A 35-year-old male presented with a 5-month history of fever, a 2-month history of a lump in the right lower abdomen, and abdominal pain. Examination found a firm lump in the right iliac fossa. Investigations including blood tests, ultrasound, CT scan, and FNAC suggested intestinal tuberculosis. The patient underwent diagnostic laparotomy and right hemicolectomy. Histopathology unexpectedly found mucinous adenocarcinoma of the cecum with lymph node metastasis. The patient will be referred to oncology for further assessment and chemotherapy.

1. A Case
of
A 35 years male with Lump in the
Right Iliac Fossa
Presented by
Dr. Md. Redwan Ahsanullah
Honorary Medical Officer
Unit II, Department of Surgery

2. Particulars of the patient
•Name: Md. Aminullah Bablu
•Age: 35yrs
•Sex: Male
•Religion: Islam
•Marital status: Married
•Occupation: House painter

3. Particulars of the patient (contd.)
•Present address: Dakkhin Pirerbag, Amtola,
Mirpur-2, Dhaka
•Permanent address: Village: Podua; PO:
Korombaksha; Upazilla: Kabirhat; District:
Noakhali

4. Particulars of the patient (contd.)
•Date and time of admission: 10:00am on 11
July 2016
•Date and time of examination: 11:00am on
11 July 2016

5. Chief complaints
1.Fever for 5 months
2.Lump in the right side of lower abdomen for
2 months
3.Pain and distension of the abdomen for 2
months

6. History of presenting illness
According to the statement of the patient, he
was reasonably well 5 months back. Then he
developed a fever, which was low grade,
intermittent, rising at evenings, associated with
night sweats, not associated with chills and
rigors, relieved by antipyretics, and was not
recorded. He also noticed a lump, 2 months

7. History of presenting illness (contd.)
back, in the right side of his lower abdomen
which was initially small but gradually
increasing in size. He also complained of pain
in the abdomen for the same duration, which
was diffuse, of moderate to severe intensity,
cramping in nature, intermittent, and was not
associated with any radiation or shifting.

8. History of presenting illness (contd.)
The pain was associated with distension and
vomiting, which was not projectile, not bile
stained, contained mostly mucous substances.
He visited the local doctor for these complaints
and took medications but his symptoms did
not subside.
He gave no history of hematemesis and
melaena, difficulty in breathing, fever, cough,

9. History of presenting illness (contd.)
hemoptysis, chest pain, bone pain, jaundice, or
any contact with TB patients. His bowel and
bladder habits are normal. He is normotensive
and nondiabetic. With the above complaints he
was admitted in this hospital for better
management. He also complained of weight
loss and anorexia.

10. History of past illness
The patient gave no significant history of any
past medical or surgical illness.
Drug history
The patient did not take any drug regularly

11. History of allergy
The patient gave no history of allergy to any
known food or drugs.
History of immunization
Patient is immunized, as per EPI schedule.
Personal history
He is a smoker, taking approx. 5-10 sticks/day
for the last 20 years. He is non-alcoholic.

12. Family history
His family consists of his wife, a son and a
daughter. None of his family members and
relatives is suffering from such type of illness.
Socioeconomic history
He comes from a low income background. He
lives in a tinshed house. He drinks clean water
and uses sanitary latrine. He takes average
Bangladeshi meals everyday.

13. •Cooperation: Cooperative
•Appearance: Anxious
•Body-build: Below average (BMI=16.07)
•Decubitus: On choice
•Nutrition: Average
•Intelligence: Normal
General Examination

14. • Anemia: Mildly anemic
• Jaundice: Absent
•Cyanosis: Absent
•Clubbing: Absent
•Koilonychia: Absent
•Leuconychia: Absent
General Examination (contd.)

15. •Edema: Absent
•Dehydration: Absent
•Pigmentation: Absent
•Hair distribution: Normal
•Deformities: Absent
•Lymph nodes: No palpable accessible lymph
nodes
General Examination (contd.)

16. General Examination (contd.)
•Thyroid gland: Not enlarged
•Neck veins: Not engorged
•Pulse: 80beats/min
•Blood pressure: 120/70 mmHg
•Temperature: 100o F
•Respiratory rate: 16 breaths/min

17. Systemic Examination
Lips, gum, oral cavity and vestibule appear
normal.
Abdomen:
•Inspection:
Shape of abdomen: Mildly distended.

18. Systemic Examination (contd.)
Flanks: Full
Umbilicus: Centrally placed, not
everted, vertically slit
Skin condition: Normal
Hair distribution: Normal
Visible peristalsis: Present

19. Systemic Examination (contd.)
Visible pulsation: Absent
Visible engorged veins: Absent
Hernial orifices: Intact
•Palpation: Superficial
Temperature: Raised
Tenderness: Present on the area overlying

20. Systemic Examination (contd.)
the lump on the right iliac fossa
Muscle guard: Absent
•Palpation: Deep
There was a lump in the right iliac fossa
measuring about 4cm × 6cm, rounded in
shape, with an irregular surface, firm in
consistency, with an ill-defined margin that

21. Systemic Examination (contd.)
did not move with respiration, was not fixed
with skin and was slightly mobile.
Liver and spleen: Not enlarged
Kidneys: Not palpable or ballotable
Fluid thrill: Absent

22. Systemic Examination (contd.)
•Percussion:
Percussion note: Tympanitic all over the
abdomen, except dull over the lump
Upper border of liver dullness: In the 5th
intercostal space on right midclavicular line
Shifting dullness : Absent

23. Systemic Examination (contd.)
•Auscultation:
Bowel sound: Present
Vascular bruit: Absent
•Digital rectal examination: On inspection
findings were normal. No skin tag, fissure or
fistula was seen. On palpation findings were

24. Systemic Examination (contd.)
normal. On withdrawal, the finger was not
blood stained.
Examination of the genitalia revealed no
abnormalities.

25. Systemic Examination (contd.)
Cardiovascular system:
Apex beat: Left fifth intercostal space in
midclavicular line
First and second heart sound: audible and
normal in character.
No added sound or murmur present.

26. Systemic Examination (contd.)
Respiratory system:
Inspection: Chest movement bilaterally symmetrical.
Palpation: Trachea centrally placed.
Percussion: Resonant in all zones of both lungs.
Auscultation: Breath sound vesicular, no added sound
present.

27. Systemic Examination (contd.)
Genitourinary system:
Urinary bladder: Not palpable.
Testes: Present and palpable.
Scrotum and penis: Normal

28. Systemic Examination (contd.)
Nervous system:
Higher psychic function: Oriented.
All cranial nerves: Intact.
Muscle tone & power: Normal.
Sensory examination: Normal.
Signs of meningeal irritation: Absent.

29. Systemic Examination (contd.)
Musculoskeletal system: NAD
Integumentary system: NAD

30. Salient Features
Mr. Amenullah Bablu, 35 years old married
Muslim housepainter hailing from Amtola,
Mirpur admitted into this hospital with the
complaints of fever for 5 months, lump in the
right lower abdomen for 2 months and
abdominal pain for the same duration. He was
reasonably well 5 months back. Then he

31. Salient Features (contd.)
developed a fever, which was low grade,
intermittent, rising at evenings, associated with
night sweats, not associated with chills and
rigors, relieved by antipyretics, and was not
recorded. He also noticed a lump, 2 months
back, in the right side of his lower abdomen
which was initially small but gradually

32. Salient Features (contd.)
increasing in size. He also complained of pain
in the abdomen for the same duration, which
was diffuse, of moderate to severe intensity,
cramping in nature, intermittent, and was not
associated with any radiation or shifting. The
pain was associated with vomiting, which was
not projectile, not bile stained, contained

33. Salient Features (contd.)
mostly mucous substances. He visited the local
doctor for these complaints and took
medications but his symptoms did not subside.
He also complained of weight loss and
anorexia.
He gave no history of hematemesis and
melaena, difficulty in breathing, fever, cough,

34. Salient Features (contd.)
hemoptysis, chest pain, bone pain, jaundice, or
any contact with TB patients. His bowel and
bladder habits are normal. He is normotensive
and nondiabetic. With the above complaints he
was admitted in this hospital for better
management.
On general examination, he was of below

35. Salient Features (contd.)
average body build, mildly anemic, non-icteric
and his vital parameters were within normal
limits.
On systemic examination, inspection of the
abdomen showed mild distension with visible
peristalsis. On palpation, the temperature was
raised with presence of a tenderness on the

36. Salient Features (contd.)
area overlying the lump in the right iliac fossa.
There was a lump in the right iliac fossa
measuring about 4cm × 6cm, rounded in
shape, with an irregular surface, firm in
consistency, with an ill-defined margin that did
not move with respiration, was not fixed with
skin and was slightly mobile.

37. Salient Features (contd.)
Examination of other systems revealed no
abnormalities.

38. Provisional Diagnosis?

39. Subacute intestinal
obstruction due to
intestinal
tuberculosis

40. Differential Diagnosis
•Crohn’s disease
•Carcinoma Cecum
•Appendicular lump

41. Investigations for diagnosis
• CBC with ESR: Hb% - 12.2%
ESR - 25mm in 1st hour
WBC – 8200/mm3
Neutrophil - 69%
Lymphocyte - 23%
Monocyte - 7%

42. Investigations for diagnosis (contd.)
Eosinophil - 1%
Basophil - 0%
Platelets – 4,63,000/mm3
• Ultrasonogram of Whole Abdomen:
Heterogenous mass like area measuring about
(7.2x5.2)cm is seen in right iliac fossa region
with multiple enlarged lymph nodes largest

43. Investigations for diagnosis (contd.)
one is about (1.79x1.91) cm.
Impression: 1. GB sludge
2. Mass in right iliac fossa
region possibly gut origin with
enlarged lymph nodes.
• Plain X-Ray Abdomen (A/P view) :
Distended bowel loops.

45. Investigations for diagnosis (contd.)
• Colonoscopy: could not be done due to
inadequate bowel preparation
• Contrast CT Scan of Whole Abdomen:
Thick wall bowel loops are seen in right iliac
fossa region. Proximal bowel loops are mildly
dilated.

46. Investigations for diagnosis (contd.)
Comment: Suggestive of gut related mass
?ileocaecal TB
Advice: FNAC.
• CEA: 11.30 ng/ml

49. Investigations for diagnosis (contd.)
• Tuberculin test: (done on 27.06.2016 before
admission)
Findings: Induration in 14 mm.
Comment: Tuberculin test is positive (+ve)

50. Investigations for diagnosis (contd.)
• Fine Needle Aspiration Cytology (done on
29.06.2016 before admission)
Microscopic Examination:
Smears show fair number of degenerated
neutrophils, few lymphocytes and occasional
histiocytes. Background shows necrotic

51. Investigations for diagnosis (contd.)
materials and red blood cells. No granuloma or
malignant cell is seen.
Dx: Right lumbar swelling (USG guided
FNAC): Acute inflammatory lesion

52. Investigations for anaesthetic fitness
• Random Blood Glucose: 81 mg/dl
• Serum creatinine: 0.8 mg/dl
• Serum electrolytes: Na+ 146 mEq/L
K+ 3.06 mEq/L
Cl- 103 mEq/L
• Chest X-Ray: Normal findings
• ECG: Normal findings

53. Management plan
•Conservative management:
•Nil per os
•Nasogastric suction
•Intravenous fluids
•Antibiotic
•Analgesics

54. Management plan (contd.)
•Catheterisation
•Blood transfusion
•Counselling
•Diagnostic laparotomy: Since symptoms of
obstruction did not subside after conservative
management, diagnostic laparotomy was done.

55. Date and time: 08 August 2016; 7:10pm
Indication: Subacute intestinal obstruction due
to ileocecal tuberculosis
Anaesthesia: General anaesthesia
Operation: Right hemicolectomy
Incision: Midline
Operation note

56. Procedure: With all aseptic precautions, after
proper prepping and draping abdomen was
opened through midline incision. After
exploration of peritoneal cavity, peritoneal
cavity was searched and there was no liver
metastasis or peritoneal seedling and no ascites
Operation note (contd.)

57. was found. Enlarged lymph nodes were found,
largest ones of which measured about 3cm. A
growth was present in the cecum measuring
about 7cm by 5cm, which was partially fixed
with posterior abdominal wall but was
resectable. Right hemicolectomy was done.
Operation note (contd.)

58. Ileum was emptied and ileo-transverese
anastomosis was done. After ensuring proper
hemostasis and leaving a drain, abdomen was
closed in layers. Resected specimen was sent for
histopathological examination.
Surgeon: Unit 2, Department of Surgery
Anaesthetist: Department of Anaesthesia
Operation note (contd.)

59. Check dressing was done on 3rd POD.
The drainage tube was removed on 8th POD.
Postoperative recovery was otherwise
satisfactory, but the patient developed infection
at the wound site on 6th POD. Sutures were
Postoperative period

60. removed at the infected site and wound dressing
is being performed.
Histopathological examination: Mucinous
adenocarcinoma grade 3 with lymph node
metastasis. Pathological staging (pTNM): pT3a
pN2 pMx
Postoperative period (contd.)

61. Final diagnosis
Carcinoma Cecum (Mucinous adenocarcinoma
grade 3 with lymph node metastasis. Pathological
staging (pTNM): pT3a pN2 pMx)

62. Referral, counselling and followup
Patient will be counselled and referred to
Oncology department for further
assessment and chemotherapy.

63. Thank you