Iliac Fossa Research Articles

In Loving Memory

<h3>Introduction/Background</h3> Adamantinoma is a rare primary low-grade malignant tum­­­­­­our of the appendicular skeleton. It primarily affects the long bones and is most commonly found in the tibia. The disease process has an indolent course and histogenic origin has not been clearly defined, however there have been several suggestions pertaining to a vascular origin in the literature. Local recurrences and lung metastases occur over a protracted duration. Less frequently, they have also been reported elsewhere; including four documented cases of soft tissue and five of pelvic bony adamantinoma. There is only one documented case of adamantinoma of the ovary and one of concurrent unrelated primary tumour. There are also no reports available regarding surgical management of a retroperitoneal adamantinoma of the pelvis within a gynaecological oncology surgical setting. Clinical guidelines have not yet been established. <h3>Results</h3> We present the case of a 65-year-old female with known recurrent and metastatic right tibial disease. On further investigation, a Positron Emission Tomography scan identified a primary breast lesion and an 11 cm mass in the right iliac fossa of suspected ovarian malignancy amenable to surgical resection (figure A). The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and resection of a retroperitoneal mass arising from the pelvic sidewall encompassing the iliac vasculature. The tumour was cleaved from the external iliac artery successfully, however the external iliac vein perforated during dissection. A Satinsky clamp was placed and a small cuff of vein wall was removed alongside adherent tumour. The vein defect was closed with 5–0 prolene, ensuring a patent lumen (figure B). The patient made an uneventful recovery with histology confirming metastatic disease. <h3>Conclusion</h3> We present an overview of adamantinoma and highlight a previously undocumented gynaecological oncology surgical approach to this novel location of metastatic disease mimicking possible ovarian malignancy. We further explore disease histogenesis and also comment on an incidental finding or primary breast cancer. Particularly in uncommon locations, its heterogeneous nature presents radiological and histological challenges regarding diagnosis and treatment. Such cases warrant a full complement of MDT specialist knowledge and expertise; with advanced surgical skills and experience regarding retroperitoneal and pelvic sidewall anatomy. We also highlight a paucity of recommendations for surveillance and follow up and propose an individualised approach. We report on this unusual case to assist clinicians in the building of a consensus opinion for optimal adamantinoma case management under current circumstances where formal guidelines do not exist. <h3>Disclosures</h3> None

Emergency Presentation of Abdominal Pain with Unusual Etiology

Abdominal pain has vast differentials and routine etiologies are diagnosed easily. Difficulty arises with uncommon presentation. This is a case of 28 years old lady presenting to emergency department of Holy Family Hospital, Rawalpindi with worsening abdominal pain, vomiting and loose stools over 2 weeks. Routine examination and workup did not help to find any cause. Ultrasound abdomen suspected matted gut loops with enlarged lymph nodes. CECT abdomen confirmed a non-differentiating tissue collection in right iliac fossa. Later diagnosis of complicated gossybioma (retained gauze surrounded by fibrotic tissue with entero-enteric fistula and fecolith in appendix) was confirmed by laparoscopy that was surgically removed. Conclusion: Gossybioma is infrequent but avoidable complication that needs to be considered by surgeon meticulously especially by swab counting, avoiding staff change over during procedure and consideration in follow up visit.

Ripasa versus Alvarado as a Scoring System in Diagnosis of Acute Appendicitis in Al-Yarmouk Teaching Hospital

Background: Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization. A number of scoring systems have been developed to try to identify people who are likely to have appendicitis and are eligible for surgery. Aim of study: is to compare the accuracy of RIPASA to Alvarado score in the diagnosis of acute appendicitis. Methods: A prospective comparative study that was conducted at Al-Yarmouk Teaching Hospital / Baghdad during the period of one year from 1st of Feb. 2019 till 1st of Feb. 2020. It included 200 patients attended the outpatient clinic or the emergency department in Al-Yarmouk Teaching Hospital complaining from lower abdominal and/or right iliac fossa pain suggestive of acute appendicitis. Scoring was done to diagnose appendicitis by two scoring systems (Alvarado and RIPASA) using the data for each patient. The individual scores were then compared to the final diagnosis made by the clinician and to the recommendations of each scoring system. Results: In this study, most of the patients (172 patients, 86%) underwent appendectomy. We noticed that 44.8% of the operated cases were diagnosed as catarrhal appendicitis. Incidences of rebound tenderness, leukocytosis, migratory pain, ROVSING sign, and right iliac fossa guarding were significantly higher in patients diagnosed with appendicitis than those in patients diagnosed as normal appendix. Means of ALVARADO and RIPASA scores were significantly increased with severity to reach the highest level in patients diagnosed with severe appendicitis than other findings. ALVARADO score was 69.7% sensitive, 87.5% specific, and 74% accurate. RIPASA score was 94.1% sensitive, 62.5% specific, and 86.5% accurate. Conclusion: RIPASA score is more accurate and more sensitive than Alvarado score, in spite of the lower specificity, so that it can be effectively conducted for the better evaluation of acute appendicitis. RIPASA score is simple, non-invasive, and cost effective way to be used in resource limited conditions.

دراسة تحليلية لموجودات اللفائفي النهائي في سياق تنظير القولونات الكامل

This study aimed at determine the diagnostic value of terminal ileoscopy according to indications for colonoscopy. In addition to, evaluating the duration of the procedure and the rate of success. The Methods An observational descriptive study was conducted for the period of one year (January2020 -January2021) at Tishreen University Hospital in Lattakia-Syria. The study included 198 patients referred for colonoscopy due to various indications. Results: The median age was 53 years, the most frequent age group was 40-60 years (42.9%), followed by the group ≤ 60 (32.8%). Males represented 58.6 % of the patients, and abdominal pain was the most frequent indication for colonoscopy. The success rate of terminal ileal intubation was 83.8% with a mean duration of the procedure 2.15±1.6 m. Abnormal macroscopic findings were found in 23 patients (13.9%) and ulceration was the most frequent feature (4.5%). Significant pathological findings were present in 11 cases (47.8%), and included Crohn's disease (10 cases) and infectious colitis with Yersinia (1 case). The diagnostic yield was 5.5% in all ileoscopies, which was significant in patients with weight loss (20%) and right iliac fossa pain (16.7%). Conclusion: Our study findings demonstrated high percentage of ileal intubation success with variable diagnostic yield according to the indications of colonoscopy.

Gunshot injury to the chest wall with an unusual bullet trajectory: A rare case report.

Introduction and importanceGunshot injuries are always a challenging case for a surgeon. Early assessment of trajectory of bullet leads to effective surgical plan. These cases require multidisciplinary approach for the satisfactory outcome.Case presentationWe present a case of 38-year-old male with gunshot injury over left anterior chest wall with an entry wound and no detectable exit wound. Contrast enhanced computed tomogram (CECT) thorax and abdomen was suggestive of an unusual route of a bullet from left anterior chest wall at the level of 5th costochondral junction to the right iliac fossa region. Emergency exploration for the bullet was performed based on CECT findings which confirmed bullet in subcutaneous plane in right iliac fossa. Patient was discharged on 3rd post-operative with satisfactory clinical improvement.Clinical discussionUnusual presentations of bullet trajectory in gunshot injury can create surgical and/or medico-legal diagnostic problems. An effective surgical plan requires an effective clinic-radiological assessment. Accurate detection of entry wound, exit wound, path and extent of tissue damage is significant in preoperative planning and prognosis of patient. However not every patient with gunshot injury has an unusual trajectory. But accurate radiological assessment in such challenging cases is a necessity. Multidisciplinary approach with preoperative planning is required for satisfactory outcome.ConclusionManagement of patients of gunshot injury is challenging for the attending surgeon. Multidisciplinary approach for preoperative planning along with good post-operative care is required in such cases of gunshot injury with atypical course.

Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature.

Introduction and importanceColon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline.Case presentationA 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with extended right hemicolectomy and en bloc resection was performed.Clinical discussionCutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case.ConclusionThere are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.

Imaging Characteristics and Value of Multislice Computed Tomography in the Diagnosis of Acute Appendicitis

Objectives: This study was done to describe the imaging characteristics of acute appendicitis on multislice computed tomography (MSCT) and the value of MSCT scan in the diagnosis of acute appendicitis. Methods: The study used retrospective and cross-sectional methods to analyze the results of 117 patients who were taken photos of CT at E Hospital from February 2021 to November 2021. Results: The most common age was over 50 years old, and the average age was 40.1±20.8. The ratio of male/female was 1/1.25. Locations of appendix: right iliac fossa 69.2%, posterior cecum 16.2%, pelvis 12%, subhepatic 0.9%, 1.7% in other places in the abdomen. The diameter of appendicitis was 10.48±2.5mm (the min was 5mm, the max was 18mm). The increase of diameter over 7mm accounted for 95.7%, appendiceal wall thickness ≥ 3mm had 83.8% of patients, and fat infiltration was seen in 88% of cases studied. Other signs: fecal stones 35%, fluid around appendix 7.7%, Douglas fluid 3.4%, right iliac fossa fluid 3.4%, mesenteric lymphadenopathy 25.7%. The rate of appendix rupture diagnosed by CT accounted was 4.3%. The sensitivity, accuracy, and positive diagnostic value of multislice CT in the diagnosis of acute appendicitis were 97.4%, 96.6%, and 99.1%, respectively. Conclusion: Multislice CT has a high value in the diagnosis of acute appendicitis.

Case Report: Fortuitous discovery of primary peritoneal psammocarcinoma

Psammocarcinoma is an uncommon subtype of low-grade serous carcinoma. It is characterized by the presence of extensive psammoma bodies and can have either an ovarian or peritoneal origin. To our knowledge fewer than 30 cases of primary peritoneal psammocarcinoma (PPP) have been reported in the English literature. We report a rare case of PPP in a 74-year-old female, discovered fortuitously within a laparotomy for gallbladder lithiasis. At laparotomy, multiple nodular implants involving the omentum, the peritoneum and a magma of intestinal loops in the right iliac fossa were noted. A biopsy from nodules was performed. Gross examination showed multiple nodules of different sizes in the fat tissue. Pathologic examination showed massive psammoma bodies representing more than 75% of the tumor. The final diagnosis was psammocarcinoma. Our patient was referred to the gynecologic department for further investigation and to ascertain whether the tumor arose from the ovaries or peritoneum. Hysterectomy, bilateral adnexectomy and omentectomy were performed. Macroscopic examination showed that both ovaries were intact having a normal size. No invasion of ovarian stroma was shown in microscopic examination. The patient died of SARS-CoV-2 (COVID-19) six days after the surgery. PPP is a rare type of low-grade serous carcinoma. The behavior of this tumor is unclear, and the treatment is not standardized because of its rarity and lack of long-term follow-up. More cases need to be studied for better understanding and improvement of the management protocols.

A unique case of Dermatofibrosarcoma Protuberans arising from an inguinal hernial repair scar in a Middle Eastern male - A Case Report.

Introduction and importanceDermatofibrosarcoma Protuberans (DFSP) is a rare and fatal variant of Spindle Cell Sarcoma. It has an annual incidence rate of 0.8 to 4.5 cases per one million individuals. It's locally aggressive and has vague and masquerading clinical presentations. Misdiagnosis is devastating as it can lead to time wasting, expenditure of unnecessary resources, and possibly raise morbidity and mortality for patients. It is warranted to raise preoperative clinical awareness to achieve prompt surgical therapeutic interventions to reach an up-to-par prognosis.Case presentationWe demonstrate the case of a 50-year-old previously healthy Middle Eastern male patient, who was referred to our General Surgery clinic with the chief complaint of an expansive bulge in his left iliac fossa. Preoperative imaging could not exclude a neoplastic cause behind the presentation. Based on the clinical picture, a surgical intervention was decided.Clinical discussionOur patient's treatment was consummated by means of classical surgical resection of the lesion with adequate negative margins and referring him to an oncologist specialized in DFSP to undergo the necessary adjuvant treatment. Definitive diagnosis was firmly entrenched postoperatively after finalization of the histopathological and immunohistochemical analyses of the resected protuberance.ConclusionDFSP is an eminently rare entity, especially DFSPs which originate from a surgical scar -as was our patient's- and fluctuates in its clinical presentation, thus, it is our responsibility to depict, study this malignant tumor, and document its incidence, so that we can make ironclad clinical decrees to plummet the morbidity and mortality of this relentless neoplasia.

Mesenteric lymphangioma – a rare tumor of the abdomen

Mesenteric lymphangioma (ML) is a cystic tumor developed at the base of the mesentery, which occurs frequently in children, rarely in adults, with nonspecific symptoms, often diagnosed late. The diagnosis is made by computer tomography and the curative treatment is the surgical one with good results and with optimal postoperative outcome. A 44-year-old patient for whom mesh surgery for incisional hernia post appendectomy has been performed was admitted to our clinic for nonspecific gastrointestinal symptoms for which he has also been investigated multiple times in other services. On the right flank and iliac fossa, a tumor of firmelastic consistency is detected, relatively well delimited. Computed tomography (CT) describes the lesion as a mesenteric tumor. Intraoperatively, a cystic tumor is detected, which is punctured, the biochemical result highlighting the lymphatic character. The surgical treatment was represented by segmental intestinal resection with entero-enteroanastomosis. No postoperative events were reported.

Circular Mini-Incision in the Left Iliac Fossa Followed by Purse-String Closure as a Minimally Invasive Approach for the Sigmoid Volvulus: A Technical Note.

Introduction: Volvulus of the sigmoid is a common cause of intestinal obstruction in Morocco. It is a serious condition with substantial mortality. Initial endoscopic decompression followed by resection of the redundant colon via laparotomy or laparoscopy is the procedure of choice. Exteriorization of the sigmoid colon through a linear skin incision in the left iliac fossa has been described as an alternative approach for the classic midline incision, with or without laparoscopic assistance, with acceptable results.Methods: We describe herein a novel, minimally invasive approach for fit patients with non-complicated volvulus sigmoid. This approach consists of a skin-disk incision in the left iliac fossa, exteriorization of the redundant colon, and resection with or without primary anastomosis, followed by a purse-string closure.Results: A 65-year-old patient with no prior notable medical history, presented to the emergency department with his first episode of sigmoid volvulus. A skin-disk incision was made in the left iliac fossa, exteriorization of the sigmoid was done easily through the incision, and resection and manual anastomosis were done. The closure was made in a purse-string fashion. Recovery was uneventful and the patient was discharged home on the fourth postoperative day. No wound infection was noted and the cosmetic result was satisfactory.Conclusion: Left iliac skin-disk incision followed by a purse-string closure is an option for approaching the abdomen in the case of sigmoid volvulus. It has been demonstrated that this technique helps reduce wound-related complications in patients undergoing stoma reversal. Authors suggest that cosmetic results are better and the incidence of surgical site infection can be lower with this technique as compared to the classic linear skin incision. Results, however, should be confirmed by larger studies.

Appendicular mucocele mimicking a right adnexal mass – a case report and literature review

The correct diagnostic of a cystic lesion at the level of the right iliac fossa in women can be hard to be established in certain cases, different pathological lesions having similar imagistic aspects and being associated with similar biological modifications. In such cases the final diagnostic is established intraoperatively and the type of surgery can be significantly modified. The aim of the current paper is to report a 63 year old woman with preoperative diagnostic of right ovarian mass who was submitted to surgery in order to have a total hysterectomy and bilateral adnexectomy; however intraoperatively the cystic lesion developed at the level of the right iliac fossa proved to be an appendicular tumor and was successfully resected by performing a radical right hemicolectomy.

Introducing the New Surgical Robot HUGO™ RAS: System Description and Docking Settings for Gynecological Surgery.

This study provides a detailed description of the new HUGO™ RAS System and suggests docking settings for gynecological surgery. The system is composed of an “open” surgical console with an HD–3D passive display, a system tower, and four arm carts. Each arm has an extremely wide range of adaptability resulting from the numerous joints. The human cadaver labs were performed at the ORSI Academy between August and December 2021. All procedures were performed by two surgical teams, each composed of a high-volume surgeon experienced in robotic surgery, gynecologic oncology, and pelvic sidewall surgery, and one bedside assistant. Three main gynecological surgical scenarios were identified: standard pelvic surgery, pelvic sidewall surgery, and para-aortic/upper abdominal surgery. Concerning the port placement, the chosen options were called “straight” and “bridge”; instead, the so-called “compact” and “butterfly” configurations were identified for the arm cart positioning. Four cadavers were used to perform total hysterectomy, radical hysterectomy, pelvic exenteration, pelvic and para-aortic lymphadenectomy, and omentectomy. We performed several tests, identifying the best system configurations to draw the proper efficiency from the flexibility of the system in all gynecological surgical scenarios. The straight port placement seems to be adequate for standard pelvic surgery. The bridge trocar position is best to reach the deeper and lateral anatomical regions of the female pelvis. The compact and butterfly arm cart allocations are adequate for both straight and bridge port placement. When deep pelvic surgery was performed, the bedside assistant became more proficient by working with a standard laparoscopic instrument from an ancillary port placed in the left iliac fossa. The arm carts needed to be moved in an open manner, like for the proposed butterfly configuration. On the contrary, the compact disposition left enough space to assist from Palmer’s point port. Several basic and advanced gynecological surgical procedures were performed and completed successfully without encountering any technical or surgical issue, the results obtained were judged sufficient to proceed with the clinical experience in daily practice. The HUGO™ RAS system is flexible and highly performative in various surgical scenarios.

A Clinico - Ultrasonological Study on Preoperative Evaluation of Right Iliac Fossa Mass

BACKGROUND&#x0D; Right iliac fossa mass, a common condition, needs accurate arrival of diagnosis since management of each condition differs. Ultrasound is a quick, non-invasive test that has bridged the gap between palpation and direct visualization. The role of ultrasound in preoperative evaluation proves to be essential as it enables the surgeon to diagnose and treat the pathology with accuracy thereby obviating the need for further investigations. We wanted to evaluate the role of ultrasound in preoperative evaluation of right iliac fossa mass.&#x0D; METHODS&#x0D; A prospective study of 60 patients with clinically diagnosed RIF mass was done. Ultrasound examination by 5 and 7.5 MHz transducers was done and the clinical, radiological findings and final diagnosis were compared.&#x0D; RESULTS&#x0D; In our study, vast majority of the cases (50 %) presented with appendicular mass, 24 % presented with appendicular abscess, ileocaecal tuberculosis 17 %, carcinoma caecum 7%, psoas abscess 1 % and ileal lymphadenopathy 1 %. The appendicular abscess was common in 15-20 years, appendicular mass in 21-40 years, ileocaecal tuberculosis in 41-50 years, carcinoma caecum was in &gt; 50 years, psoas abscess in 21-30 years, and ileal lymphadenopathy in 20-34 years of age. Ultrasound was able to find out the bowel thickening with target sign and pseudo kidney sign in ileo-caecal tuberculosis and carcinoma caecum with moderate specificity. Psoas abscesses were confirmed with ultrasound.&#x0D; CONCLUSIONS&#x0D; Appendicular pathology constituted a majority of cases. The ultrasound was able to detect appendicular abscesses with high sensitivity and specificity. It is an adjuvant diagnostic tool in cases of ileocaecal tuberculosis and carcinoma caecum. Ultrasound helped in the early assessment of the patient, enhanced the treatment effectiveness thereby reducing the morbidity and enabled early surgical intervention whenever necessary. Ultrasound, a non-invasive radiological imaging without any exposure to radiation with excellent results is an ideal first-line imaging modality in the preoperative evaluation of RIF mass.

Oblique-ilioischial plate technique: a novel method for acetabular fractures involving low posterior column

BackgroundComplex acetabular fractures involving the anterior and posterior columns are an intractable clinical challenge. The study investigated the safety and efficacy of oblique-ilioischial plate technique for acetabular fractures involving low posterior column.MethodsA retrospective analysis of 18 patients operated with the oblique-ilioischial plate technique by the modified Stoppa approach (or combined with iliac fossa approach) between August 2016 and July 2021 for low posterior column acetabular fractures was conducted. The anterior column was fixed with a reconstructed plate from the iliac wing along the iliopectineal line to the pubis. The low posterior column was fixed with the novel oblique-ilioischial plate running from the ilium to the ischial ramus. Operative time, intraoperative blood loss, reduction quality, and postoperative hip function were recorded.ResultsOut of the 18 patients, 10 were male and 8 were female. The mean age was 48.6±10.2 years (range: 45–62 years); The mean interval from injury to operation was 7.2±1.4 days (range: 5–19 days); The mean operative time was 2.1±0.3 h (range: 1.0–3.2 hours); The mean intraoperative blood loss was 300±58.4 mL (range: 200–500 mL). Postoperative reduction (Matta’s criteria) was deemed as excellent (n = 9), good (n = 4), and fair (n = 5). At the final follow-up, the hip function (modified Merle d’Aubigne-Postel scale) was deemed as excellent (n = 11), good (n = 3), and fair (n = 4). The mean union time was 4.5±1.8 months (range: 3–6 months). No implant failure, infection, heterotopic ossification, or neurovascular injury were reported.ConclusionThe oblique-ilioischial plate technique via anterior approach for acetabular fractures involving low posterior column offers reliable fixation, limited invasion, little intraoperative bleeding, and fewer complications. However, larger multicenter control studies are warranted.

Ex vivo removal of stones in donor kidneys by pyelotomy prior to renal transplantation: a single-center case series

BackgroundDonors with incidentally discovered asymptomatic renal stones was considered a relative contraindication to the kidney donation because of a potential increased morbidity risk for renal transplant recipients. Stone clearance from the donors should be done before donation to ensure safety of the recipient. This study aimed to observe the safety and efficacy of kidney transplantation from donors with nephrolithiasis who received pyelolithotomy before transplantation.MethodsBetween January 2015 and March 2021, 14 deceased organ donors at The Second Affiliated Hospital of Guangzhou Medical University were found to have kidney stones during predonation evaluation. After donor kidney repair, all of the donor kidneys underwent ex vivo pyelolithotomy. Then the organs were transplanted to the right iliac fossa of 17 patients with end-stage renal failure. Data were analyzed for technical feasibility, intraoperative and postoperative complications, and stone clearance. Ultrasonography and urinal routine were followed at the 1-, 3-, and 6-month postoperatively.ResultsThe stones were successfully removed ex vivo by pyelotomy with an average time of 41.0±12.8 minutes. Seventeen recipients successfully underwent renal transplantation, and their renal function recovered well. Slight gross hematuria occurred in 12 cases after operation, and hematuria disappeared after conservative treatment. Ureteral stents were removed within two months after the procedure. There were no complications such as delayed recovery of renal function, acute rejection, ureteral necrosis, and urinary fistula. The serum creatinine of 17 patients 1 month after the operation was 136.8±26.7 µmol/L. None of the 17 patients included in the study suffered from stone recurrence or graft dysfunction in the follow-up period.ConclusionsEx vivo removal of stones by pyelotomy was a technically feasible means of safely and efficiency rendering a stone-bearing donor kidney stone-free. The procedure obtained good early-middle outcomes in kidney transplantation and is therefore worthy of clinical application.

Shabir's "SMART-LAB" score for predicting complicated appendicitis-a prospective study.

Complicated appendicitis needs an aggressive and urgent management, hence there is need of an efficient scoring system for predicting complicated appendicitis. With this in mind, the author developed the present scoring system for predicting complicated acute appendicitis. The study aimed to assess the suitability of this novel (Shabir's SMART-LAB) score for predicting diagnosis of complicated appendicitis. In this prospective study, a novel score designated as "SMART-LAB" SCORE, proposed by the author (Shabir) based on his previous observations was calculated in all patients. This score includes sonography (S), migratory right iliac fossa pain (M), anorexia (A), rebound tenderness (R), tenderness (T), leukocytosis (L), Acute phase protein-CRP (A), and serum bilirubin (B). Of a total of 150 patients included in this study, 52 cases turned out to be perforated and/or gangrenous appendicitis on intraoperative/histopathologic examination. The most commonly affected age group was 10-19 years. SMART-LAB score of >9 was present in significantly higher number of patients in complicated (perforated and gangrenous) appendicitis than uncomplicated appendicitis (p value<0.001 i.e., highly significant). Hence, high likelihood of complicated appendicitis is reflected by a score >9 (with a sensitivity= 80.7%, specificity= 92.9%, PPV= 85.7%, NPV= 90.1%, and accuracy= 88.7%), while a score 7-9 needs further confirmation to reach a conclusion, and for a score of <7, there is low likelihood of complicated appendicitis. It seems that this novel score (Shabir's SMART-LAB score) is a reasonably good tool to predict the diagnosis of complicated appendicitis. Early diagnosis of appendiceal perforation is important to limit the associated abdominal sepsis.

Prospects of mesenteric lymphadenopathy in children with chronic abdominal pain (CAP).

Objective: To evaluate the incidence rate and severity of mesenteric lymphadenopathy in children presenting with CAP in comparison with healthy counterparts. Study Design: Prospective Cross-sectional study. Setting: Department of Pediatric, Nishtar Medical University &amp; Hospital Multan. Period: June 2020 to June 2021. Material &amp; Methods: The prospective cross-sectional study included children aged between 5 to 15 years who were divided into two groups: the study group included children who presented with CAP and the control group included the ones who visited the hospital to undergo abdominal sonography for other reasons. All the study population underwent analysis through abdominal ultrasonography. The existence of enlarged nodules, their size, location, and other related findings was assessed. Baseline characteristics were analyzed in both groups through descriptive statistics whereas Pearson's Chi-square test was performed for comparison of categorical variables. Results: After passing through the study criteria, a total of 80 cases were compared with 110 controls. No significant difference was between the two genders in terms of the occurrence of mesenteric lymphadenopathy. 62 (77.5%) cases were found positive for mesenteric lymph nodes (MLN) by ultrasonography as compared to 19 (17.2%) positive controls. Among them, 42 CAP (52.5%) cases had significant MLN (&gt;10mm long axis or ≥5 mm short axis) while 8 (7.2%) controls were found to have significant MLN (p&lt;0.001). The mesenteric lymph nodes were most commonly located in the right iliac fossa (82%) and peri-umbilical region (75.1%). Conclusion: Mesenteric lymphadenopathy is a significant finding in children with chronic abdominal pain.

Clinical Study of Pain in Right Iliac Fossa

Background: To study the clinical profile of pain in right iliac fossa.&#x0D; Methods: 100 patients with signs and symptoms of right iliac fossa mass admitted in Hospital were identified and were studied by taking detailed clinical history, physical examination and were subjected to various investigations like x ray erect abdomen, chest x-ray, contrast x-ray .&#x0D; Result: In this study of out of 100 cases, 71.00% of cases were related to appendicular pathology either in the form of appendicular mass or appendicular abscess. There were 9.00% cases of Ileocaecal tuberculosis.&#x0D; Conclusion: Appendicular lump remains the most common cause for right iliac fossa pain. Ileocaecal tuberculosis is one of the most important differential diagnoses for pain abdomen.&#x0D; Keywords: Appendicitis, , Right Iliac Fossa Mass, Pain

Serum C-Reactive Protein A Helpful Marker in Diagnosis of Acute Appendicitis

Objective: evaluate the diagnostic accuracy of serum C-reactive protein levels in acute appendicitis (AA) Methodology: Two hundred suspicious cases of AA presenting with pain in right iliac fossa in addition to nausea/vomiting, direct tenderness in right iliac fossa of either gender in adult population were included. Intravenous blood sample was drawn for CRP evaluation. Appendectomy was performed in all these cases, and histopathological examination was done to confirm presence/absence of AA. Both the reports were evaluated and AA was considered positive if CRP levels are &gt;6 μg/dl. A 2x2 table was drawn to analyze diagnostic accuracy of CRP. Results: The mean age was 27.11+10.42 years, 80.5% (n=161) cases were diagnosed as acute appendicitis on histopathology. The diagnostic accuracy of serum C-Reactive Protein levels shows 81.63% for sensitivity, 73.58% for specificity, 89.55% had positive predictive value, 50.09% negative predictive value while 79.50% had accuracy rate. Conclusion: serum C-reactive protein levels is a useful marker for diagnosing acute appendicitis and may be used in rural areas where USG and CT scan facility is not available. Keywords: Acute appendicitis, diagnosis, serum C-reactive protein, diagnostic accuracy