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Surgery Essay

A 25-year old female presents with pain and tenderness


in the right iliac fossa. Briefly discuss the possible
causes and outline the management.

Pain in the right iliac fossa is a localised pain; hence it is


unlikely to be due to viscera as these are innervated by
autonomic nerves, hence there is no dermatome distribution.
Pain in the right iliac fossa is therefore due to inflammation,
referred pain, or pain in an organ or mass.

The differential diagnosis in this case would be: Intestinal


causes: acute appendicitis, mesenteric adenitis, a perforated
peptic ulcer, a Meckel’s diverticulum; gynaecological causes:
ectopic pregnancy, ovarian cyst. It could also be a pelvic
inflammatory disease, or a urinary tract infection (UTI).

The first step of management is history taking. The site of pain


at onset and the current site of pain (if the pain started
centrally and moved to the RIF that are suggestive of acute
appendicitis). The character of pain: is it colicky (could be
flatus), or constant? Does it radiate anywhere? Was it sudden
onset (ovarian torsion)? Any exacerbating or relieving factors?
If the patient finds moving worse, together with coughing and
deep breathing this is suggestive of peritonitis. Any
associations: dysuria, frequency and urgency suggest UTI. It is
also important to ask for past medical history for peptic
ulceration and dyspepsia also a menstrual history: which may
exclude ectopic pregnancy.

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Surgery Essay

During the examination looks out for signs of shock any


dehydration: peripheral shut down, pallor etc. Is the patient
also sweaty, taking shallow breaths and keeping rigid (suggests
peritonitis)? During the examination, tenderness, rigidity or
guarding should be noted as these are signs of peritonitis.
Assess also any pain on percussion. Feel for any masses.
Masses in RIF could be due to appendix, gynaecological mass
such as an ovarian cyst, a lymph node mass. Check for bowel
sounds: if absent could be due to peritonitis, also they could be
high pitched and tinkling suggestive of obstruction
(appendicitis).

Pregnancy tests, to rule out ectopic pregnancy must be done.


Urine dipstick and microscopy should be done to rule out UTIs.
In the case of UTIs, an outpatient antibiotic against the
offending organism as shown by microscopy should be given if
the patient is stable and not in shock. A CBC is useful, as white
cell count may help. In acute appendicitis the neutrophils
increase, while in mesenteric adenitis, the leukocyte count
increases. In addition for medical causes of abdominal pain: a
blood glucose level: to exclude diabetic ketoacidosis, U& E’s to
exclude hypercalcemia.

The patient should next be admitted into hospital. Resuscitation


is important: this includes oxygen, IV fluids, and analgesia, and
the patient should be observed (NG tube, catheters, fluid
balance, repeated examinations). If pain and tenderness
settles, then no further treatment may be necessary. However
if they persist, further investigation is needed, such as
ultrasound. This can visualise ovaries, and look for free fluid. It
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Surgery Essay

can also show an enlarged appendix. US is very sensitive


although not specific, and does not rule out appendicitis of no
abnormality is seen. If thre is peritonitis, laparoscopic
visualisation is required, and laparoscopic appendicectomy can
then be done if needs be. If appendicitis is excluded, the small
intestine should be searched for a Meckel’s diverticulum. In the
case of peptic ulcer perforation, a vagotomy (truncal or
selective): with pyloroplasty or gastroenterotomy, or antectomy
with vagotomy, then anastamosis via Billroth I or II. If
gynaecological conditions are excluded by US and laparoscopy
does not reveal anything: mesenteric adenitis is possible and
this should be treated by paracetamol.

28/02/09