DDx of RIF Mass

Prepared by: Nurul Syazwani Ramli (K5)

Introduction
Right

Iliac Fossa (RIF) is an anatomical term that refers to the right-inferior part of the surface of human abdomen It is a way of lo9calising pain and tenderness, scars and lump

Division of Abdomen

Organs of the Abd. Quadrants

Organs of the Abd. Regions

Right Lower Quadrent Pain And Mass:

Intestinal Reproductive

Renal
Psoas abscess Cholecystitis Gallbladder pain (large liver) Perforated posterior ulcer

Right Iliac Fossa Mass/Swelling

Small bowel Ascending colon

Groin Swelling

Approach to the RIF Mass

History Taking
Number (single/multiple) Onset Location Duration Size (increasing) Ass. symptoms (a/w pain or not and etc)

Physical Examination
Inspection Palpation, Percussion rebound tenderness Guarding Auscultation Rectal Exam Pelvic Exam

Approach to the RIF Mass

Laboratory Tests CBC, BUSE, LFT, Urine analysis Urine Pregnancy (depending on DDx) Diagnostic studies Plain Films Ultrasound CT Scan Further Ix depends on Dx

DDx of RIF Mass

Skin & Soft Tissue
Sebaceous cyst Lipoma sarcoma

Bowel
Ca of caecum Crohns mass TB of terminal ileum Appendicular mass / abscess Meckels diverticulum

Gynaecology
Ovarian tumours Fibroid uterus

Male Reproductive System

Undescended testis Ectopic testis

Urological System
Transplanted kidney Ectopic kidney Bladder diverticulum

Blood Vessels
External iliac or common iliac artery aneurysm lymphadenopathy

Acute Appendicitis

Introduction
Appendicitis

is the most common abdominal surgical emergency Luminal obstruction is thought to be the inciting event leading to inflammation and infection of the appendix

Clinical Presentation of Appendicitis

Symptoms o Classical presentation is of a central Colicky abdominal pain which localises to McBurney's point. The central abdominal pain, is visceral and midgut in origin (hence the umbilicus), and the localisation is caused by local peritoneal irritation in the RIF o Associated symptoms: Malaise, nausea, vomiting, anorexia. -In infants : diarrhoea & vomiting may be the only symptoms.

- 40% of patients present atypically. - Atypical presentation more likely if extremes of age, pregnant immunocompromised, or atypical anatomical location of appendix.

O/E
General tachycardia Fever (low grade) Abdomen -Tenderness and guarding at McBurneys point the junction of the middle and outer thirds of a line which joins the umbilicus to the ASIS -Rovsings Sign: Pressure applied in LIF causes increased pain in the RIF -Rebound tenderness

Investigations :
Diagnosed clinically (usually) WBC elevated X-ray if ureteric colic is suspected US for females to role out ovarian pathology

Treatment & Complication

Treatment : appendectomy with prophylactic metronidazole by suppository should be given 1hour preoperatively to reduce the risk of wound infection Complication : 1- appendicular mass : Omentum & small bowel adhere to inflamed appendix Rx: conservative ( IV fluid , analgesics , cefuroxime , metronidazole ) if the mass resolved carry out an interval appendectomy after 3 months, if it gets bigger , it is likely that an appendicular abscess has formed. 2- appendicular abscess : CT to diagnose it Rx: drainage and appendectomy or percutaneous drainage under US or CT control & interval appendectomy is required subsequently .

Meckels Diverticulum

Meckels diverticulum

A true diverticulum of the bowel, located on the antimesenteric border within 100 cm of the ileocaecal valve. Known as the Disease of 2's:

occur in 2% of the population 2 feet from the ileocaecal valve (60cm) 2 inches in length (5 cm) 2 times more common in males 2 types of mucosa, (gastric and intestinal or pancreaatic). 2 major complicarion ( bleeding & obstruction/inflammation )

Clinical feature

Vary greatly and may be noted as an incidental finding. However the Meckels may present with:

- Confirmation of Dx : 99m Tc sodium pertechnetate (Meckels scan) to detect ectopic gastric mucosa.

Acute diverticulitis mimic appendicitis Intussusception Small bowel obstruction Perforation 'Gastric' ulcer type picture (ectopic peptic ulcer on mesentric border of adjacent ileum), due to the presence of gastric mucosa cells; Abdo pain and small-bowel bleeding .

Management
Asymptomatic:

= Incidental finding - if in Children: - Generally removed as a precaution - if in Adults: - Generally left in situ. Symptomatic: = Acute diverticula - Treat as in diverticulitis according to complication they cause.

Most cases are corrected surgically by a wedge excision of diverticulum Broad-based diverticula may require ileal resection.

Crohns Disease

Crohns Disease

Crohns disease (CD) is a chronic relapsing inflammatory condition usually with flare-ups alternating with periods of remission, and an increasing disease severity and incidence of complications as time goes on. The incidence is lower in non-white races. The incidence is rising. Bimodal age distribution:20-40 yrs/60-80 yrs Females are affected more than males 1.2:1 It can affect any part of the gastrointestinal tract from the mouth to the anus.

 For

typical sites & proportion of patients affected see below:

Extensive Small Bowel 5%

Terminal Ileum only 20%

Ileocaecal 45%

Colon only 25%

Other: anorectal, gastroduodenual, oral only 5%

Pathology

Transmural (full-thickness) inflammation of the involved bowel Normal bowel alternates with areas of disease (skip lesions or cobblestoning) Granulomas (non-caseating) are present in one-third of cases Perforation, stricture, and fistula formation may occur

Clinical Features

Diarrhea Abdominal pain (colicky) Weight loss Fever RLQ mass (may mimic appendicitis) and steatorrhea may be present if there is extensive ileal involvement Sxs of complications may be present

Bowel obstruction Fistula formation Intra-abdominal abscess Perianal or perirectal disease Peritonitis, shock and/or sepsis may occur with perforation.

Diagnostic evaluation

Definitive dx of CD is made by colonoscopy, upper GI series with small bowel follow through, and barium enema.

Check stool cultures for bacteria and ova/parasites Fecal leukocytes will be present in stool analysis Abd. X-rays may show perforation (free-air) or obstruction. Abd. CT may show free-air, abscesses, thickened bowel loops or mesentery and fistula formation CBC may reveal anemia and leukocytosis

Nodularity, rigidity, cobblestoning, fistulas, and strictures may be seen.

Management

IV fluids as necessary to correct dehydration NG tubes insertion and NPO may be necessary in acute flare-ups or bowel obstruction Antidiarrheal tx (eg: loperamide) Acute dzs is treated with amunosalicylates, antibiotics and immunosuppressants. Infliximab (TNF-alpha inhibitor) may be useful in acute flae-ups and possibly as a maintenance tx Ileal and/or colon resection may be useful; however, dzs tends to recur around areas of surgery

50% of pts require further surgery w/in 5 yrs.

Ca of caecum and right colon

Introduction

Colon(+rectum) cancer is the 3rd most common cancer after breast and lung. F>M Pathophysiology: majority are adenocarcinoma Site

Rectum 57% Sigmoid 21% Caecum 6% Trans Colon 5% Asc colon 3% Splenic flexure 3% Hep flexure 2%

Synchronous lesions (2 simultaneous colonic sites of ca).Up to 3% of patients have one or more synchronous cancers

Clinical Features

Weight loss, fatique and weakness Change in bowel habits and caliber of stool Right-sided cancers present with right-sided mass, iron def. anemia, postprandial discomfort and occult heme-positive stools Left-sided ca. present with alternating diarrhea and constipation, increased risk of obstruction and haematochezia. Signs of obstruction may be present (eg: nause, vomiting, no bowel movement or flatus, abd. distention)

On examination Usually unremarkable general appearance: pale & thin. tenderness in RIF irregular mass. dull in percussion. normal bowel sound unless obstruction or peritonitis.

Investigation
- Stool: +ve for occult blood. - Blood film: iron def. anaemia. - Barium enema: apple core lesion or constrictions or intraluminal mass. - Colonoscopy :

Investigation of choice Direct observation of whole colon

CEA {carcinoembryonic antigen} should be used as marker for elimination or recurrence

- Tumour marker

and not in the diagnosis [raised]

- ESR: raised

Staging

Earlier staging was done by Dukes classification; however, TNM system is now most commonly used Quick TNM staging:

Stage I : any T1 or T2 lesion and N0 Stage II : any T3 or T4 lesions and N0 Stage III : any T with positive nodes Stage IV : Metastatic dzs (often liver)

Management

Surgical resection is curative for early cancer ( stage I and II ) Surgical resection + adjuvant chemotx is indicated for some stage II lesions and stage III and IV lesions Liver mets may be resected, chemoembolized or direct arterial infusion chemotx into the hepatic artery

Thank You For Listening

Case Scenario