Right Iliac Fossa Mass - Chennai City Branch Of ASI

Report
R I G H T I L I AC F O S SA
MASS
By,
Prof R.A.Pandyaraj,
MS, FICS,FAIS,FMAS(Laproscopy).
Head of surgery department,
Govt. Royapettah Hospital.
BOUNDARIES;
 TRANS TUBERCULAR LINE

MIDCLAVICULAR LINE

ILIAC CREST
CONTENTS;
•Appendix
•Caecum
•Mesoappendix
•Terminal ileum
• Retro peritoneal tissue
• iliac nodes
•iliac arteries
APPROACH
•INSPECT
•PALPATE
•PERCUSS
•AUSCULTATE
•PV / PR
•OTHER MASS
PAIN
•Dullaching
•Colicky
•Continuous / intermittent
CLASSIFICATION
RIF MASS
ANATOMICAL
PARIETAL
INTRA
ABDOMINAL
CLINICAL
SOLID
CYSTIC
ANATOMICAL
PARIETAL
1. LIPOMA
2. DESMOID TUMOR
3. PYOGENIC ABSCESS
4. INTRA ABDOMINAL ABSCESS
BURROWING THROUGH
1. ILIAC ABSCESS
2. APPENDICULAR ABSCESS
INTRA
ABDOMINAL
ANATOMICAL
PARIETAL
INTRA
ABDOMINAL
INTRA PERITONEAL
ANATOMICAL
PARIETAL
INTRA
ABDOMINAL
INTRA PERITONEAL
RETRO PERITONEAL
CLINICAL
SOLID
•APPENDICULAR MASS
•CARCINOMA CAECUM
•ILEO-CAECAL TUBERCULOSIS
•EXTERNAL ILLAC
LYMPHADENITS
•RETRO PERITONEAL
SARCOMA
•CROHN’S
•UNASCENDED KIDNEY
•ACTINOMYCOSIS
CYSTIC
•APPENDICULAR ABSCESS
•PSOAS ABSCESS
•RT.OVARIAN CYST
•ILIAC ARTERY ANEURSYM
APPENDICULAR
MASS
ILEO CAECAL TB
CA.CAECUM
AGE
ANY AGE,COMMON
IN YOUNGER AGE
YOUNG& MIDDLE AGE
MIDDLE &
OLDER AGE
PAIN
SHORT DURATION,
>3 DAYS,MIGRATING
INITIALLY
Colicky
NO PAIN, MAY
BE IN LATE
STAGE
FEVER
HIGH GRADE
LOW GRADE
RECURRENT
Absent
VOMITING
++
+++,
IF OBSTRUCTED
++
IF
OBSTRUCTED
ALTERED
BOWEL
HABITUS
-
DIARRHOEA ALTERED
WITH CONSTIPATION
+
MASS CHARACTERISTICS
APPENDICULARMASS
ILEO-CAECAL TB
CA.CAECUM
TENDER
SOFT TO FIRM
ILL DEFINED BORDERS
IRREGULAR & FIXED
TYMPANIC NOTE
NON-TENDER
FIRM TO HARD
HIGHLY PLACED
DOUGHY ABDOMEN
NON-TENDER
HARD
FIXED
ASCITES
HEPATOMEGALY
INVESTIGATIONS
•
•
•
•
•
•
Blood HB , TC,DC,ESR
RFT
X-Ray – Chest,Abdomen Erect
Barium Enema
USG Abdomen
CT Scan Abdomen
APPENDICULAR
MASS
PLAIN XRAY LOCALISED ILEUS
ILEO-CAECAL TB CA.CAECUM
MULTIPLE
AIR-FLUID LEVELS
CALCIFIED
TBNODES
_
BARIUM
STUDY
NOT INDICATED
PULLED UP
CAECUM,
NARROWED
TERMINAL ILEUM
WIDENING OF
ILEO-CAECAL
ANGLE
IRREGULAR
FILLING DEFECT,
APPLE CORE SIGN
USG
MIXED ECHOGENIC
LESION
DILATED ILEUM
THICKENED CAECUM
SOLID CAECAL
MASS
HEPATOMEGALY
,ASCITIS
APPENDICULAR MASS
This is caused by inflammation and swelling of
the appendix, caecum, omentum and distal part
of the terminal ileum
•Treat conservatively with bowel rest, antibiotics,
analgesics and fluids
•Consider interval appendicectomy if symptoms
recur
APPENDICULAR MASS
Approach A OSCHNER REGIMEN
Initial conservative treatment followed by interval
appendicectomy six to eight weeks later
Approach B
Immediate appendicectomy following inflammatory
mass resolution
Approach C
An entirely conservative approach without interval
appendicectomy in patients with appendiceal mass
APPENDICULAR MUCOCELE
•Appendicular mucocele is a rare lesion (0.2 ‐ 0.3% of
surgical appendicectomy specimens)
•It is a descriptive term denoting an obstructive
dilatation of the appendicular lumen by mucinous
secretions
MUCINOUS CYSTADENOMA AND
CYSTADENOCARCINOMA
MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA
ACCOUNT FOR 60 ‐ 70% OF ALL MUCOCELES
LESS COMMON CAUSES:

RETENTION CYST

MUCOSAL HYPERPLASIA

CARCINOID

APPENDICOLITH

ENDOMETRIOSIS

ADHESIONS

VOLVULUS
MUCINOUS CYSTADENOMA AND
CYSTADENOCARCINOMA
‐ High Correlation Of Synchronous Or Metachronous Colorectal
Adenomas And Carcinomas (Up To 20%)
‐ Association With Mucin‐secreting Tumors Of The Ovary
‐ Pseudomyxoma Peritonei (Avoid Iatrogenic Rupture Of The
Mucocele)
TREATMENT
•Appendicectomy Is Used For Simple Mucocele Or For
cystadenoma
•Right Hemi‐colectomy Is Recommended For Cystadenocarcinoma
TREATMENT
ILEO-PSOAS ABSCESS
• Cough with expectorant,evening
raise of temperature,haemoptysis,
• Attitude of flexion,spine
tenderness,gibbus
• Cross fluctuation
• No line of separation/space
between mass&iliac spine
CROHN’S DISEASE
• INFLAMMATORY DISEASE INVOLVING ILEUM , CAECUM
, COLON
• PTS.PRESENT WITH DIARRHOEA , FEVER , MULTIPLE
FISTULA (PERIANAL) , WITH SIGNS OF INTESTINAL
OBSTRUCTION
• COBBLESTONE APPEARANCE , PSEUDOPOLYPS, SKIP
LESIONS
• STRING SIGN OF KANTOR ( NARROWING OF TERMINAL
ILEUM )
COBBLESTONE APPEARANCE
ILEO-CACEAL TB
ABDOMINAL
TUBERCULOSIS
EXTRA
INTESTINAL
INTESTINAL
ULCERATIVE
HYPERPLASTIC
STRICTOROUS
MIXED
PERITONEUM
ACUTE
CHRONIC
MESENTRY
SOLID
ORGANS
GENITOURINARY
SYSTEM
ABDOMINAL TUBERCULOSIS
ABDOMINAL TUBERCULOSIS
ILEO-CAECAL TB
ILEO CAECAL REGION IS MORE COMMONLY INVOLVED ???????
RICH LYMPHATICS IN PEYER’S PATCHES
ALKALINE MEDIUM
ILEOCECAL VALVE PRECIPITATES STASIS
TERMINAL ILEUM IS MAXIMUM AREA OF
RESORPTION
TREATMENT
• CATEGORY I – ATT
• IN CASE OF COMPLICATIONS
–LIMITED RESSECTION
–RIGHT HEMICHOLECTOMY
• CALCIFIED TB
MESENTRIC NODES
MESENTERIC-CYST
CARCINOMA CAECUM
• APPLE CORE
APPEARANCE IN
CA.CAECUM
INTUSSUSCEPTION
INTUSSUSCEPTION
COMPLICATIONS
RT.TUBO-OVARIAN MASS
• Menstrual h/o;
menorrhagia,polymenorrhagia,dysmenorrhea
• Leucorrhea,dyspareunia,
• Lower border not felt,
• Per vaginal; rt.fornix tenderness,

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