Acute Right Iliac Fossa Pain Research Articles

WP7.17 - Routine Use of Validated Risk Prediction Model in the Management of Acute Appendicitis in a District General Hospital

Abstract Aim Acute appendicitis is the most common general surgery emergency in the UK. Currently, there is no optimal diagnostic pathway for managing the right iliac fossa (RIF) pain. The right iliac fossa pain treatment (RIFT) study group has previously performed an analysis of different risk prediction models to search for the most specific one and made a website (appy-risk.org) to calculate risk scores on presentation. We aimed to look into our practice in a DGH and see how compliant we are in documenting risk scores on presentation with acute RIF pain. Method A list of patients presenting with acute RIF pain to the surgical assessment unit in September was prepared. Admission clerking notes were reviewed from the electronic patient record to look for the documentation of the appendicitis risk score. Standard statistical packages were used for data analysis. Results A total of 95 patients were presented with RIF pain. Of them, 17 were excluded from the analysis for being over 45 years old. Of the remaining 78 patients' records, only 7 (8.97%) had appendicitis risk scores documented in the clerking notes. Conclusions The RIFT study highlighted a high normal appendicectomy rate (NAR) in the UK in comparison to other European countries. In our hospital, NAR was 9.74% in the first six months of 2023. We are in the process of implementing a pathway to manage acute RIF pain using a risk prediction model as advised by the RIFT group to reduce our NAR to less than 5%.

Emergency surgery for appendectomy and incidental diagnosis of superficial peritoneal endometriosis in fertile age women

Research questionThis study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis. DesignAn observational case–control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed. ResultsAppendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age <40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings. ConclusionsThe incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist.

Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females.

Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint. We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain. This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis. 5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment. The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.

Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium

Case reportA 35 year old primiparous woman attended the emer-gency department at 17 weeks of gestation for acute rightiliac fossa pain with guarding. Rebound pelvic examinationwas painful. The patient’s temperature was 38.6jC andlaboratory tests showed no leucoytosis. Ultrasound re-vealed a single intrauterine viable pregnancy equivalentto dates and additionally a uterine mass in the left lateralwall of the uterus, 5 cm in length. Due to a suspectedadnexal torsion, a laparoscopy was performed, whichrevealed a degenerating pedunculated uterine leiomyomawithout torsion of the pedicle. It was situated on theanterior surface of the uterus below the right uterine cornu.Because the woman was so symptomatic, myomectomywas performed by resection of the myoma using monopolarcutting diathermy via a hook electrode with a 40 W poweroutput. Despite the insertion of an endoloop constrictingthe pedicle prior to electroresection, the top of the pediclewas slightly electrocoagulated to ensure perfect hae-mostasis. The uterine cavity was not opened. The myomawas extracted via a transumbilical approach, by morcella-tion. Histological examination confirmed the diagnostic ofaseptic degeneration of uterine leiomyoma. Abdominalpain occurred six days post-operatively, with associatedileus and pus at the umbilical incision but with no fever.The umbilicus was irrigated with Betadine and penicillin Vwas started. Clinical improvement occurred and she wasdischarged from hospital. She returned two weeks laterwith an intestinal obstruction mass in the right iliac fossaand a recurrence of umbilical infection. Ultrasound exam-ination showed collection of 10 cm diameter, comparedwith the area of myomectomy extending to the neighbour-ing myometrium. Laparotomy was performed via an umbil-ical median incision and revealed an abscess on the anteriorsurface of the uterus. It was situated on the scar of thepedicle of the resected myoma. Following peritoneal lavage,a full thickness of myometrium was lost due to uterinenecrosis. An area approximately 7 2 cm of the amnioticsac was clearly visible (Fig. 1). The edges of the defectwere brought together with three slow absorption stitches.The remainder of the abdominopelvic cavity was normal.The right iliac fossa was drained using a natural rubbercorrugated drain (Peters Laboratories, France). Parenteralantibiotics were initiated with piperacilline and tazobactam,gardenerella vaginalis, peptostreptococcus and anaerobicnegative gram bacillus were obtained on bacteriology. Oralmedication (amoxicilline and clavulanic acid) was contin-ued for three weeks. Tocolysis was achieved using indo-methacin following laparatomy. The remainder of thepregnancy was normal. The woman was readmitted at ges-tation for 37 weeks to elective caesarean section. The babyweighed 3530 g with an Apgar score of 10 at 5 minutes oflife. During the caesarean section, adhesions were identifiedin the right iliac fossa and were divided. There was noobvious defect in the uterine wall. There was a placentaaccreta and removal of placenta was distinct. The area ofaccreta was adjacent to the previous myomectomy. Due toprofuse arterial bleeding from this area, the uterine pedicles,