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Published in Anna Kowalewski, SBAs and EMQs in Surgery for Medical Students, 2021
This patient is most likely suffering from appendicitis. Right iliac fossa pain accounts for half of all cases of acute abdominal pain, and in only half of those suspected to have appendicitis is the preoperative diagnosis correct. Note, causes of right iliac fossa include appendicitis, urinary tract infection, non- specific abdominal pain, pelvic inflammatory disease, renal colic, ectopic pregnancy and constipation. Remember the bimodal distribution for appendicitis – the second peak is in later life.
Appendectomy
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Acute appendicitis is usually diagnosed on the basis of the classical clinical symptoms of migratory right iliac fossa pain, nausea, right lower quadrant tenderness, and fever. Children aged over 5 years more often experience a longer delay in diagnosis and higher incidence of perforation. Every effort should be made to confirm the diagnosis of appendicitis before surgery. Formerly reported rates of negative explorations (20–40%) are no longer acceptable. Repeated clinical examinations and appropriate imaging should reduce the negative rates below 10%. Abdominal US is an excellent and accurate screening tool for acute appendicitis. Computed tomography (CT) has slightly higher sensitivity and specificity than US, but the radiation dose remains a significant concern. Therefore, CT with minimized radiation dose is preserved for special situations and complicated patients with an unclear diagnosis and increased operation risk. Significant medical conditions causing appendicitis-like symptoms should be ruled out by clinical examination, laboratory tests, and imaging. These include right basal pneumonia, cholecystitis, meningitis, urinary tract infections, Henoch–Schönlein purpura, and acutely presenting ketoacidosis of type 1 diabetes.
Emergency medicine
Published in Roy Palmer, Diana Wetherill, Medicine for Lawyers, 2020
Appendicitis classically presents with a history of gradually worsening abdominal pain which is originally central in situation but which migrates to the right iliac fossa, and which is associated with a mild fever, nausea/vomiting and bowel disturbance, which could be either diarrhoea or constipation. On examination the patient is tender in the right iliac fossa, i.e. low down on the right side of the abdomen, and may be guarding the area, i.e. reflexly tensing the muscles of the anterior abdominal wall to prevent the examiner’s hand exerting pressure on the inflamed contents. A rectal examination may be helpful in eliciting tenderness high up on the right side but unfortunately there is no diagnostic investigation, although the patient’s white blood cell count may be elevated.
Incidentally found mucinous epithelial tumors of the appendix with or without pseudomyxoma peritonei: diagnostic and therapeutic algorithms based on current evidence
Published in Acta Chirurgica Belgica, 2021
Wim Ceelen, Marc De Man, Wouter Willaert, Gabrielle H. van Ramshorst, Karen Geboes, Anne Hoorens
When the diagnosis is made on imaging studies, the first step is to exclude extra-appendiceal disease using either CT scan or diffusion-weighted MR imaging. When PMP is found, the appropriate algorithm applies (Figure 2). When the disease is limited to the appendix, the patient should undergo a (laparoscopic) appendectomy that should encompass the mesenteriolum, which is a peritoneal duplicature that connects the appendix with the mesentery of the ileum. In patients with large mucinous tumors (e.g. mucocele), care must be taken to avoid rupture and spillage of the cystic contents. When the tumor extends to the base of the appendix, a caecal wedge resection should be performed. During the same procedure, the peritoneal surfaces should be thoroughly inspected. Areas at risk include the right iliac fossa, right paracolic gutter, right diaphragmatic surface, greater omentum, and pelvic peritoneum. Any suspicious lesions should be biopsied. In female patients, the ovaries are frequently involved and should be carefully inspected.
Beyond the commonest: right lower quadrant abdominal pain is not always appendicitis
Published in Alexandria Journal of Medicine, 2020
Mahmoud Agha, Maha Sallam, Mohamed Eid
Three patients (0.3%) had been presented with chronic right iliac fossa pain, with acute exacerbation. WBC was normal in two patients and elevated in only one patient. They had been diagnosed with CT scan as ileocecal tumors; which were proven pathologically to be adenocarcinoma. The one who had associated high WBC was presented with carcinoma associated with acute appendicitis (Figure 1). Acute abdomen may be the initial presentation of an ileocecal malignant tumor, commonly at this site adenocarcinoma or lymphoma, gastrointestinal stromal tumor, or metastasis, especially if complicated with perforation or abscess. The differentiation between an appendicular mass and a malignant ileocecal lump may be straightforward at the CT scan; if the appendix could be clearly identified and separated from the ileocecal mass lesion. However, this is not always a simple easy task. [10,11]
Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction
Published in Acta Chirurgica Belgica, 2019
Alexandre Haumann, Sarah Ongaro, Olivier Detry, Paul Meunier, Michel Meurisse
A 27-year-old female patient was admitted to the emergency department for abdominal pain that started 48 hours prior to presentation, associated with pseudo-grippal syndrome. Symptoms predominated in the right iliac fossa and progressively spread to the entire abdomen. The patient also suffered from nausea and vomiting. Her vital signs were normal and she was afebrile. Abdominal examination was significant for tenderness of the whole abdomen and McBurney’s sign. She had no medical or surgical history. Intrauterine contraceptive device (ICD) was set up with no complication 1 month earlier. Laboratory tests revealed normal leucocytosis of 9870/mm3 with hyperneutrocytophilia of 75.6% and mild C-reactive protein increase at 42 mg/L (normal values: 0.0–5.0 mg/l). Liver and renal functions were normal as well as serum chemistry and human chorionic gonadotropin.