Cause Of Right Iliac Fossa Pain Research Articles

An Ulcerated Ileal Gastrointestinal Stromal Tumor Disguised as Acute Appendicitis

Background Gastrointestinal stromal tumor (GIST) of the ileum is not a common differential to consider in the management of acute right iliac fossa (RIF) pain and tenderness. Finding of a normal-looking appendix intraoperatively should arouse the surgeon to explore further and look for other unanticipated pathologies. We present a case, clinically diagnosed as acute appendicitis and intraoperatively found to be an ulcerated ileal GIST. Case Presentation A 28-year-old female without previous comorbidities presented to the emergency unit with sudden pain around the umbilicus that later migrated and localized to the RIF for one day. There was associated intermittent fever and anorexia without urinary symptoms. Abdominal examination revealed guarding and rebound tenderness at RIF. Examination by 2 senior surgeons at different points of time, the same day, made a clinical diagnosis of acute appendicitis. Ultrasonogram (USG) was inconclusive. At laparotomy through Lanz incision, the appendix was found to be normal and no other pathology was identified on walking bowel up to 3 ft proximal to ileocecal junction (ICJ). Just when closure was thought of, an ulcerated lesion could be seen through the medial aspect of the incision. On further exploration, a 7 × 5 cm ulcerated lesion arising from the antimesenteric border of the ileum was noted with localized interloop hemoperitoneum and inflammatory exudates. Ileal segmental resection anastomosis was done with peritoneal toileting. The lesion was subsequently reported to be an ulcerated malignant GIST. Conclusion The commonest cause of RIF pain with localized peritonitis is an acutely inflamed appendix. Dilemma arises when the appendix is found to look normal. Further exploration is indicted to not miss other findings.

Bilirubin; a diagnostic marker for appendicitis

IntroductionEvery investigation that can contribute towards a diagnosis of appendicitis is valuable to the emergency general surgeon. Previous research has suggested that hyperbilirubinaemia is a more specific marker for both simple and perforated appendicitis than WBC (white blood count) and CRP (C-reactive protein), but this investigation is not commonly used to help diagnose appendicitis. AimsThis study investigated whether there is an association between hyperbilirubinaemia and appendicitis. We also reviewed the diagnostic value of bilirubin in perforated vs simple appendicitis, and compared it with the serum C-reactive protein (CRP) and white blood cell count (WBC). MethodsThis single centre, prospective observational study included all patients admitted with right iliac fossa (RIF) pain who had liver function tests performed. Statistical analysis was performed using Fisher's exact test to compare bilirubin, WBC and CRP levels for normal appendices, simple appendicitis, and perforated appendicitis. Results242 patients were included in this study, of whom 143 were managed operatively for RIF pain.Hyperbilirubinaemia was significantly associated with appendicitis vs RIF pain of other aetiologies (p < 0.0001). Bilirubin had a higher specificity (0.96), than WBC (0.71) and CRP (0.62), but a lower sensitivity (0.27 vs 0.68 and 0.82 respectively).Hyperbilirubinaemia was associated with perforated appendicitis vs simple appendicitis with statistical significance (p < 0.0001). Bilirubin had a higher specificity (0.82) than both WBC (0.34) and CRP (0.21), but a lower sensitivity (0.70 vs 0.80 and 0.95 respectively). ConclusionOur findings confirm that hyperbilirubinaemia has a high specificity for distinguishing acute appendicitis, especially when perforated, from other causes of RIF pain, particularly those not requiring surgery.