RIGHT ILIAC FOSSA MASS DDS INVESTIGATIONS BY ZIYANA

RIGHT ILIAC FOSSA MASS -DDS & INVESTIGATIONS BY ZIYANA LIYAKATH 2002 BATCH 10 1

ILIAC FOSSA REGIONANATOMYY 10 2

TOPOGRAPHY OF RIF 10 3

Swellings in RIF PARIETAL n rare except iliac abscess/appendicular abscess burrow through anterior abdominal wall & may become parietal n INTRA ABDOMINAL n Two types n Structures normally present in the site n Structures abnormally invade region n 10 4

NORMALLY PRESENT APPENDIX n CAECUM n TERMINAL PART OF ILEUM n LYMPH NODES n ILIAC ARTERIES n RETROPERITONEAL CONNECTIVE TISSUE n 10 5

ILIOPSOAS SHEATH n ILIUM n 10 6

ABNORMALLY INVADE RENAL SWELLING n GALL BLADDER SWELLING n UTERINE SWELLING n URINARY VESICAL n UNASCENDED TESTIS n PELVIC ABSCESS n 10 7

APPENDIX 10 8

ANATOMY Average length: 7. 5 -10 c. m n Position>retrocaecal(44%), pelvic(21%), subca ecal(1. 5%), postileal(. 5%), paracaecal( 2%), preileal(1%) n Histology->mucosa, sub mucosa, muscularis propria, serosa n Mesentry->meso appendix n Blood supply->appendicular artery, acessory appendicular n 10 9

Position of appendix 10 10

APPENDICULAR MASS n n n n n 10 Third day or earlier after attack of appendicitis At the position of appendix O/E->irregular firm tender & fixed mass Rigidity of abdominal musculature Tympanitic on percussion CONSTITUENTS Inflamed appendix Greater omentum Oedematous caecal wall. coils of small intestine 11

APPENDICULAR ABSCESS n n 10 Failure of resolution of appendix mass Continued spiking pyrexia 12

RARE MUCOCELE n When proximal end of lumen slowly becomes completely occluded by fibrotic stricture & retained sterile secretions , appendix enlarged greatly & sometimes contains several milli litres of mucus n When infection supervenes empyema develops n 10 13

Mucocele appendix 10 14

NEOPLASMS CARCINOID TUMOUR[ARGENTAFFINOMA] n Arise from argentaffin tissue[kulchitsky cells of crypts of lieberkuhn], most commonly in vermiform appendix n 10 times more common n Frequently distal 3 rd n Feels hard n 10 15

Carcinoid tumour 10 16

CARCINOMA CAECUM n n Patient above 40 Hard fixed lump May not be any change in bowl habit if present alternate constipation & diarrhoea Anemia, anorexia, weig ht loss 10 17

AMOEBIC CAECAL MASS n n 10 Entamoeba Histolytica Tenderness on deep palpation over caecum & sigmoid 18

ACTINOMYCOSIS n n n 10 Hard & fixed mass Multiple sinuses seen discharging sulphur granules Discoloration of affected skin 19

TERMINAL ILEUM n n n 10 IMPACTION OF ROUND WORMS Lower part of ileum History of passing worm with stools/vomitus 20

CROHN’S DISEASE CLINICAL FEATURES n INFLAMATORY STAGE n Tender mass n Fever n Anemia n Diarrhoea n COLITIS STAGE n 10 21

Diarrhoea, fever, anemia, loss of weight, occult blood & mucus present in stool n Steatorrhoea n Fissure in ano n Perianal abcess n Anal fistula n STENOTIC STAGE n Small intestinal obstruction n 10 22

FISTULA n External/internal n 10 23

CROHN’S DISEASE 10 24

ILEOCAECAL REGION HYPERPLASTIC ILEOCAECAL TB n Injection of mycobacterium TB. Infection starts in lymphoid follicles &then spreads to submucous & subserous planes n Intestinal wall thickened, lumen narrowed n Matted lymphnodes+terminal part of ileum & caecum involvement produced lump n 10 25

Gross specimen of ileum showing multiple hypertrophied tubercular pseudopolyps and cut part of appendix pecimen of ileum showing multiple hypertrophied tubercular pseudopolyps and cut part of ap 10 26

n n n 10 COMPLAINTS 1. Recurrent attacks of abdominal pain with diarrhoea 2. Blind loop syndrome 3. lump 4. general 27

GIBBUS OF SPINE 10 28

LYMPH NODES n n n 10 Enlargment of iliac group of lymphnodes A. FILARIAL Periodic attacks of fever with simultaneous tenderness & swelling of nodes 29

n n n 10 B. TUBERCULOUS LYMPH NODE GENERAL FEATURES Matted lymph nodes 30

n n n 10 C. LYMPHOSARCOMA Rapid enlargment of nodes Young subject D. SECONDARY CARCINOMA Other evidence of primary ca Usually old 31

ANEURYSM OF ILIAC ARTERIES n 10 RARE 32

ILIOPSOAS SHEATH ILIAC ABSCESS n Infection of haematoma in iliacus muscle n Pain, tenderness restricted to region n Clear space btw abscess&ilium n 10 33

TENDER POINT OF ILIACUS 10 34

PSOAS ABSCESS n n 10 Down the thoracolumbar vertebra to pelvis&crosses inguinal ligament to thigh Cross fluctuation present 35

ABSCESS IN THE THIGH 10 36

ILIUM n 10 Bony swelling 37

ABNORMALLY INVADING n n n n 10 1. KIDNEY A. PELVIC KIDNEY The first rudiment appear in pelvis With development ascend to final position Due to unknown reasons kidney fail; to ascend & remains permanently in pelvis/right iliac fossa B. DROPPED/MOVABLE KIDNEY Extremely rare 38

GALL BLADDER SWELLING n 10 Hugely distended gall bladder with enlarged liver descend as low as right iliac fossa 39

UTERINE & IT’S APPENDAGE 10 40

n n n n 10 h/o vaginal discharge Menstrual irregularities p/v can confirm clinically A. tubo-ovarian mass B. pyosalpinx C, . cyst & abscess of broad ligament D. fibroid of uterus E. ovarian cyst 41

UNDESCENDED TESTIS n n 10 Develops in lumbar region As foetus grows, testis descends through inguinal canal into scrotum Fails to descend Commonestsuperficial ing pouch 42

PELVIC ABSCESS n n n 10 Most common presentation-spiking pyrexia Pelvic pressure/discomfort associated with loose stool, tenesmus P/R->Boggy tender mass in pelvis anterior to rectum 43

INVESTIGATION 10 44

n n n 10 1. ROUTINE BLOOD A. ANEMIAmalignancy, tuberculosi s, crohn’s disease B. ESRmalignancy, tuberculosi s, crohn’s disease 45

n n n 10 C. POLYMORPHONU CLEAR LEUCOCYTOSIS D. EOSINOPHILIA E. MICROFILARIAE 46

MICROFILARIAE 10 47

EOSINOPPHILIA 10 48

n n n 10 2. URINE UTI RBCs 3. STOOL Occult blood microscopy 49

4. TUBERCULOUS ETIOLOGY n Psoas abscess, ileocaecal T. B, lymphnode n AFB STAIN n C & S n LUMBAR X-RAY, DORSAL SPINE X-RAY n 10 50

AFB SMEAR 10 51

CHEST&DORSAL SPINE 10 52

n 10 5. ULTRASOUND- 53

TRANSVAGINAL 10 54

n n n 10 6. BARIUM ENEMA A. obstructive appendicitis-faecolith as filling defect B. Ca caecum-filling defect C. crohn’s disease-string of kantor, caecum in normal position not elevated D. ileocaecal TB-long narrow constricted terminal ileum & ascending colon with caecum higher up 55