Introduction to Right Iliac Fossa

The ilium is one of 3 bones that form the hip bone.

The inside surface of the ilium is a large, concave, smooth
surface known as the iliac fossa.
Pain of the right iliac fossa (RIF) can be cause for alarm as it
is a sign of a number of health conditions such as
appendicitis.
Like most medical issues, appendicitis presents itself with
varied symptoms, and there are several other diagnoses to be
considered when a patient is experiencing RIF pain.

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Region of abdomen

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 Complication of Acute Appendicitis
and its management
• Complication

1. A ruptured appendix.(Peritonitis)
2. A pocket of pus that forms in the abdomen.
(Abscess)

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 Peritonitis
• If your appendix bursts, it releases bacteria
into other parts of the body. This can cause a
condition called peritonitis if the infection
spreads to the peritoneum, the thin layer of
tissue that lines the inside of the abdomen.

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• Symptoms of peritonitis can include:
• severe continuous abdominal pain
• feeling sick or being sick
• a high temperature (fever)
• a rapid heartbeat
• Shortness of breath with rapid breathing
• swelling of the abdomen

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• If peritonitis isn't treated immediately, it can
cause long-term problems and may even be
fatal. Treatment for peritonitis usually
involves antibiotics and the surgical removal
of the appendix (appendectomy).

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 Abscesses
• Sometimes an abscess forms around a burst
appendix. This is a painful collection of pus
that occurs as a result of the body's attempt
to fight the infection.
• It can also occur as a complication of surgery
to remove the appendix in about 1 in 500
cases.

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• Abscesses can sometimes be treated using
antibiotics, but in the vast majority of cases
the pus needs to be drained from the abscess.

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• This can be carried out under ultrasound or
computerised tomography (CT) guidance using
local anaesthetic and a needle inserted
through the skin, followed by the placement
of a drain.
• If an abscess is found during surgery, the area
is carefully washed out and a course of
antibiotics is given.

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 Management
1.Emergency management
2.Definitive management

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 Emergency Management
• Resuscitation
• Established IV access
• Catheterize and place on a fluid balance chart
only if decrease BP or septic
• Request FBC(Hb,WCC),U&E(Na,K),CRP(usually
increase WCC,CRP)

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• Established a diagnosis
• The diagnosis is a clinical one in all but exceptional
cases investiations are usually unnecessary
• CT is appropriate in adult(over 65yrs)
• Ultrasound scan is indicated in young women with
childbearing age
• Laparoscopy is a useful surgical diagnostic manoeuvre
• Early treatment- Avoid IV antibiotics without a clear
dianosis

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 Definitive Management
• Acute appendicitis
• Open or laparoscopic appendicectomy
• IV antibiotics on induction, continued antibiotics only
indicated for perforation

• Appendix mass or appendix abscess

• IV antibiotics( Cefuroxime 750mg tds+ metronidazole
500mg tds)
• If symptoms settle,delayed appendectomy after 6 weeks
• If symptoms fail to settle,may need acute appendectomy
• Appendix abscess may be amenable to CT-guided drainage

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 References
• Bailey & Love’s Short Practice of Surgery - 26th
Edition
• Browse’s Introduction to the Symptoms &
Signs of Surgical Disease 6th Edition
• Oxford handbook clinical medicine 10th
edition
• https://www.nhs.uk/conditions/peritonitis/tre
atment/

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Common Pathologies in Right Iliac
Fossa:
Symptoms and Physical Signs
By : Muhammad Aiman Syafiq bin Mohd
Arif.

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 Introduction
• Symptoms : Subjective evidence of disease perceive by
patient.

• Sign : Evidence of disease that can be detected by

doctors upon inspection and examination.

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 Literature review
• Based on research that has been done by 2 researchers, Sarah Wu Weng Gray and Peter Kang.

• In an 2014 article of “A differential for right iliac fossa pain and the importance of consenting properly”.

• In this article, the reseachers discussed the case of a 39-year-old man presented with a 2-day history of central
abdominal pain which had subsequently localised to the right iliac fossa, with clinical signs of tenderness with
guarding in the right iliac fossa.

• The patient underwent laparoscopy, which revealed a normal appendix but a torted, ischaemic greater omentum.
This was successfully removed laparoscopically.

• They found out that no matter classical presentation, there could be an unusual pathology causing the patient's
symptoms.

• On discussion they stated the differential diagnosis of right illiac fossa pain.

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 Appendicitis

Symptoms :
• Peri umbilical colic
• Pain shift to right iliac fossa
• Nausea
Sign
• Pyrexia
• Rebound tenderness
• Muscle guarding
• Localised tenderness in the right iliac fossa

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 Test for Appendicitis
• Rovsing’s sign
-Positive when pressure over the patient’s left lower
quadrant cause pain in right lower quadrant.
• Psoas Sign
-Patient lies down on left side and clinician hyperextends
the right hip. Painful hip extension shown a positve sign.
• Obturator test
-Clinician flexes the patient’s right hip and knew and then
internally rotates the right hip.

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 Children

• Mesenteric lymphadenitis

• Intussusception

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 Mesenteric lymphadenitis

• Inflammation of lymph nodes in a membrane that

attaches the intestine to the abdominal wall.
• Common in children due to infection of Yersinia
enterocolitica.
Sign & symptom
• Colicky pain in right iliac fossa.
• High fever.
• Cervical lymph nodes enlarged.
• Raised white blood cell count.

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 Intussusception

• A segment of intestine invaginates into adjoining intestinal

lumen causing bowel obstruction.
• 5-10 months age.
Sign & symptoms
• Vomiting
• Colicky, severe, intermtittent pain.
• Abdominal distenstion due to obstruction.
• Dance Sign
*sausage shaped mass in hypochondrium and emptiness in
RIF. The mass hard to detect and best palpate when infant is
quiet.

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 Adult
• Ureteric colic

• Testicular torsion

• Pancreatitis

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 Ureteric colic

• Blockage of urinary tract such as ureter by renal stone.

Sign & symptoms
• Pain in lower abdomen
• Pain spread to the back or groin
• Nausea/vomitting
• Hematuria

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 Testicular torsion

• Testicular tortion occur when a testicles rotates twisting

the spermatic cord and blood supply to the scrotum.
• Reduced blood flow will case severe pain
• Common in adolescent.
Sign & Symptoms
• Pain in abdomen and groin
• Painful urination
• Swelling in scrotum
• Nausea and vomiting

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 Female

• Pelvic inflamatory disease

• Ectopic Pregnancy

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 Pelvic inflammatory disease

• Infection of woman reproductive organs.

• Often caused by sexually transmitted disease such as
clamydia.
Signs & Symptoms
• Pain in lower abdomen
• Fever
• Discharge from vagina
• Burning pain when urinate

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 Ectopic Pregnancy

• Ectopic pregnancy occurs when the fertilized eggs

attaches itself in other place other than uterus.
• Mostly ectopic pregnancy occur in fallopian tube.
Signs & Symptoms
• Sharp or stabbing pain in right iliac fossa
• Vaginal bleeding
• Dizziness
• Urinary pregnancy test positive

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 Elderly
• Cecum is short pouch like region located in the lower
right quadrant of the abdominal cavity inferior and
lateral to ileum.
• Carcinoma of caecum is more likely occur in elderly
person.
Signs & Symptoms
• Pain in right iliac fossa
• Anemia
• Fatigue

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 References
• Bailey & Love’s Short Practice of Surgery - 25th Edition,page
1205-1217.
• A differential for right iliac fossa pain and the importance of
consenting
properly,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948
101/
• Testicular Torsion Clinical Presentation, 23 Jun. 2017,
https://emedicine.medscape.com/article/2036003-clinical
• “What to Know About Ectopic Pregnancy”, Ectopic Pregnancy:
Symptoms, Risk Factors, Diagnosis, and Treatment, 21 Jan.
2017, https://www.webmd.com/baby/pregnancy-ectopic-
pregnancy

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 Clinical Features of
Appendicitis
BY MUHAMMAD NURIL ANWAR ABD KARIM
BMS15091684

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 Aetiology of Appendicitis
• It may due to
• decrease dietary fibre
• An alteration of bacteria flora
• luminal obstruction due to faecolith or a
stricture
• foreign body
• carcinoma
• parasite, particularly Oxyuris Vermicularis
(pinworm)

Faecolith– a hard mass of faeces within the colon,

appendix, or rectum, due to chronic constipation: a cause
of inflammation.

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 PATHOPHYSIOLOGY
• Obstruction of the lumen by faecolith

• Secretion builds up due the obstruction

• Promotes the growth of bacteria and results

in inflammation

• Inflammation compromises the

arteriovenous blood supply, hence the
appendix undergoes necrosis

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 Literature Review
• Research that has been done by 2 surgeons, Ali Akbar Salari, Fariba Binesh.

• In an article of “Diagnostic value of anorexia in acute appendicitis”

• In this article, the surgeons hypothesized that anorexia is not a cardinal

features for appendicitis.

• However, absence of anorexia cannot rule out the diagnosis of acute

appendicitis.

• On their research, among 400 cases of appendicitis, 355(86%) of them had

anorexia and another 45 patient did not come with anorexia.

• So, anorexia increases probability of appendicitis bit its absence cannot rule
out diagnosis of acute appendicitis.

• On discussion, they stated the classic clinical features of acute appendicitis.

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 Cardinal signs of Appendicitis
• Pain i) On navel/umbillicus
ii) On RIF
• Vomiting and nausea
• Fever or pyrexia
• Tenderness concentrated on RIF
• Rebound tenderness on RIF
• Diarrhea or constipation
• Facial flush, dry tongue and fetor oris
• Tachycardia
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Anatomical consideration in presentations
of acute appendicitis
1. Retroceacel
Right loin pain with tenderness
Psoas stretch sign
2. Subceacel and pelvic
Suprapubic pain and increased urination
Diarrhea due to irritation of ceacum
3. Preilial and postileal
Vomiting and diarrhea- irritation of distal ileum

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 Management of Acute Appendicitis
• Investigations of acute appendicitis

1) Full blood count.. WBC (greater than 10,500 cells/µL),

RCP, leukocytosis, neutrophils counts

2) Urinalysis… rule out UTI (pyuria++) and kidney stones

… and also urinary 5 hydroxyindoleacetic acid

(U5HIAA)

3) UPT… to rule out ectopic pregnancy

4) CXR… rule out lower lobe pneumonia

5) Abdominal scanning… USG(Doppler), CT scan, Barium 41

 GOLD
STANDAR
Abdominal Scanning D TEST

Figure 1: CT scan reveals an enlarged

appendix with thickened walls, which
do not fill with colonic contrast agent,
lying adjacent to the right psoas
muscle. 42
 Abdominal Scanning

Figure 2: Appendicitis; transverse view, color Doppler

ultrasound image. Circumferential colors are observed in
the wall of the inflamed appendix (arrows), a strong
indicator of acute appendicitis. 43
 Abdominal Scanning

Figure 3: Acute appendicitis in magnetic resonance image. A

markedly enhanced and thickened inflamed appendix (arrows)
with pericecal enhancement due to the extent of inflammation
is shown.
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Management of Acute Appendicitis
• Treatment of acute appendicitis can be
1) Surgical
Appendectomy
Open surgery or laparoscopy
2) Medicine
Painkillers…. Acetaminophen and Ibuprofen
Antibiotics…. Broad spectrum antibiotics

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46
Alvarado Score

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 Abdominal Scanning

Figure 2: Appendicitis; transverse view, color Doppler

ultrasound image. Circumferential colors are observed in
the wall of the inflamed appendix (arrows), a strong
indicator of acute appendicitis.
 References
• Bailey’s and Love, Short Practice of Surgery 26th Edition
• Appendicitis Workup.” Appendicitis Workup: Approach
Considerations, Complete Blood Cell Count, C-Reactive
Protein, 19 Sept. 2017,
• BMJ Best Practice, bestpractice.bmj.com/topics/en-gb/290.
• “Welcome to appendicitis.pro.” Imaging studies in the
Diagnosis of Appendicitis | Welcome to appendicitis.pro
• Diagnostic value of anorexia in acute appendicitis,
www.pjms.com.pk/issues/janmar07/article/article12.html.
• “Appendicitis Causes, Symptoms, Treatment - When to Seek
Medical Care.”
• “Appendicitis Clinical Presentation.” Appendicitis Clinical
Presentation: History, Physical Examination, Appendicitis
and Pregnancy, 19 Sept. 2017,
emedicine.medscape.com/article/773895-clinical.
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