JVP. Look for evidence of generalised peritonitis- tachycardia,tachypnoea , falling bp

10. abdomen Movement with respiration Redness, swelling, scar .dilated veins Organomegaly Guarding, rigidity Mass palpable Tenderness over which quadrant Scrotum and testes

11. Specific signs Rebound tenderness Rovsing’s sign Cough impulse testicular tenderness Renal angle tenderness Herpetic patch

12. investigations Cbc Crp,esr Urine r/e, UPT Stool r/e ABD xray erect, KUB U/S abd and pelvis CT abd

13. ACUTE GENERAL SURGICAL RGICAL GYNECOLOGICAL Appendicitis, perforation,Abscess / mass formation Ruptured ectopic Ureteric colic Twisted/Ruptured Ovarian cyst Torsion tesits Obstructed hernia Mittleschmerz - ovulation time Mesentric adenitis Psoas abscess OTHER CONDITIONS: Epididymo orchitis Pelvic adenitis Pleuritic pain Disc compression/ Neuralgia Herpes zoster Cholecystitis Faecal impaction Intussussception Liver abscess Amoebic / entero colitis Ilio caecal TB Diverticulitis Crohn’s disease Caecum / colonic tumour / malignancy

14. ACUTE APPENDICITS Sudden onset pain, in some peri umbilical pain migrates to RIF Loss of appetite, nausea, vomiting Fever comes later constipation No involvement of CNS and Respiratory symptoms

15. Clinical signs General- pulse about 80-90 in most , but if perforated or abscess tachy Mild elevated temperature, more in abscess P/A tender RIF McBurneys point Rebound – Blumberg’s sign- in children pain on cough/ hopping/ percussion Rovsing’s – pressure on LIF causes pain over RIF Obturator sign- rotating hip with flexion of knee Psoas sign – hyper extension of hip Aaron’s sign – pain over epigastrium on pressing McBurney’s point

16. MCBURNEY’S POINT

17. M A N T R E L S

18. INVESTIGATIONS CBC CRP/ESR URINE R/E, UPT Plain Xray abd U/S abdomen CECT

19. Biomarkers for Appendicitis Serum and urinary CP - calprotectin and LRG - leucine -rich alpha glycoprotein-1, in children. PCT - Procalcotonin , IL6 - interleukins, urinary5HIAA - 5 hydroxy indole acetic acid

20. Management - Mainly surgical Rarely conservative in early cases

21. prevention High fibre diet prevents appendicits in siblings

22. Mesentric adenitis Common DD for appenditis Evidence of generalised symptoms like fever, URI,Gastroenteritis VIRAL and Bacterial causes- common organism- yersinia enterocolitica Pain less marked Tenderness reduced on left lateral position Less peritonitis features

23. INVESTIGATIONS CBC/ CRP/ ESR Stool r/e, c/s U/S ABD

24. Management conservative antibiotics

25. RENAL / URETERIC COLIC Commonest condition in Khasab Risk factors Poor water intake Diet rich in animal proteins – meat/dairy products Hyperparathyroidism Metabolic abnormalities

26. Renal / ureteric colic

27. Ureteric colic Locaction of stone Area of pain Renal pelvis / upper ureter Testes in males / labia majora in females Mid ureter Lumbar / illiac fossa Lower ureter Upper thigh,scrotum , perineum intramural suprapubic / tip of penis with strangury

28. Clinical features Symptoms of groin to loin pain, dysuria , frequency, strangury . Hematuria . Calcaluria Less or no GI symptoms Marked tenderness in renal angle / RIF/ suprapubic regions Absence of peritonitis features- rebound tenderness Changing areas of tenderness

29. investigations Urine r/e – look for RBCs, crystals, pH,type of crystals – oxalates / uric acid Urine C/S RFT, uric acid, calcium KUB xray – 90% stones visible in well prepared one U/S pick up dilated collecting systems, less specific for stones Spiral CT – investigation of choice for ureteric calculus

30. KUB Xray

31. PLAIN CT

32. Management 5mm or < - conservative treatment Inj Diclofen well tolerated even in G6PD deficient Treatment of associated UTI Rest- ESWL, Ureteroscopy . Laser, PCNL Open surgery

33. Diet Urine volume > 2litres/ day in patients with normal RFT Avoid airated / fizzy drinks – high citrate and fructose level Black tea,dark chocholates , straw berries, spinach Nuts- almond> peanits >cashew> pistaccios

34. prevention

35. Foods High in uric acid

36. Faecal impaction Can produce pain in RIF , common in children History of constipation and straining at stool CBC CRP- Will be normal To r/o Hypothyroidism in recurrent cases X ray abdomen will give clue

37. Plain Xray abdomen

38. Management Phosphate enema Diet modification

39. Irreducible hernia Pt may not have noticed swelling earlier Can be missed easily in usual clinical examination Cough impulse may be absent Good exposure and examination Admission and observation essential to manage pt

40. Herpetic neuralgia Sudden onset severe pain, may be burning in nature No GI symptoms Patient may not have seen the rash Can mimic appendicitis

41. Herpes zoster

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