Right Iliac Fossa Masses RIF RIGHT ILLIAC FOSSA
- Slides: 32
Right Iliac Fossa Masses (RIF)
RIGHT ILLIAC FOSSA LOCATION Abdomen is divided into ❾ regions. ❷ Horizontal planes: - Upper: Transpyloric. - Lower: Trans-tubercular. ❷ Vertical planes: one on either side, midclavicular to midpoint between ASIS and symphysis pubis
Appendix Caecum Right Ovary Small bowel
RIGHT ILLIAC FOSSA ANATOMY • Appendix. • Caecum. • Ileocecal junction/valve. • Right ureter. • Right Ovary/Fallopian tube(female)
RIF mass Abdominal wall Intra abdominal Retroperitoneal
Abdominal wall mass - Hematoma - Abscess - Incisional hernia ( post appendictomy) - Tumors as Lipoma, Fibroma
Appendicular abscess Appendicular mass Appendicular neoplasms Ileocecal tuberculosis Mucocele of the appendix RIF ddx Carcinoma caecum Actinomycosis Psoas abscess Non-Hodgkin lymphoma Ectopic kidney Undescended testis Ectopic/transplanted kidney
Appendicular mass ▪ It is the localization of infection occurring 3 to 5 days after an attack of acute appendicitis. ▪ Inflamed appendix, greater omentum, edematous caecum, parietal peritoneum and dilated ileum (Ileus) forms a mass in the right iliac fossa. ▪ Fever (+/-) ▪ This mass is tender, smooth, firm, well localized, not moving with respiration, not mobile, well localized and resonant on percussion. ▪ Investigations: ♦ CBC ♦ U/S confirms the mass.
Appendicular mass ▪ Treatment: ▪ Conservative (Ochsner-Sherren Regimen), Includes: ▪ Temp, BP, pulse chart, marking the (progression/regression). ▪ Antibiotics (Ampicillin, metronidazole), IV fluids and analgesics. ▪ Contraindications for Ochsner-Sherren regimen: 1. When diagnosis is in doubt. 2. In acute appendicitis in children and elderly. 3. Gangrenous appendicitis. 4. Diffuse peritonitis sets in.
Appendicular abscess ▪ It occurs due to suppuration in an acute appendicitis or appendicular mass. ▪ Abscess commonly occurs in retrocaecal region ▪ Pelvic abscess is also common after an attack of acute appendicitis. ▪ High grade fever and tachycardia. ▪ Smooth, soft, tender and dull mass in the right iliac fossa with indistinct borders.
Appendicular abscess Investigations • CBC. • U/S confirms the mass. • USG: fluid collection (hypoechoic) in the appendicular region Treatment: • Antibiotics are started. • Surgery. Interval appendicectomy after 3 months. USG- Appendicular abscess
Mucocele of the appendix • It occurs when proximal end of the lumen of appendix gets slowly and completely occluded. • Mimics sub acute appendicitis, infection leads to empyema. • Rupture causes pseudomyxoma peritonei • Clinical Features: Colicky pain , Tenderness in the right iliac fossa. • Investigations: U/S abdomen. • Treatment: Appendicectomy
Appendicular neoplasm ▪ It is rare and often post-appendicectomy histological diagnosis. ▪ ▪ Carcinoid tumor. Arise from Kulchitsky cells in crypts of Lieberkuhn. Vermiform appendix is the most common site. Most common neoplasm of the vermiform appendix. It’s commonly a incidental finding, painless well defined, firm to hard mass Treatment: Appendicectomy ▪ ▪
Ileocecal tuberculosis • Most common site of abdominal tuberculosis due to presence of Peyer’s patches • Causative organism: mycobacterium tuberculosis. • Types: • Ulcerative 60%, Ulcerohyperplastic 30%, Hyperplastic. • C/F: • Abdominal pain is the most common symptom (90%) • Anaemia, loss of weight and appetite, Diarrhoea, Fever Note the multiple transverse undermined ulcers.
Ileocecal tuberculosis ➢Investigations: • Chest X-ray to find out primary focus. • Mantoux test • ESR is raised. • U/S abdomen. • Barium study X-ray. • Colonoscopy ➢Treatment: • Drugs: INH; rifampicin; pyrazinamide; ethambutol. • Surgeries: limited ileocaecal resection ileocaecal tuberculosis in barium study X-ray
Carcinoma of cecum • Site : It is nodular, hard, mass in the right iliac fossa. • C/F: unexplained pain in RIF, anemia, malaise. • It is nodular, hard, mass in the right iliac fossa. • Often features of intestinal obstruction may be present.
Carcinoma of cecum • investigations, Imaging : CBC Tumor markers US CT • Surgery is the only curative modality for localized colon cancer.
ACTINOMYCOSIS • It is caused by Actinomyces israelii. • Clinical Types: • In right iliac fossa: It presents as a mass abdomen with discharging sinus. • Facio-cervical: It is the most common type • Thorax, liver, pelvic C/F: • Discharging sinus with induration and nodules. • No lymph nodal involvement
ACTINOMYCOSIS • Investigations • Pus under microscopy shows branching filaments. • Gram’s staining shows Gram-positive mycelia • Treatment • Penicillin G for longer period (6 -12 weeks). • Surgical debridement is occasionally required.
Retroperitoneal Mass
PSOAS ABSCESS • It’s a cold abscess due to TB of Thoracolumbar spine T 10. • It can also be a pyogenic abscess. • It is localized, smooth, soft, nonmobile mass in the right iliac fossa. • Caseating pus from vertebra gravitates via medial arcuate ligament underneath psoas sheath. • Spinal tenderness + spinal movements will be restricted. • psoas sign • Cross fluctuation – pus tracks below inguinal ligament into thigh
PSOAS ABSCESS ➢Investigations: • X-ray spine and chest, CT scan. • Mantoux test, ESR, peripheral smear. • U/S abdomen. ➢Treatment: • Anti-tuberculous drugs are started • Drainage, only lateral approach is advised.
Non-Hodgkin lymphomas • Tumors originating from lymphoid tissues, mainly of lymph nodes. • Enlarged lymph nodes, fever, sweating and chills, weight loss, fatigue (extreme tiredness), swollen abdomen. • CT, bone scan, biopsy. • Chemotherapy • Surgery in the treatment of patients with NHL is limited.
Others • Ectopic kidneys. • Undescended testis. • Tubo-ovarian mass.
GIT causes: - carcinoma of sigmoid or descending colon - diverticular abscess - Loaded sigmoid colon (in sever constipation) - Bilharzial colonic mass - amoebic mass (amoeboma) Extra-GIT: - ovarian tumor or cyst - psoas abscess - hernia - transplanted kidney - tumors of un-descended testis
Sigmoid colon Left ovary Small bowel Rectum
• Accounts for 14% of all cancer death (second to lung cancer) • Risk factors include: 1. Adenomatous polyps 2. Genetic Factor 3. Dietary Factors 4. Inflammatory Bowel Disease
• abdominal pain & tenderness • change in bowel habit • blood in stool • weight loss • intestinal obstruction • abd. & rectal exam. may reveal a mass.
CBC, RFT, LFT. CT, MRI Biopsy, Histopathology. Sigmoidoscopy It is a must along with PR examination Can show any mucosal abnormality up to mid sigmoid colon (25 cm) • Colonoscopy It visualize the entire colon. • •
ü Suspect Clinically. ü Confirm by Imaging. ü Prove by Histology.
It is surgical and require hemicolectomy Complications include: • Hemorrhage • Injury of the bladder, ureter, small bowel, spleen, sexual function.
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