Acute Rt iliac fossa pain is the commonest emergency surgical problem. Acute appendicitis is the major cause for this problem,

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ACUTE RIGHT ILIAC FOSSA PAIN
A PROBLEM ORIENTED APPROACH
ACUTE RIGHT ILIAC FOSSA PAIN
A PROBLEM ORIENTED APPROACH
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ACUTE RIGHT ILIAC FOSSA PAIN
A PROBLEM ORIENTED APPROACH
Dr.B.SELVARAJ MS;Mch;FICS;
NEONATAL & PEDIATRIC SURGEON
PIMS
PONDICHERRY INDIA
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ACUTE RIGHT ILIAC FOSSA PAIN
A PROBLEM ORIENTED APPROACH
Recognise various conditions
Clinch the correct diagnosis
Appropriate early treatment
Appropriate surgical referral4
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OBJECTIVES
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ACUTE RIGHT ILIAC FOSSA PAIN
CAUSES
CAUSESMesenteric
Lymphadenitis
Acute Appendicitis
Ectopic pregnancy
Mittelschmerz
Meckel’s Diverticulitis
Twisted ovarian cyst
PID
UTI
Right ureteric calculusP
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ACUTE APPENDICITIS
PATHOPHYSIOLOGY
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ACUTE APPENDICITIS- “Murphy’s Triad”
Anorexia
Nausea
Vomiting
Fever
Pain in RIF
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ACUTE APPENDICITIS- Physical Examination
1.RIF Tenderness
2. RIF Rebound Tenderness
Blumberg’s sign
3. Guarding/Rigidity
4.Cope’s Psoas Test
5.Cope’s Obturator Test
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ACUTE APPENDICITIS
Alvarado’s Scoring
●Migration of pain from periumbilical to
RIF region 1
●Anorexia 1
●Nausea/ Vomiting 1
● Tenderness RIF 2
●Rebound Tenderness 1
●Elevated temperature >37.5* C 1
●Leukocytosis 2
●Shift to left polymorphs > 75% 1
(MANTRELS)
Total Score 10
Alvarado’s
Scoring
Symptoms
Signs
Labs
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ACUTE APPENDICITIS
Imaging Studies
AXR
USG Abdomen
CT Abdomen
●Graded
compression
technique
●Non compressible
tubular structure
>6mm diameter
●Periappendicularc
ollection
●Dilated hypodense
appendix > 6mms
●Periappendicular
fat stranding
●Collection in RIFP
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●Fecolith
●Focal Ileus

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ACUTE APPENDICITIS
AXR&USG Abdomen
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ACUTE APPENDICITIS
CT Abdomen
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RIGHT ILIAC FOSSA PAIN
Algorithm
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ACUTE APPENDICITIS
Algorithm
Appendicitis
Investigations: TWBC;DC;U R/E;Alvarado’s
scoring; USG Abd; CT Abd
>36 hrs of Illness
CT Scan
<36 hrs of illness
Children with
typical
presentation
Surgery
Children with
typical
presentation
Surgery
Treatment
Abscess
Percutaneous
Drainage
Interval
Appendicectomy
Abscess
Percutaneous
Drainage
Interval
Appendicectomy
History&Physical Exam
Women in
child bearing
age group
Imaging
Diagnostic S
urgery
Women in
child bearing
age group
Imaging
Diagnostic S
urgery
Men
Surgery
Men
Surgery
Elderly
Early CT
Surgery
Elderly
Early CT
Surgery
Phlegmon
Antibiotics
Bowel rest
Interval
Appendicectomy
Phlegmon
Antibiotics
Bowel rest
Interval
Appendicectomy
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ACUTE APPENDICITIS- Perforation Rate
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ACUTE APPENDICITIS- Negative Appendicectomies
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ACUTE APPENDICITIS
Open Appendicectomy
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ACUTE APPENDICITIS
Laparoscopic Appendicectomy
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ACUTE APPENDICITIS
Laparoscopic Appendicectomy
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ACUTE APPENDICITIS
Complications
ComplicationsAbscesses Local,
Pelvic,Subdiaphragmatic
Post op adhesive intestinal
obstruction
Perforation
General Peritonitis
Wound infection
Wound Dehiscence
Incisonal Hernia
HemorrhageP
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Stump Blowout
Fecal Fistula

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ACUTE APPENDICITIS
“ Mindmaps”
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Meckel’s Diverticulitis
• Remnant of V.I. Duct
• Mimic Ac Appendicitis
• Present as pain abdomen,Hematochezia
Melena,umbilical discharge or intestinal
obstruction.
• Pre op diagnosis by Tch 99 Scintigraphy
• Treatment: Excision&EEA
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Meckel’s Diverticulitis- Rule of 2
• Occur in 2% of the population
• Peak age of presentation 2 yrs
• 2 feet from ileocecal junction
• 2 Cms in diameter
• 2 inches in length
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24. Meckel’s Diverticulm
Various Presentations
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Meckel’s Diverticulm
Timing of various presentations
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Meckel’s Diverticulitis
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Perforated Meckel’s Diverticulum
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Meckel’s Diverticulitis-Tch99 Scintigraphy
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Mesenteric Adenitis
• Common in children
• Secondary to upper respiratory viral infection
• Pain is less severe but more generalised
• Tenderness is not fixed to RIF “ Shifting
Tenderness”
• Non Progressive and Self Limiting
• In doubtful cases exploration, Biopsy of nodes
and Appendicectomy
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