right iliac fossa pain
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Cureus ◽  
2021 ◽  
Author(s):  
Alya A Khashoggi ◽  
Nouf A Hakami ◽  
Majdoleen A Alghamdi ◽  
Hussam Y Ayed ◽  
Ali D Alqarni ◽  
...  

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Ahmed Salman Bodla ◽  
Chinedu Ndegbu

Abstract Aims Acute surgical presentations and management approaches have witnessed a changing pattern occasioned by COVID-19 pandemic and attendant lockdown. We report the spectrum of right iliac fossa (RIF) pain referrals and management trend within an acute surgical unit before and during the National lockdown. Methods A retrospective review of all patients referred to the acute surgical unit with RIF pain before and during first National lockdown was undertaken. Patients managed during these periods were segregated into Pre-Lockdown (January-2020) and Lockdown (April/May-2020) cohorts. Relevant data were obtained from patients’ electronic medical records and main outcome measures compared between both arms were definitive diagnosis, rate of acute appendicitis, diagnostic imaging modality utilised, management approach and post-operative 30-day complications. Results RIF pain referrals were fewer (17% vs. 23%, P = 0.045) but more likely to be related to acute appendicitis during the lockdown (52% vs. 28%, P = 0.002). However, the risk of presenting with complicated appendicitis did not alter significantly (26% vs. 19%, RR = 1.34, P = 0.56). Diagnostic imaging was increasingly deployed (for RIF pain: 91% vs. 74%, P = 0.07; for appendicitis: 77% vs. 42%, P = 0.007) especially computerised tomography scan (45% vs. 31%). Increased adoption of conservative approach in the management of acute appendicitis was significant (61% vs 23%, RR 2.65, P = 0.01) although other outcomes such as length of stay, post-operative complication and 30-day re-presentation rates were comparable to pre-lockdown phase. Conclusion Fewer RIF pain but more likelihood of acute appendicitis, increased use of radiological imaging and conservative approach to management reflect an evolving pattern during the lockdown phase.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Heather Davis ◽  
Caitlin Marshall ◽  
Md Abu Kamal Nahid ◽  
Ankur Shah

Abstract Case report A 43-year-old woman presented with acute onset migratory right iliac fossa pain, on a background of intermittently painful right groin swelling. CT demonstrated differential diagnosis of appendicitis besides an ovarian cyst. Diagnostic laparoscopy was undertaken with a view to diagnosis and treat possible appendicitis, ovarian cyst and inguinal hernia. To our surprise, a haemorrhagic nuchal cyst was seen intraoperatively, and duly aspirated. Post-operatively she recovered well and was discharged the same day. Introduction The Canal of Nuck is a small evagination of parietal peritoneum which accompanies the round ligament through the inguinal canal, in females. It is obliterated in the first year of life. When this remains patent, it can fill with fluid and result in the formation of cysts (akin to hydroceles in patent processus vaginalis). In current literature there are only sixteen case reports of Nuck hydroceles in adults, with only one haemorrhagic cyst reported. These are typically diagnosed in children, but occasionally present in women (aged 35.18 ± 3.27) with groin swelling and are frequently misdiagnosed as hernias. It is only when these woman are taken to theatre, that the correct diagnosis is discovered. Conclusion This case highlights the importance of considering Canal of Nuck cysts when women present with groin swellings, to ensure quick diagnosis and appropriate management is delivered under the correct speciality.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Lará Armstrong ◽  
Conor McGuigan ◽  
Muhammad Yousaf

Abstract Background Acute appendicitis remains the most common acute surgical presentation among children and adults. Ultrasonography is a commonly used investigation for patients with right iliac fossa pain were the diagnosis is unclear, however in a district general hospital (DGH), appropriate radiologists are not often readily available. The aim of this study was to determine the value of ultrasonography in the diagnosis of appendicitis in children. Methods A retrospective review was carried out of all paediatric patients (aged 5-16), who underwent an appendicectomy in a single acute surgical unit, over a 6 month period.  An institutional database and up to date electronic care records were used to record preoperative ultrasound results, intraoperative findings and histopathology results. Results A total of 59 patients were admitted with possible appendicitis within the audit window, 31 of which underwent an appendicectomy, 58% performed laparoscopically.  38.7% underwent pre- operative ultrasound, 33.3% of which identified an acutely inflamed appendix. The remaining patients who did not proceed to theatre were successfully discharged with no re-attendance following a period of observation. Following histopathological confirmation, ultrasonography was found to have a sensitivity and specificity of 100%. Negative appendicectomy rate returned at 6.7%. Conclusion Ultrasonography is a low cost, highly sensitive diagnostic tool in appendicitis, where provisions are in place to do so. Visualising the appendix on ultrasound can reduce negative pathology rates. This is a small study within a DGH and access to ultrasound is limited. Better utilisation or the development of a protected ultrasound slot should be sought.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Abhishek Dey ◽  
Nicholas Symons

Abstract Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately. An 29 year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis. On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed. The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief. This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Abhishek Dey ◽  
Mohamed Elmasry ◽  
Robert Marshall

Abstract Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis or high intraluminal pressures. Enterolith formation within these diverticula and intra-luminal bowel obstruction from them are a less encountered complication. A seventy-five year old man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces were noted on rectal examination. Biochemistry indicated raised inflammatory markers and an acute kidney injury. Abdominal CT scan revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract suggestive of passage of gallstone to ileum. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.


2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Laura Ballance ◽  
Chloe Withers ◽  
Dheepa Nair ◽  
Simon Galloway

Abstract Background Right iliac fossa pain is a common presenting complaint in males. Ultrasound is a cheap non-invasive investigation, yet results can be non-diagnostic. CT is becoming more accessible and available for patient assessment. Aim Our primary aim is to estimate how many unnecessary US scans are gained prior to CT imaging, thereby delaying surgery, increasing cost and increasing length of stay (LOS). Method We conducted a retrospective analysis of all male patients over the age of 16 admitted to a single unit with RIF pain over 12 months. Outcome and length of stay was recorded. Results 162 male patients were admitted to a single University teaching hospital between 2017 and 2018. 33% (n = 53) of patients having an US scan require further imaging, 40% ( n = 21 ) of these had a surgical pathology, 80% (n = 17) of these requiring appendicectomy. Patients (n = 39) who had an initial CT scan subsequently requiring surgery length of LOS 3.6 days compared with US imaging with additional imaging requiring surgery ( n = 17) LOS 5.8 days. Conclusion Evaluation of practice of males over the age of 16 shows that US is frequently non diagnostic, requiring further investigation with CT or MRI. Imaging initially with CT scan aid diagnosis and decrease length of stay. An education steering committee of surgical trainees, consultants and radiographers has been created to adapt practice in our centre through continued education and training.


2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Dey ◽  
N Symons

Abstract Appendicitis involving the appendix stump is a recognised post appendicectomy complication but the same involving the appendiceal tip is rare. Similarly, abdominal wall abscess secondary to retained appendicolith is also infrequently encountered. Our case highlights a rare combination of both complications arising separately. A 29-year-old man presented with 3 days of generalised malaise and progressively worsening right iliac fossa pain some ten months after a laparoscopic appendicectomy. This had been complicated by residual right iliac fossa inflammation that was treated conservatively and serial scans demonstrated gradually resolving inflammation. He also had well controlled ulcerative colitis. On examination, he was noted to be pyrexial with a tender fluctuant mass in the right flank. An ultrasound scan demonstrated inflammatory changes in the abdominal wall with no intra-abdominal collections. A diagnostic laparoscopy found an inflamed appendix tip, attached to the residual mesoappendix and embedded in the abdominal wall behind the mid-ascending colon. A completion appendicectomy was performed. The patient recovered well but returned 4 months later with persistent pain and a fluctuant mass over the right iliac fossa. Radiological investigation revealed an abdominal wall collection containing a calcified appendicolith. The collection was refractory to ultrasound guided drainage and an exploration of the abdominal wall allowed extraction of the appendicolith followed by symptomatic relief. This case emphasizes the importance of complete excision of the appendix and extraction of debris, which can be challenging when the appendix lies in a retro-colic position.


2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
M Barghash ◽  
A Iskandar ◽  
S Fawzy ◽  
B Ali

Abstract Aim Ultrasound scan is a crucial clinical tool in the management of acute appendicitis in children. That is because it can aid in the diagnosis without exposing the patient to potentially harmful ionising radiation from computed tomography scans. In this project, we were assessing whether children presented with right iliac fossa pain receive their scans on time. In addition, we were exploring whether definitive management and hospital length of stay were affected by the scan delay. Method This was a retrospective project in which we assessed case notes of paediatric patients who had an ultrasound scan between September 2019 and September 2020 in one of the district general hospitals in the UK. The project included notes of patients who were below 16, admitted with right iliac fossa pain, and had an inpatient ultrasound scan. Results A total of 33 patients met the inclusion criteria. The waiting time ranged from 1 hour to 89 hours with a mean of around 19.5 hours and a median of 14.5 hours. The hospital length of stay ranged from 1 day to 21 days with a mean of around 2.5 days and a median of 1 day. Conclusions An ultrasound scan should be conducted within the same day of admission for all paediatric patients presented with right iliac fossa pain.


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