Surgery Essay

Surgery Essay

A 25-year old female presents with pain and tenderness in the right iliac fossa. Briefly discuss the possible causes and outline the management. Pain in the right iliac fossa is a localised pain; hence it is unlikely to be due to viscera as these are innervated by autonomic nerves, hence there is no dermatome distribution. Pain in the right iliac fossa is therefore due to inflammation, referred pain, or pain in an organ or mass. The differential diagnosis in this case would be: Intestinal causes: acute appendicitis, mesenteric adenitis, a perforated peptic ulcer, a Meckel’s diverticulum; gynaecological causes: ectopic pregnancy, ovarian cyst. It could also be a pelvic inflammatory disease, or a urinary tract infection (UTI). The first step of management is history taking. The site of pain at onset and the current site of pain (if the pain started centrally and moved to the RIF that are suggestive of acute appendicitis). The character of pain: is it colicky (could be flatus), or constant? Does it radiate anywhere? Was it sudden onset (ovarian torsion)? Any exacerbating or relieving factors? If the patient finds moving worse, together with coughing and deep breathing this is suggestive of peritonitis. Any associations: dysuria, frequency and urgency suggest UTI. It is also important to ask for past medical history for peptic ulceration and dyspepsia also a menstrual history: which may exclude ectopic pregnancy.

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Surgery Essay

During the examination looks out for signs of shock any dehydration: peripheral shut down, pallor etc. Is the patient also sweaty, taking shallow breaths and keeping rigid (suggests peritonitis)? During the examination, tenderness, rigidity or guarding should be noted as these are signs of peritonitis. Assess also any pain on percussion. Feel for any masses. Masses in RIF could be due to appendix, gynaecological mass such as an ovarian cyst, a lymph node mass. Check for bowel sounds: if absent could be due to peritonitis, also they could be high pitched and tinkling suggestive of obstruction (appendicitis). Pregnancy tests, to rule out ectopic pregnancy must be done. Urine dipstick and microscopy should be done to rule out UTIs. In the case of UTIs, an outpatient antibiotic against the offending organism as shown by microscopy should be given if the patient is stable and not in shock. A CBC is useful, as white cell count may help. In acute appendicitis the neutrophils increase, while in mesenteric adenitis, the leukocyte count increases. In addition for medical causes of abdominal pain: a blood glucose level: to exclude diabetic ketoacidosis, U& E’s to exclude hypercalcemia. The patient should next be admitted into hospital. Resuscitation is important: this includes oxygen, IV fluids, and analgesia, and the patient should be observed (NG tube, catheters, fluid balance, repeated examinations). If pain and tenderness settles, then no further treatment may be necessary. However if they persist, further investigation is needed, such as ultrasound. This can visualise ovaries, and look for free fluid. It 2

Surgery Essay

can also show an enlarged appendix. US is very sensitive although not specific, and does not rule out appendicitis of no abnormality is seen. If thre is peritonitis, laparoscopic visualisation is required, and laparoscopic appendicectomy can then be done if needs be. If appendicitis is excluded, the small intestine should be searched for a Meckel’s diverticulum. In the case of peptic ulcer perforation, a vagotomy (truncal or selective): with pyloroplasty or gastroenterotomy, or antectomy with vagotomy, then anastamosis via Billroth I or II. If gynaecological conditions are excluded by US and laparoscopy does not reveal anything: mesenteric adenitis is possible and this should be treated by paracetamol. 28/02/09

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