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Rif mass

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right iliac fossa mass

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Rif mass

  1. 1. RIGHT ILIAC FOSSA MASS
  2. 2. RIGHT ILLIAC FOSSA • Abdomen is divided into 9 regions 2 Horizontal planes: Upper/Transpyloric Lower/Transtubercular 2 Vertical planes: one on either side through the midpoint between ASIS & symphysis pubis.
  3. 3. RIF Abdominal wall Intra abdominal Retroperitoneal
  4. 4. RIF mass Structures Normally present Anterior Abdominal wall GIT Mesentery Blood vessels Lymphatics Nerves Bones Posterior abdominal muscles Structures from adjoining areas Kidneys(unascended, transplanted) Testis(undescended), Gallbladder, Uterus & its Appendages, Urinary bladder
  5. 5. Abdominal wall • Haemotoma • Abscess • Incisional hernia ( post appendicectomy) • Tumours Benign Lipoma, Fibroma, Neurofibroma and fibromatosis. Malignant tumours (rare) Desmoid tumour, Soft tissue sarcomas (fibrosarcoma , dermatofibrosarcoma , liposarcoma).
  6. 6. Intra peritoneal • Appendicular mass • Appendicular abscess, • Ileocaecal tuberculosis • Carcinoma caecum • Mesentric lymph nodes • Amoebic typhylitis • Crohn’s disease • Actinomycosis • Intussuception • Mesentric cyst • Diverticulosis.
  7. 7. Retroperitoneal • Soft tissue sarcoma • Aneurysm • Iliopsoas abscess • Tumor from bony or cartilage of ilium • Undescended Testis • Retroperitoneal lymph nodes, (tuberculosis or filariasis,lymphoma, Secondaries) • Transplanted kidney • Unascended Kidney
  8. 8. Miscellaneous • loose bodies • foreign body • ovarian mass/tubo-ovarian mass • Uterine mass
  9. 9. APPENDICULAR MASS complication of acute appendicitis.  Mass consists of greater omentum with oedematous caecal wall & loops of distal small intestine with inflammed appendix in centre, natural phenomenon to contain spread of infection Firm , tender, irregular mass in RIF ,with localised guarding & rigidity & systemic manifestations  USG and CECT –helpful in assessing the nature & size of mass
  10. 10. 1.Conservative(Ocshner-Sherren regimen)  pulse and temperature monitoring Monitoring the size of mass I.V Fluids & I.V Antibiotics Interval-Appendicectomy after 6 weeks 2.Emergency Surgery Rising pulse rate & temperature persistant vomiting Increasing abdominal pain Increase in size of the mass,
  11. 11. APPENDICULAR ABSCESS  Complication of acute appendicitis  Pt. is toxic ,with high grade fever & tachycardia.  tender mass with indistinct borders , guarding & rigidity  USG/CT for size of abscess  Treatement conservative( < 4 cms) USG guided aspiration( > 4 cms ) surgical drainage ( failure of other modes ) Interval appendicectomy after 12 weeks
  12. 12. Neoplasms of the appendix Carcinoid tumour (argentaffinoma) arise from Kulchitsky cells of the crypts of Lieberkühn 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 carcinoid syndrome(flushing & diorrhoea) in liver metastases
  13. 13. Investigations 24 hrs urine 5HIAA,  sr.chromogranin A , USG , CECT , SOMATOSTATIN RECEPTOR SCINTIGRAPHY Treatment < 1 cm – appendicectomy >1 cm – right hemicolectomy metastases – metastasectomy
  14. 14. Mucocele of the appendix • retained mucous secretions / tumour • mimicks sub acute appendicitis, infection leads to empyema. • Rupture causes pseudomyxoma peritonei. • USG / CT • benign – appendicectomy • psuedomyxoma peritoni - cytoreductive surgery/ - intra-peritoneal chemotherapy
  15. 15. Adenocarcinoma • Rare • presents as painless hard mass • USG / CECT / colonoscopy • Right hemicolectomy
  16. 16. abdominal tuberculosis abdominal tuberculosis intestinal ileo-caecal 1.ulcerative 2.hyperplastic 3.sclerosing ileal stricture diffuse colonic peritoneal acute chronic 1.ascitic 2.loculated 3.adhesive 4.purulent others 1.mesenteric 2.omental 3.ano-rectal & sigmoid 4.miliary 5.gastro- duodenal 6.retro- peritoneal
  17. 17. ILEOCAECAL- TUBERCULOSIS Site : ileum, proximal colon and peritoneum are commonly affected Etiology ; mycobacterium tuberculosis Mode of spread: 1.Ingestion of food contaminated with tubercle bacilli 2.Ingestion of infected tubercle bacilli containing sputum 3.Haematogenous spread from pulmonary tuberculosis. 4.Lymphatic spread through tuberculous cervical adenitis. 5 .Retrograde spread through genitourinary tract in females Types: 1. ulcerative. 2. hyperplastic 3. mixed
  18. 18. Mass in abdominal TB • mesenteric TB • Hyperplastic type of ileocaecal TB • Peritoneal TB (loculated ascities )
  19. 19. Hyperplastic type : less virulent infection, good host resistance  intermittent abdominal pain, diarrhoea,  steatorrhea, anemia and wt.loss , low grade fever  intestinal obstruction (acute / sub-acute)  irregular firm non-tender mass  investigations CXR, AXR, USG, CECT, colonoscopy , D-lap , mantoux , ELISA , PCR  Treatement umcomplicated - ATT complicated - ileocaecal resection
  20. 20. ILEOCAECAL TB
  21. 21. CROHN`S DISEASE Can involve any part of GIT . ileocoloic region most common site skip lesions  (cobblestone appearance) Mucosal ulceration with oedema of mucosa between the ulcers  Transmural inflammation leading to adhesions & inflammatory masses formation with mesenteric abscess & fistula formation into adjacent organs.  Serosa is opaque,with mesenteric thickening &enlarged mesenteric lymph nodes.  CECT , Barium meal follow through , colonoscopy & biopsy  uncomplicated - steroids , anti-inflammatory, immunosupressants Complicated – resection & ostomy/ reconstruction
  22. 22. CROHN`S DISEASE
  23. 23. CARCINOMA CAECUM
  24. 24. CARCINOMACAECUM 3rd common site for colonic carcinoma  unexplained anemia is the common presentation Altered bowel habits , obstruction , perfotation  hard, nontender, fixed mass
  25. 25. • Aetiology ; • 1. DIET -Red meat, saturated fat and cholesterol • 2.Alcohol and smoking • 3.Radiation • 4. Post-cholecystectomy and ileal resection and ureterocolostomy status • 5.Genetic causes Familial Adenomatous polyposis coli. Gardner's syndrome and Turcot’s syndrome. Peutz jeger’s syndrome and Juvenile polyposis syndrome. HNPCC , Lynch syndrome1, Lynch syndrome 2 Aspirin and other NSAIDs, calcium are protective against large bowel cancers
  26. 26. Types 1.Polypoidal 2. Ulcerative, 3.Annular, 4.Mucinous. Investigations-stool for occult blood, Barium meal follow through-irregular filling defect in caecum & normal terminal ileum Colonoscopy & Biopsy Treatement - Right hemicolectomy, chemotherapy (FOLFOX)
  27. 27. ACTINOMYCOSIS  anaerobic gram positive branching filamentous fungal like bacterium Actinomycosis israeli (‘Ray fungus.’) Types : 1. cervicofascial 2. thoracic , 3.Abdominal actinomycosis (rare)  fixed indurated mass in right iliac fossa with abscess and multiple sinuses , discharging sulphur granules  No intestinal luminal narrowing or lymph node involvement Treatement: high dose penicillin or co-trimoxazole
  28. 28. Actinomycosis
  29. 29. AMOEBOMA Entamoeba histolytica (trophozoite)  feco-oral route  flask shaped ulcers in ileum and large bowel  Blood and mucus diarrhoea , pain abdomen , mass abdomen  stool examination , colonoscopy & biopsy , PCR Treatement : metronidazole 800mg tds for 7-10 days. Diloxanate furoate, Paromomycin and Iodoquinol. surgery for complications like obstruction
  30. 30. MESENTRIC CYSTS 1.chylolymphatic cysts congenital maldeveloped lymphatic system commonest type enucleation 2.enterogenous cysts duplication or diverticulum of adjacent bowel contains all layers of bowel tillaux triad resection and reconstruction 3.congenital remnant cysts 4.teratomatous dermoid cyst 5.traumatic mesenteric haematoma and cyst formation 6.mesenteric cold abscess formation 7.hydatid cyst of mesentery.
  31. 31. INTUSUSCEPTION
  32. 32. INTUSUSCEPTION Cause: Children : Hyperplasia of peyer’s patches Adult : polyps, submucosal lipoma, tumour, prolonged fasting Types: ileo-ileal , ileo-colic , Colocolic common in adults Pathology 3 parts Entering or inner tubes ( blood supply is commonly impaired) Returning or middle part, sheath or outer tube(Intessuscipiens)
  33. 33. o acute / sub-acute o colicky abdominal pain ,bilious vomiting , abdominal lump freely mobile , becomes firm on palpation , intestinal obstruction , guarding & rigidity ( gangrene ) o red current jelly stool o emptiness on the RIF(sign de dance) o investigations AXR – absent caecal gas / multiple air-fluid levels barium enema – claw sign USG – psuedokidney sign/ bull’s eye sign CECT o treatment hydrostatic reduction resection and reconstruction .
  34. 34. ILIOPSOAS ABSCESS
  35. 35. PSOAS ABSCESS It’s a cold abscess due to Tuberculosis of Thoracolumbar spine (Pott`s disease)  caseating pus from vertebra gravitates via medial arcuate ligament underneath psoas sheath  psoas sign - Thigh is in fixed flexion position due to psoas muscle spasm  Cross fluctuation – pus tracks below inguinal ligament into thigh  Spinal tenderness/Gibbus can be demonstrated.  X-ray of spine ,CT , MRI  Treatment –Image guided aspiration / I & D ATT spinal support with bed rest
  36. 36. Retroperitoneal tumours • painless ill-defined masses , restricted mobility , doesn’t fall on knee-elbow position • USG , CECT , MRI , biopsy • benign – excision • sarcoma – wide local excision / chemoradiation • lymphoma – chemo–radiation • Secondaries – palliative therapy
  37. 37. Aneurysm • well defined fusiform pulsatile mass • may present with distal ischemia • USG ,duplex , Angiography • stenting / resection & reconstruction
  38. 38. OTHER CAUSES ROUND WORM BOLUS MASS soft tender mass in RIF. With H/O of passing round worms in Stools. Most common in children in endemic areas,causing intestinal obstruction. TUMOURS OF ILIAC CREST Osteochondroma,hard fixed bony swelling .
  39. 39. RARE CAUSES • KIDNEY- Unascended kidneys/mobile normal kidneys • TESTIS- Undescended testis • GALL BLADDER- Huge distended GB • UTERUS & APPENDAGES-Tubo-ovarian mass,ovarian cyst,fibroid uterus • URINARY BLADDER DIVERTICULUM

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