Pain In Right Iliac Fossa Research Articles

DIAGNOSTIC ACCURACY OF ALVARADO SCORING SYSTEM IN ACUTE APPENDICITIS

OBJECTIVE: Acute appendicitis is one of the commonest surgical emergency. There are different scoring systems in use to diagnose the appendicitis. Aim of this study was to document the diagnostic accuracy by application of Alvarado Scoring System in clinical practice for acute appendicitis. DESIGN: Descriptive case series. SETTING: Surgical Unit-II, Liaquat University Hospital Hyderabad, Sindh – Pakistan; from January 2003 to September 2004. METHODS: All the patients with suspected appendicitis were admitted in the ward. A profroma was designed and relevant findings were documented. These were observed regarding the increase or decrease in severity of symptoms and hence the change in the initial score according to Alvarado Scoring System was documented at the time of admission. Decision regarding surgical intervention was made on the basis of change in the score. RESULTS: A total of 227 patients with clinical features suggesting acute appendicitis was admitted in the ward. Among them, 150 (66.07%) were males and 77 (33.92%) were females. Age ranged from 10-62 years. Main symptoms at presentation included pain in right iliac fossa 67.8%, fever 66.9% and nausea and vomiting 49.7%. Thirty two patients were received with Alvarado Score of 1-4 and three out of them required surgery. Thirty five patients were in the score of 5, twenty three out of them required surgery. One hundred sixty patients were in the score of 6 and above, all of them required surgery. Out of 185 patients who underwent surgery, 178 patients had appendicitis. The negative appendicectomy rate was 3.78%. CONCLUSION: It is concluded that according to Alvarado the patients with score up to 4 probably do not require surgery and among the patients with score up to 5, most of them need surgery while the patients with the score of 6 and above will require surgery.

Acute presentation of a solitary caecal diverticulum: a case report

IntroductionSolitary caecal diverticulitis is a rare cause of abdominal pain in Caucasian patients. The condition is often misdiagnosed and only correctly identified on exploration for suspected acute appendicitis. Our aim is to improve awareness of this condition amongst surgical trainees to ensure that its first encounter is not in the operating theatre. We review the role of pre-operative radiological imaging in this condition and the wide and controversial management options are also discussed.Case presentationA 67 years old man was admitted with a 24 hour history of pain in right iliac fossa. A pre-operative diagnosis of acute appendicitis was made but at operation a 2.5 cm inflamed and gangrenous solitary diverticulum of caecum was found. This was treated by right hemicolectomy as there was the suspicion of underlying malignancy.ConclusionCaecal diverticulitis, although rare in the Western population, should be considered in the differential diagnosis of patients complaining of right iliac fossa pain. The surgical approach should be tailored to the clinical scenario but may include conservative management, diverticulectomy, limited ileocaecal resection or right hemicoloectomy.

Elective Laparoscopic Appendicectomy for Chronic Right Iliac Fossa Pain in Children

To determine whether elective laparoscopic appendicectomy is justified for chronic right iliac fossa (RIF) pain of undetermined origin. A retrospective audit of all laparoscopic appendicectomies between January 1997 and August 2003 was performed. The expanded medical audit system (EMAS) and a Microsoft Access database of operative records were used to identify patients with chronic RIF pain subjected to elective appendicectomy. Case notes were retrieved and analysed for patient profile, duration of symptoms including clinic visits and admissions, operative findings, histological analysis, and postoperative performance. A correlation between histological findings and final outcome was investigated. Ninety-eight patients underwent laparoscopic appendicectomy during the period of the study. A total of 11 cases with chronic RIF pain were identified. Nine were female and 2 male. Age ranged from 9 to 14 years with a mean of 11.9 years. The number of clinic visits and admissions for chronic RIF pain ranged from 2 to 8, with a mean of 4. Duration of symptoms ranged from 1 to 36 months, with a mean of 12.1 months. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. Patients were followed up in postoperative clinics for between 1 and 72 months, with a mean of 16.1 months. Histology of resected appendices showed acute inflammation (3 cases), fecoliths (2 cases), lymphoid hyperplasia (LH) (1 case), LH and a foreign body reaction (1 case), LH and mucosal hyperplasia (1 case), and Enterobius vermicularis parasites in 1 case. The appendix was normal in 2 cases. Eight patients had complete resolution of RIP pain. Seven of these had pathology within the appendix and 1 was histologically normal. Two patients with resolved RIF pain, but with pain elsewhere, had lymphoid hyperplasia noted within the appendix. One patient with persistent pain 6 years postoperatively had a normal appendix. This study demonstrates that a significant number of patients with chronic RIF pain have pathology within the appendix. The majority of these cases will benefit from elective appendicectomy. It is critical however that all other possible causes of pain in the RIF are excluded. Laparoscopy is an integral part of the diagnosis and management of this particularly difficult group of patients.

AN AUDIT OF THE PRACTICE OF ROUTINE CT IMAGING FOR RIGHT ILIAC FOSSA PAIN

Aim: To review the practice and implications of performing computed tomography (CT) for patients with right iliac fossa (RIF) pain. Methods: Patients admitted for RIF pain between July 1998 to April 2000 were classified clinically as having appendicitis, equivocal appendicitis or other conditions. They would all undergo CT abdomen and then managed accordingly. The accuracy of clinical and CT diagnosis were compared, with histology of the resected appendix as gold standard. Results: There were 348 patients with RIF pain and 201 of them underwent CT abdomen. Appendicitis was diagnosed clinically in 45 patients, the remaining patients were either equivocal or suspicious of other conditions. From CT abdomen 82 were diagnosed to be appendicitis and 119 were found to be normal or having other pathology. For those with radiological appendicitis, 74 were proven on histology (sensitivity = 85%, positive predictive value (PPV) = 90% (74/82)). Within the clinical appendicitis group, 37 were confirmed by histology (PPV of clinical diagnosis = 82% (37/45)). Among the equivocal group, 50 patients turned out to be appendicitis. Conclusion: Although CT is useful in diagnosing appendicitis, we do not recommend routine CT abdomen for patients with RIF pain as no significant additional benefit is seen in the group of patients with clinical appendicitis. However, there may be a role for it in patients with equivocal clinical features but a randomized clinical trial is needed for further evaluation.

Computed tomography in the diagnosis of equivocal appendicitis.

The clinically obscure right iliac fossa (RIF) pain remains a diagnostic problem. The present study examines the use of computed tomography (CT) in improving the accuracy of clinical assessment in these difficult surgical cases. The trial design was a retrospective review of all patients admitted under one surgeon with suspected acute appendicitis, between 1 January 1995 and 30 June 1997. The study setting was a district hospital (Calvary Hospital) that received patients from both an urban and rural environment. The patient cohort was identified from the Unit Registry and an International Classification of Diseases-based review of medical records. Twenty-one prospective data points were obtained from patient records. Those patients admitted with RIF pain and equivocal symptoms and signs subsequently underwent a CT and/or ultrasound (US) examination, conducted by the attending radiologist. For those patients who proceeded to appendicectomy, the histopathological findings were correlated with the imaging report. Those patients who were discharged after imaging without proceeding to operation were not readmitted to any regional hospital during the course of the study. A total of 84 patients were identified. Thirty-three patients (39%) underwent appendicectomy without imaging and were excluded from further analysis. A total of 51 patients (61%) underwent 61 imaging procedures. The CT scan was correct in 35/36 patients (97%), while US was correct in 17/25 patients (68%). The present study suggests that CT can be used to improve the accuracy of diagnosis of obscure RIF pain. As a pilot study, it supports the development of a randomized controlled trial in a multicentre regional study.

Laparoscopic Management of Unruptured Interstitial Ectopic Pregnancy

A 27 years old women para -1 had a complaint of dullache pain in right iliac fossa for 5 days with irregular spotting. Her previous menstrual cycle was normal but in last one month she had an irregular spotting. On examination she was normotensive. Hb% was 65%. there was no tenderness during per abdominal examination but tenderness during per vaginal examination on right side. Transvaginal ultrasonography (TUVS) detected a degenerative sub serous fibroid of 3.5 x 3 cm on the right fundoanterior side, both adnexae were normal, no fluid was present in cul-de-sac. Her pregnancy test was positive but signs and symptoms of pregnancy were absent. Operative plan was intervention by laparoscope. An unruptured interstitial ectopic pregnancy was found at the anterolateral wall of the fundus. Laparoscopic excision was done and the uterine wall sutured with 2/0 polyprolylin. Post operative outcome was good. DOI: 10.3329/jbcps.v26i3.4199 J Bangladesh Coll Phys Surg 2008; 26: 147-148

ACUTE INTESTINAL OBSTRUCTION IN CHILDREN DUE TO ROUND WORMs.

Objective: To know about the various presentations and management of acute intestinal obstruction due toworms in children.Design:An observational studyPlace and duration of study: This study was conducted at the saidu teaching hospital Swat, from Jan 2010to December 2010.Material and method: Total 118 children were included in the study. The necessary work up was carriedout. 68 children (patients) were treated conservatively. 50 Patients were operated upon as there was noimprovement with conservative treatment.Result: 118 children were studied, 70 male 48 female (ratio of 1.4:1). Abdominal pain was the leadingsymptom in all patients. 108 patients (91%) presented with abdominal distention. Vomiting present in 88patients (74%). History of worms pass per rectally or in vomits in 99 patients (84%). 73 patients (62%)presented with absolute constipation. 54 patients (45%) attend the OPD with pain in right iliac fossa. 03(2%)patients presented with jaundice. Low hemoglobin level was observed in 89(75%) patients, deranged LFTsin 03(2%), air fluid levels in 91 (77%) patients on abdominal X-Rays, abdominal ultrasound finding weresuggestive of acute intestinal obstruction in 77(65%) patients. All patients were treated conservatively, bykeeping nil per oral, nasogastric decompression, IV antibiotics, fluids, kleen enema per rectum. 68 patient(57%) improved with conservative treatment. While surgical intervention was carried out in 50 patients(43%). Mean hospital stay for conservatively treated patients were four days, while for surgically treatedpatients it ranged from 7-12 days. Morbidity were noticed in 7 operated patients (8.26%), 4 patients withparalytic ileus and 3 patients with wound infection. Three patients died among the surgically treatedpatients, mortality is 2.5% in our study.Conclusion: Acute intestinal obstruction due to round worms, can be treated conservatively but if noresponse, then surgical intervention must be planned.