Pain In Right Iliac Fossa
Introduction – Right iliac fossa (RIF) pain is one of the most common presentations to acute general surgical services.1 Causes include appendicitis, other gastrointestinal, urological, gynaecological, vascular and musculoskeletal pathologies. Given this range of potential pathologies, variation in presentation and similarity to other conditions, particularly ovarian pathologies in women of reproductive age, diagnosing appendicitis can be a challenge.2 Traditionally, surgeons have relied on clinical history, examination findings and basic laboratory investigations for diagnosis.
Objective stratifiers such as the Appendicitis Inflammatory Response (AIR) 3 and Alvarado scores 4 have been developed to combat this diagnostic uncertainty; yet, these derived from small retrospective cohorts, are poorly validated, and not widely used.5 Since delayed appendicectomy is associated with increased risk of complications, prompt diagnosis and treatment is essential.6 Diagnostic uncertainty, coupled with the risks of diagnostic delay, has led to surgeons having a low threshold for operating on patients with equivocal symptoms resulting in high rates of negative appendicectomy: a national audit in 2012 found the UK’s negative appendicectomy rate to be 20.6%.7 8 Recent guidelines stipulate that appendicectomy should be performed laparoscopically unless this is contraindicated 9 10 ( table 1 ).
However, in 2012 one-third of patients underwent open appendicectomy.7 Unlike laparoscopic surgery, open procedures typically commit the surgeon to proceed to appendicectomy even if the appendix is found to be macroscopically normal once visualised.8
Contents
What are the differential diagnosis for right iliac fossa pain?
Pain in the right iliac fossa (RIF) immediately raises the suspicion of appendicitis. Appendicitis can be varied in how it presents but there are also many other diagnoses to consider when a patient presents with RIF pain. Assessment of abdominal pain in children can be very difficult.
What does the right iliac fossa do?
Reexamining the right iliac fossa with the patient in a left decubitus position allows movement of the mobile small bowel and cecum into different positions, redistribution of bowel gas, and improved access to a retrocecal appendix.
What does a lower right hernia feel like?
Inguinal hernia – Inguinal hernias occur when part of the membrane lining the abdominal cavity (omentum) or intestine protrudes through a weak spot in the abdomen — often along the inguinal canal, which carries the spermatic cord in men. An inguinal hernia isn’t necessarily dangerous.
A bulge in the area on either side of your pubic bone, which becomes more obvious when you’re upright, especially if you cough or strain A burning or aching sensation at the bulge Pain or discomfort in your groin, especially when bending over, coughing or lifting A heavy or dragging sensation in your groin Weakness or pressure in your groin Occasionally, pain and swelling around the testicles when the protruding intestine descends into the scrotum
How do I know if I have a hernia in my lower right abdomen?
Q: What Does a Belly or Abdominal (Ventral) Hernia Feel Like? – A: If you have a ventral hernia in the belly area, you may see or feel a bulge along the outer surface of the abdomen. Typically, patients with ventral hernias describe mild pain, aching or a pressure sensation at the site of the hernia.
What muscle is the right iliac fossa?
Description – The iliacus muscle is shaped like a triangle, flat and an exact fit of the iliac fossa — the curved surface of the largest pelvic bone. Together with the psoas major muscle, it is also called the iliopsoas muscle, A portion of this muscle is attached to the iliac fossa, two-thirds from its top.
Another portion is attached to the inside portion of the iliac crest, the top, outer portion of the pelvic bone.Other fibers of this muscle are attached to the iliolumbar and anterior sacroiliac ligaments (located at the base portion of the sacrum) and up to the anterior iliac spines (bony projections that lie toward the edges of the iliac).
These muscle fibers then converge and insert on the tendon at the lateral (outer) side of the psoas major muscle, which stretches from the lumbar spine in the lower back to the lower pelvis. Some of these fibers extend to the femur bone, or thighbone.
What is the ultrasound of the right iliac fossa?
Caecal tumour – In the older patient population, who present with acute right iliac fossa pain, an important diagnosis to consider is an underlying obstructing caecal tumour at the base of the appendix, presenting as acute appendicitis. Alternatively, the caecal tumour may itself be the primary diagnosis due to localised tumour perforation or peritoneal infiltration.
On ultrasound, neoplastic thickening usually involves a short segment of bowel with disruption of the gut wall layers. The bowel wall typically appears solid and hypoechoic ( Figure 7 ). If a solid mass is identified within the right colon on ultrasound, then CT is recommended to further assess ( Figure 8 ).
CT will provide more information on the nature of thickening, stage of the tumour and help determine optimum management for the patient. Axial ultrasound image of colon cancer demonstrating asymmetric hypoechoic bowel wall thickening with disruption of the gut wall layers Colonic tumour: sagittal ultrasound image demonstrating a short segment of bowel thickening with disruption of the gut wall layers corresponding to an ‘apple core’ lesion on coronal and sagittal CT images
Why does the spleen go to the right iliac fossa?
Wandering spleen: a surgical enigma 1 Department of Surgery, Command Hospital, Pune, Maharashtra, India and Find articles by 2 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India Find articles by 1 Department of Surgery, Command Hospital, Pune, Maharashtra, India and Find articles by 1 Department of Surgery, Command Hospital, Pune, Maharashtra, India and Find articles by Received 2015 May 31; Accepted 2015 Jun 23.
© The Author(s) 2015. Published by Oxford University Press and the Digestive Science Publishing Co. Limited. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Wandering spleen, also referred to as ‘ptotic spleen’, is a rare clinical condition characterized by splenic migration form its normal left hypochondrial position to any other abdominal or pelvic position. Among the multifactorial etiologies proposed, laxity of the spleen’s primary supporting ligaments is the most agreed-upon hypothesis.
- We present one rare case of wandering spleen in an 11-year-old girl who presented with recurrent abdominal pain with no localizing features.
- Her abdominal examination revealed an intra-abdominal left iliac fossa lump with restricted mobility, which was confirmed as a wandering spleen by abdominal sonography and contrast-enhanced computed tomography.
Intraoperatively, an infarcted spleen was encountered with tortuous, elongated, torsional splenic pedicle and a single dense adhesive band with descending colon. Splenectomy was offered to the patient. Post-operatively, the patient is healthy and symptom free at one-year follow-up.
The rare clinical diagnosis of this condition, particularly in the paediatric age-group, makes it an enigma for the surgical world. Keywords: wandering spleen, splenic ligaments, torsion Wandering spleen (WS), is a rare clinical condition, with only about 500 cases reported worldwide and an incidence rate of 0.2%,
One of the first documented descriptions of WS came from Dr Josef Dietl, a Polish clinician, who not only documented three cases between 1854 and 1863 but also described the laxity of splenic ligaments as the likely etiology, Among the various hypotheses proposed, laxity of the spleen’s supporting ligaments is the most agreed upon.
- The condition leads to migration of the spleen from its normal position in the left hypochondrium to the pelvic or iliac region.
- This migration in turn often leads to torsion of the elongated splenic pedicle, which makes the patient symptomatic.
- WS is usually seen in women of child-bearing age, and the condition is particularly rare in the paediatric population,
We present one such rare case of a WS in a child who presented with intermittent abdominal pain that was clinically and radiologically confirmed as WS with splenic infarction. The patient was offered a splenectomy. An 11-year-old girl presented to us with repeated episodes of intermittent, moderate-to-severe intensity, non-radiating pain in the right iliac fossa for the last six months.
- She had no history of fever, vomiting or urinary symptoms.
- On physical examination, a 10 x 4 cm intra-abdominal, ballotable, smooth-surfaced lump, which had restricted mobility with respiration, was palpated in the left iliac fossa.
- Her routine haematological and biochemical investigations were within normal limits.
Abdominal sonography, and colour Doppler flow imaging revealed a 13 x 15 cm spleen with heterogeneous echogenicity, situated antero-inferior to the left kidney in the left iliac fossa with tortuous, elongated splenic vessels with torsion and a low blood-flow profile.
Contrast-enhanced CT of the abdomen revealed a 15 x 17 cm spleen in the left iliac fossa, with a long, tortuous pedicle (approximately 15 cm) with torsion and focal areas of splenic parenchymal ischemia (). Contrast-enhanced CT images of abdomen. (A) Coronal reformatted image shows that the spleen has migrated from the left hypochondrium and is ectopically located in the left lumbar and iliac region (marked with an arrow).
(B) Sagittal reformatted image shows that the spleen is located inferior to the left kidney. The patient was scheduled for an elective splenectomy and was immunized against Hae mophilus influenza e, pneumococcus and meningococcus as per the protocol.
Intraoperatively, the spleen was found in the left iliac region, antero-inferior to the left kidney. There was a dense band between the splenic hilum and descending colon, which was probably responsible for the restricted mobility of the spleen during clinical examination. A long splenic pedicle with torsion was also found.
The spleen showed multiple areas of infarction. (). Keeping in view the above findings, a splenectomy was performed. The histopathological report inferred that there were several areas of extensive splenic haemorrhage and infarction with neutrophilic infiltration of the splenic vessel walls.
The postoperative period has been uneventful, and the patient has been healthy and symptom free at her one-year follow-up. Among all the solid organs in the human body, the spleen is possibly the least understood and the most discredited. Our medical knowledge on the spleen has come a long way from the days when it was considered to be the seat of laughter, associated with black bile and credited with disharmony of life, to the present day concept in which it is recognized as an important reticuloendothelial organ,
WS is a rare clinical facet of this organ, which was first described by Von Horne in 1667, WS is defined as the condition in which the spleen migrates from its normal position in the left hypochondrium, mostly likely due to an error in the embryological development of the primary supporting ligament of spleen with elongation of its vascular pedicle.
- The credit for documenting the first case of this condition goes to the Polish clinician, Dr Jozef Dietl.
- He not only prognosticated the life-threatening complications of this condition, he also predicted that hypoplasia of splenic ligaments was probably the major culprit,
- Anatomically, the spleen has six peritoneal attachments (primary suspensory ligaments) that are directly associated with it (gastrosplenic, splenorenal, splenophrenic, splenocolic, pancreaticosplenic and presplenic folds) and two ligaments (pancreaticocolic and phrenicocolic) in indirect association.
Failure of fusion of the dorsal mesogastrium to the posterior abdominal wall during embryogenesis leads to failure or defective attachment of these ligaments, leading to WS. The gastrosplenic, splenorenal and phrenicocolic ligaments have been primarily implicated (),
A second school of thought incriminates the hormonal changes and abdominal laxity in multiparous women as an acquired cause of WS and better explains the presence of WS in women of child-bearing age, Huge, heavy spleens due to malaria, infectious mononucleosis and benign haematologic diseases have also been implicated in the literature,
The abnormal fixation of the spleen predisposes the splenic vascular pedicle to become tortuous, elongated and prone to intermittent torsion, in turn making the spleen vulnerable to infarction, Often labelled as a rare clinical diagnosis, especially in the paediatric population, the presentations of WS can be vivid,
The spectrum can range from an asymptomatic abdominal mass, an incidental finding on routine abdominal sonography, intermittent abdominal pain (as in our patient) and splenomegaly to severe abdominal pain and discomfort due to torsion of the splenic vascular pedicle. Clinically, a mobile mass can be felt on abdominal examination.
However, in our case the presence of a dense band between the spleen and descending colon restricted the mobility of the spleen. A sonographic examination of the abdomen usually suffices to delineate the location, size and any architectural deformities of the spleen in most cases.
When the splenic vascularity is in question, either colour Doppler flow imaging or contrast-enhanced CT can both confirm the diagnosis and provide additional information on the blood flow profile in the splenic pedicle. Splenic parenchymal ischemia is characterized by a change in blood flow and a heterogeneous echogenicity of the spleen.
This information plays a vital role in the pre-operative decision to offer the patient splenoplexy or splenectomy as the choice of surgery. The surgical intervention is defined by the vascularity of the spleen. A patient with splenic infarction due to torsion of the splenic pedicle, as in our case, is offered splenectomy.
- Splenoplexy, either open or laparoscopic, is offered to most of the other patients in whom splenic pedicle detorsion and splenic fixation to either the diaphragm or abdominal wall are done,
- Nonoperative management of a WS is not advised as there is a 65% chance of torsion with ischemic splenic infarction without fixation of the spleen,
WS is a rare condition that often presents as a clinical enigma. A clinician should have a high degree of suspicion for WS, particularly in women of child-bearing age and children who present with recurrent abdominal pain and a mobile abdominal mass. Modern imaging techniques are usually diagnostic and can identify the splenic pedicle torsion with a high degree of accuracy.
- Surgical intervention, in the form of either splenoplexy or splenectomy, is largely governed by the findings of pedicle torsion and the associated risk for acute splenic infarction.
- Conflict of interest statement : none declared.1.
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