Right Iliac Fossa Masses RIF RIGHT ILLIAC FOSSA

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Right Iliac Fossa Masses (RIF)

Right Iliac Fossa Masses (RIF)

RIGHT ILLIAC FOSSA LOCATION Abdomen is divided into ❾ regions. ❷ Horizontal planes: -

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

Appendix Caecum Right Ovary Small bowel

RIGHT ILLIAC FOSSA ANATOMY • Appendix. • Caecum. • Ileocecal junction/valve. • Right ureter.

RIGHT ILLIAC FOSSA ANATOMY • Appendix. • Caecum. • Ileocecal junction/valve. • Right ureter. • Right Ovary/Fallopian tube(female)

RIF mass Abdominal wall Intra abdominal Retroperitoneal

RIF mass Abdominal wall Intra abdominal Retroperitoneal

Abdominal wall mass - Hematoma - Abscess - Incisional hernia ( post appendictomy) -

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

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

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,

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

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

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

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

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

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

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

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

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

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

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

Retroperitoneal Mass

PSOAS ABSCESS • It’s a cold abscess due to TB of Thoracolumbar spine T

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,

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

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.

Others • Ectopic kidneys. • Undescended testis. • Tubo-ovarian mass.

GIT causes: - carcinoma of sigmoid or descending colon - diverticular abscess - Loaded

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

Sigmoid colon Left ovary Small bowel Rectum

 • Accounts for 14% of all cancer death (second to lung cancer) •

• 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

• 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

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.

ü Suspect Clinically. ü Confirm by Imaging. ü Prove by Histology.

It is surgical and require hemicolectomy Complications include: • Hemorrhage • Injury of the

It is surgical and require hemicolectomy Complications include: • Hemorrhage • Injury of the bladder, ureter, small bowel, spleen, sexual function.