Patient with Right Iliac Fossa Pain: Differentials & management

1. 17-year-old male presenting with right iliac fossa pain of 1 day duration: Differentials &
Management
The presentation with right iliac fossa (RIF) pain presents a diagnostic challenge for
management under general surgery, due to the fact that there is a wide range of differential
diagnosis.
The most common diagnosis is that of appendicitis; however, this is based on the presenting
history and physical examination. Therefore, based on the clinical picture, a range of
diagnosis should be considered. Other differentials to consider would include; urinary tract
infection, ureteric colic, gastroenteritis and Crohns disease. There are also gynecological
conditions such as pelvic inflammatory disease or ovarian torsion to consider but these
would not be relevant in this particular patient.
The patient is 17 years old and presents at the emergency department with RIF pain of a
day’s duration. The initial assessment of the location of presentation would correlate to the
fact that the patient would be acutely ill and in some distress. Based on the age and location
of the pain; we can rule out a number of conditions such as acute pancreatitis (typically
above 40years and pain is in upper abdomen) and acute cholecystitis (late 30s with flatulent
dyspepsia).
A detailed history of the pain is essential to determine the diagnosis and is helpful in ruling
out or ruling in out or ruling in the various differentials.
Since the diagnosis is typically based on clinical findings: the key would be to focus on the
patient’s presentation in the history and the findings of clinical examinations.
The main differentials can be grouped into:
Acute Appendicitis: The pain typically begins as dull and centered in the central abdomen in
the peri-umbilical area before settling in the RIF. It is severe, constant and may not have
aggravating or relieving factors. There is vomiting at the onset and it typically associated
with diarrhoea and urinary symptoms such as frequency and dysuria.

2. On examination, the patient will have a raised pulse and may be tachypneic. The abdominal
signs would include tenderness over the site in the RIF and if the parietal peritoneum is
involved, there may also be rebound tenderness, guarding and rigidity in the RIF.
Perforated Peptic Ulcer: The history may be suggestive of previous dyspepsia belching,
bloating, distention, and fatty food intolerance. There may also have been episodes of
heartburn with chest pain, a history of frequent NSAID use or abuse or previous treatment
for H.pylori infection with non-compliance.
The onset of the pain is in the epigastriumand may then spread to include other parts of the
abdomen. Breathing is shallow with tachypnea and tachycardia. There may also be grunting.
The abdomen does not move with respiration and there is generalized tenderness and
rigidity. Bowel sounds may be absent.
Large Bowel Perforation: There is a history of fever and dysentery. The patient appears
acutely ill. Onset of pain is sudden with generalized tenderness and rigidity.
Acute Intestinal Obstruction: There may be a history of vomiting, absolute constipation and
abdominal distention. There might also be a history of previous abdominal surgery either in
the childhood period or more recently for hernia. There might be general signs of
dehydration such as rapid pulse, low blood pressure, dry tongue and sunken eyes.
There might be visible peristalsis over the abdomen with tenderness, rebound tenderness
and guarding.
Right Ureteric Colic: The pain is colicky and intermittent. It usually starts in the right lumbar
area and may move down into the right iliac fossa. There may be vomiting, sweating and
restlessness. There is also frequency but with passage of only small amounts of urine.
Acute Right Epididymo-Orchitis: The pain is felt in the right iliac fossa but may be a referred
pain. There is frequency, dysuria and a discharge from the urethra. There is typically no
tenderness in the RIF but an enlarged and tender epididymis and discharge are seen on
examination.
There are a number of investigations that can be used to support the diagnosis and may be
useful in narrowing down the diagnosis. They include:

3. Abdominal Ultrasound: which would reveal an increased lumen of an inflamed abdominal
viscus as in appendicitis, thickened walls and the presence of fluid.
A plain abdominal Xray would may also show gas or air-fluid levels or the presence of a
faecolith.
Supportive investigations would include a full blood count with normal or slightly elevated
WBC count, a blood film urine routine examination and blood sugar levels
Management would depend on the cause and can be divided into general and specific:
General Management would include:
 Resuscitation and stabilization of the patient checking and correcting any issues with
airway, breathing and circulation. This would involve:
 IV fluid therapy: to correction of fluid, electrolyte imbalances usually with Ringers
lactate. Fluid lost is replaced and then a maintenance dose of about 3L is given.
 Urine output measurement with the passing of a urinary catheter
 Nasogastric decompression by passing an NG tube which helps to prevent aspiration
and also minimize loss of fluid and electrolytes through the intestines
 Pain relief with IV paracetamol or 100mg of Pethidine via IM route
 We may also need to give prophylactic broad-spectrum antibiotics in cases where an
infective cause is suspected.
 Monitoring is also important and would involve BP and pulse measurements at 30
min intervals, hourly urine output measurement.
As soon as the diagnosis is certain; more definite measures can be taken. This may include
an exploratory laparotomy to identify and correct the specific cause.
After the surgery, IV fluid therapy and gastric content aspiration are continued until bowel
sounds appear or flatus is passed. Oral fluids can be started at about 12 hours post op and a
light diet 24 hours later. Stitches are removed in 7-10 days.
Complications of surgical intervention would include:
 Pain
 Abscess formation

4.  General peritonitis
 Bleeding
 Septicemia
In conclusion, the prompt review and assessment of the patient presenting with RIF pain is
essential to prevent considerable morbidity and mortality due to the varied differentials
associated with the presentation.