Approach to right iliac fossa(RIF) pain
- 1. Approach to RIF pain Dr Ilavarasan Kannaiyan
- 2. “Patient is the centre of medical universe around which all our works revolve and towards which all our efforts trend” - J.B Murphy Professor of Surgery, USA
- 3. RIF PAIN Common condition is our practice Difficult to diagnose
- 4. Pain Site Duration onset Severity Character Continuous or intermittent Migration radiation
- 5. Associated symptoms Vomiting Nausea Loss of appetite Loose stools Constipation Hematochezhia, malena Fever Dysuria, hematuria, calcaluria, pyuria Missed periods Difficulty to walk/move Skin rash on back
- 6. Symptoms of other systems cough Throat pain Chest pain
- 7. Past history Similar episodes Surgery done Travel to abroad TB, HIV, Crohn’s disease,Malignancy Relevant medical history
- 8. Family history Incidence of appendicitis, ureteric colic in family
- 9. Clinical examination Vitals- general condition Look for jaundice and pallor Cynosis. Generalised lymphadenopathy, pedal edema.JVP. Look for evidence of generalised peritonitis- tachycardia,tachypnoea, falling bp
- 10. abdomen Movement with respiration Redness, swelling, scar .dilated veins Organomegaly Guarding, rigidity Mass palpable Tenderness over which quadrant Scrotum and testes
- 11. Specific signs Rebound tenderness Rovsing’s sign Cough impulse testicular tenderness Renal angle tenderness Herpetic patch
- 12. investigations Cbc Crp,esr Urine r/e, UPT Stool r/e ABD xray erect, KUB U/S abd and pelvis CT abd
- 13. ACUTE GENERAL SURGICAL RGICAL GYNECOLOGICAL Appendicitis, perforation,Abscess/ mass formation Ruptured ectopic Ureteric colic Twisted/Ruptured Ovarian cyst Torsion tesits Obstructed hernia Mittleschmerz - ovulation time Mesentric adenitis Psoas abscess OTHER CONDITIONS: Epididymo orchitis Pelvic adenitis Pleuritic pain Disc compression/ Neuralgia Herpes zoster Cholecystitis Faecal impaction Intussussception Liver abscess Amoebic / entero colitis Ilio caecal TB Diverticulitis Crohn’s disease Caecum/ colonic tumour/ malignancy
- 14. ACUTE APPENDICITS Sudden onset pain, in some peri umbilical pain migrates to RIF Loss of appetite, nausea, vomiting Fever comes later constipation No involvement of CNS and Respiratory symptoms
- 15. Clinical signs General- pulse about 80-90 in most , but if perforated or abscess tachy Mild elevated temperature, more in abscess P/A tender RIF McBurneys point Rebound – Blumberg’s sign- in children pain on cough/ hopping/ percussion Rovsing’s – pressure on LIF causes pain over RIF Obturator sign- rotating hip with flexion of knee Psoas sign – hyper extension of hip Aaron’s sign – pain over epigastrium on pressing McBurney’s point
- 16. MCBURNEY’S POINT
- 17. M A N T R E L S
- 18. INVESTIGATIONS CBC CRP/ESR URINE R/E, UPT Plain Xray abd U/S abdomen CECT
- 19. Biomarkers for Appendicitis Serum and urinary CP- calprotectin and LRG - leucine-rich alpha glycoprotein-1, in children. PCT-Procalcotonin, IL6- interleukins, urinary5HIAA- 5 hydroxy indole acetic acid
- 20. Management - Mainly surgical Rarely conservative in early cases
- 21. prevention High fibre diet prevents appendicits in siblings
- 22. Mesentric adenitis Common DD for appenditis Evidence of generalised symptoms like fever, URI,Gastroenteritis VIRAL and Bacterial causes- common organism- yersinia enterocolitica Pain less marked Tenderness reduced on left lateral position Less peritonitis features
- 23. INVESTIGATIONS CBC/ CRP/ ESR Stool r/e, c/s U/S ABD
- 25. RENAL / URETERIC COLIC Commonest condition in Khasab Risk factors Poor water intake Diet rich in animal proteins – meat/dairy products Hyperparathyroidism Metabolic abnormalities
- 26. Renal / ureteric colic
- 27. Ureteric colic Locaction of stone Area of pain Renal pelvis / upper ureter Testes in males / labia majora in females Mid ureter Lumbar / illiac fossa Lower ureter Upper thigh,scrotum , perineum intramural suprapubic/ tip of penis with strangury
- 28. Clinical features Symptoms of groin to loin pain, dysuria, frequency, strangury. Hematuria. Calcaluria Less or no GI symptoms Marked tenderness in renal angle / RIF/suprapubic regions Absence of peritonitis features- rebound tenderness Changing areas of tenderness
- 29. investigations Urine r/e – look for RBCs, crystals, pH,type of crystals – oxalates / uric acid Urine C/S RFT, uric acid, calcium KUB xray – 90% stones visible in well prepared one U/S pick up dilated collecting systems, less specific for stones Spiral CT – investigation of choice for ureteric calculus
- 30. KUB Xray
- 31. PLAIN CT
- 32. Management 5mm or < - conservative treatment Inj Diclofen well tolerated even in G6PD deficient Treatment of associated UTI Rest- ESWL, Ureteroscopy. Laser, PCNL Open surgery
- 33. Diet Urine volume > 2litres/ day in patients with normal RFT Avoid airated/ fizzy drinks – high citrate and fructose level Black tea,dark chocholates, straw berries, spinach Nuts- almond>peanits>cashew>pistaccios
- 34. prevention
- 35. Foods High in uric acid
- 36. Faecal impaction Can produce pain in RIF , common in children History of constipation and straining at stool CBC CRP- Will be normal To r/o Hypothyroidism in recurrent cases X ray abdomen will give clue
- 38. Management Phosphate enema Diet modification
- 39. Irreducible hernia Pt may not have noticed swelling earlier Can be missed easily in usual clinical examination Cough impulse may be absent Good exposure and examination Admission and observation essential to manage pt
- 40. Herpetic neuralgia Sudden onset severe pain, may be burning in nature No GI symptoms Patient may not have seen the rash Can mimic appendicitis
- 41. Herpes zoster
- 42. THANK YOU
- 43. LOVE IS THE GREAT QUALITY OF HUMANS BUT THE GREATEST LOVE IS THE LOVE OF GOD ON HUMANS