Role of ultrasonography in evaluation of right iliac fossa mass compared to CT scan

Background: With the demonstration of origin and nature of RIF mass by high-resolution ultrasound and multidetector CT scan, the patients presenting with clinically palpable mass in RIF need not to undergo time consuming, uncomfortable and unpalatable barium study. The objective is to evaluate the diagnostic precision of CT and ultrasonography in the diagnosis of right iliac fossa masses and to assess the effectiveness of USG in diagnosing various right iliac fossa masses in comparison with CT scan in terms of sensitivity, specificity, and predictive accuracy. Methods: The study was conducted on 35 patients presenting with right iliac fossa mass who were stable enough to undergo USG followed by CT scan. The time gap between these studies had kept to minimum to make the studies comparable. USG and CT scan was performed by 2 expert radiologists, who had been blinded of each other findings. Results: More than 50% cases were related to appendicular pathology. Ultrasound abdomen had a sensitivity and specificity of 88.9% and 94.11% in diagnosis of appendicular mass, 71.42% and 96.42% in diagnosis of appendicular abscess, 66.7% and 96.6% in diagnosis of ileo-caecal tuberculosis, 50% and 100% in diagnosis of carcinoma caecum respectively as compared to CT scan. Conclusions: USG is the most easily available bed side investigation and excellent screening test for RIF mass. However, CECT whole abdomen remains the gold standard investigation for etiological diagnosis of RIF mass.

Endometriosis de la pared abdominal en una paciente con antecedente de histerectomía. Reporte de caso / Abdominal wall endometriosis in a patient with a history of hysterectomy. Case report

Resumen ANTECEDENTES: La endometriosis de la pared abdominal implica la coexistencia de tejido endometrial en la superficie peritoneal parietal; la incidencia reportada es de 0.03 a 3.5%. Su causa aún no está debidamente esclarecida. CASO CLÍNICO: Paciente de 35 años, con antecedentes ginecoobstétricos de: tres embarazos, tres cesáreas, última cinco años previos a la intervención, en la que se practicó una histerectomía obstétrica indicada por sangrado transoperatorio. El padecimiento actual se inició 24 horas previas a su ingreso a Urgencias, con dolor espontáneo en la fosa iliaca derecha, de difícil relación con los ciclos menstruales debido al antecedente quirúrgico, acompañado de aumento de volumen y náuseas. En la exploración inicial se identificaron dos masas intraabdominales que se confirmaron en la tomografía computada, situadas por encima de la aponeurosis. Se procedió a la intervención quirúrgica para extirpación de ambas masas. El estudio histopatológico reportó: tumores compatibles con endometriosis. CONCLUSIÓN: La endometriosis es un padecimiento con alta prevalencia en el mundo, no así en su ubicación en la pared abdominal. A pesar de que aún no se conoce con certeza su causa, se sabe que la inoculación directa (muchas veces debida a un procedimiento ginecológico quirúrgico) y la proliferación celular tienen participación relevante en su origen.

Abstract BACKGROUND: Abdominal wall endometriosis is the coexistence of endometrial tissue on the parietal peritoneal surface with a reported incidence of 0.03 to 3.5%. Its cause is not well understood. CLINICAL CASE: 35-year-old female patient with a gyneco-obstetric history of: three pregnancies, three cesarean sections, last five years prior to surgery, in which an obstetric hysterectomy was performed, indicated by transoperative bleeding. The current presentation began 24 hours before her admission to the emergency department with spontaneous pain in the right iliac fossa, difficult to relate to menstrual cycles due to her surgical history, accompanied by increased volume and nausea. Initial examination revealed two intra-abdominal masses, confirmed by computed tomography, located above the aponeurosis. Surgery was performed to remove both masses. Histopathologic examination revealed tumors compatible with endometriosis. CONCLUSION: Endometriosis is a very common disease in the world, but not in the abdominal wall. Although its cause is still not known with certainty, it is known that direct inoculation (often due to gynecologic surgery) and cell proliferation play a relevant role in its origin.

Úlcera solitaria de ciego como etiología poco frecuente de abdomen agudo inflamatorio quirúrgico / Solitary cecal ulcer as a rare cause of acute surgical abdomen

RESUMEN Las úlceras solitarias de ciego (USC) son infrecuentes y no se registran aún en la literatura de la Ar gentina. Existen informes de casos y pequeñas series en otros países. Son de etiología desconocida y diagnóstico diferencial amplio. En este caso se resolvió mediante una hemicolectomía derecha supra selectiva por laparotomía de emergencia.

ABSTRACT Solitary cecal ulcers (SCUs) are rare and no cases have been published in Argentina. Few cases or series have been reported in other countries. The etiology is unknown and many other diseases must be ru led out before making the diagnosis. This case was solved with selective right hemicolectomy through laparotomy in an emergency basis.

A rare cause of right iliac fossa lump: contained fish bone perforation of caecum

Ingested foreign bodies usually pass uneventfully through the gastrointestinal tract but few of them can cause symptoms. They can get stuck at acute angulations or narrow part of intestine and can perforate leading to localized to generalized peritonitis, collection or abscess formation. We describe a case of 59 year old gentleman who presented with pain in right iliac fossa with fever and a hard, tender lump. Initial investigation revealed a mass in right iliac fossa adherent to anterior abdominal was in right iliac fossa region with a foreign body inside. Patient was managed with exploratory laparotomy, removal of a fish bone from cacecum and limited right hemicolectomy. Fishbone perforation of caecum is a rare entity. Careful corroboration between patient’s presentation and radiological findings with a high index of suspicion is needed for pre-operative diagnosis.

Migration of Abdominal Pain - An Effective Tool to Identify Appendicitis and the Only Parameter to Screen.

Acute appendicitis is a common disease. It may be tough to identify even with radiological and laboratory investigations. Migratory pain in the abdomen is a helpful key symptom, provided the patient presents within 24 hours of onset of appendicitis. METHODSPatients clinically presenting as acute appendicitis and operated for appendicectomy were recruited in the study. The presence and absence of migratory pain in the abdomen were evaluated and compared with the histopathology of the appendix. Parameters of diagnostic accuracy were measured. RESULTSThe sensitivity and specificity of migration of abdominal pain was found to be 97 percent and 100 percent respectively. The positive predictive value and the negative predictive value was 100 percent and 94 percent respectively. Overall diagnostic accuracy was 98%. CONCLUSIONSMigratory pain in the abdomen is a significant symptom to identify as well to rule out acute appendicitis.

Clinical Relevance of Modified Alvarado Score in Acute Appendicitis in Present Scenario

Introduction: Appendix is surely, the most commonlyharvested organ of the body. On looking up the literature,we found, that the negative appendectomy rates have beenconsistently maintained all through these years. Negativeappendectomy not only increases economic burden on healthcare facilities of a developing country like India, but alsohas a negative impact on the overall health of the patient.The following study was therefore, taken up to evaluate thediagnostic accuracy of the Modified Alvarado scoring systemand its ultimate effect on mortality and morbidity of the patient.Though this is an old score, but we restudied it, to revalidateas well as to promote the use of this simple, economicaland objective clinical score which actually uses establishedclinical methods, important for residents training program, toreach the diagnosis instead of the costly radiological methods.Material and methods: 50 patients presenting with thelower quadrant abdominal pain and fulfilling the inclusioncriteria were selected randomly and included in the study.Modified Alvarado Score was calculated for each one ofthem. Confirmation of the diagnosis was done after thehistopathological examination of appendix.Results: Modified Alvarado Score >7 was found in 80% (i.e.82.75% of males and 76.19% of females) of patients withappendicitis. In addition to these findings, we also got exactinformation about the age and sex distribution along withthe most common presenting complaint, the postoperativecomplications and the need for post operative stay inappendicitis patients.Conclusion: Modified Alvarado Score is a fast, simple,noninvasive, repeatable and highly economical score. Whenapplied purposefully and objectively, it can prevent delayin surgeries and hence complications as well as can reducenegative appendectomies.

Análisis de la laparoscopía diagnóstica y estudios de imagen en el manejo del dolor en fosa ilíaca derecha de etiología incierta / Analysis of diagnostic laparoscopy and imaging studies for the handling of pain in undetermined etiology right iliac fossa / Análise da laparoscopia diagnóstica e estudos de imagem no manejo da dor na fossa ilíaca direita de etiologia incerta

Introducción: el dolor en la fosa ilíaca derecha (FID) es un motivo de consulta habitual en los servicios de urgencias. El principal desafío es diferenciar si es un cuadro quirúrgico o no. Objetivo: conocer qué rol ocupa la laparoscopía diagnóstica (LD), la ecografía de abdomen y la tomografía computada (TC) en el algoritmo de estudio de los pacientes con dolor en FID con diagnóstico incierto en Uruguay. Método: estudio observacional, descriptivo, prospectivo, multicéntrico, sobre pacientes que consultaron por dolor en FID desde el 1º de junio al 31 de agosto de 2017 en centros asistenciales de Uruguay. Se recolectaron los siguientes datos en una planilla electrónica: sexo, edad, sintomatología, hallazgos físicos, exámenes solicitados, conducta tomada, hallazgos intraoperatorios, complicaciones. Resultados: se completaron 159 planillas. Luego de una valoración primaria se planteó duda diagnóstica en 69 (43,4%) pacientes. La TC se solicitó en 29 (42%) pacientes. Se realizó TC al 78% de los mayores de 50 años versus 18% entre los de 15 y 29 años. Del total, 13 (44,8%) se informaron como normales, confirmando en el intraoperatorio cuatro (30,7%) apendicitis agudas. Se realizaron 29 LD en los casos con duda diagnóstica, dos tercios fueron en pacientes de 15 a 29 años. En 22 (76%) casos se arribó a un diagnóstico. No hubo complicaciones. Conclusiones: la LD permitió realizar diagnóstico y tratamiento en la mayoría de los casos. La sensibilidad de la TC fue baja en comparación con datos internacionales. El algoritmo diagnóstico debe ser individualizado, basado en protocolos adaptados a los recursos de cada institución. (AU)

Introduction: right iliac fossa (RIF) pain is a frequent reason for consultation at the Emergency Units. The main challenge lies in defining whether it is a surgical condition or not. Objective: to learn about the role of diagnostic laparoscopy, abdominal ultrasound and CT scan in the studies algorithm of patients with RIF pain of unknown etiology in Uruguay. Method: observational, descriptive, prospective, multi-center study of patients who consulted for RIF from June 1st to August 31, 2017 in Health Institutions in Uruguay. The following data were gathered in an excel sheet: sex, age, symptoms, physical findings, tests requested, conduct adopted, intraoperative findings and complications. Results: 159 sheets were completed. Upon a primary assessment a diagnostic doubt was arose in 69 patients (43.4%). A CT scan was requested to 29 patients, and a CT was performed to 78% of patients older than 50 years old vs 18% of those between 15 and 29 years. Conclusions: the diagnostic laparoscopy allowed for diagnosis in most cases. Sensitivity of the CT scan was low when compared to international data. The diagnostic algorithm needs to me individualized, based on protocols adapted to the resources of every institution.

Introdução: a dor na fossa ilíaca direita (FID) é um motivo habitual de consulta habitual nos Serviços de Urgências. O principal desafio é diferenciar entre um quadro cirúrgico e um não cirúrgico. Objetivo: conhecer o papel da laparoscopia diagnóstica (LD), do ultrassom de abdômen e da tomografia computada (TC) no algoritmo de estudo dos pacientes com dor na FID com diagnóstico incerto no Uruguai. Método: estudo observacional, descritivo, prospectivo, multicêntrico sobre pacientes que consultaram por dor na FID no período 1º de junho - 31 de agosto del 2017 em Centros Assistenciais no Uruguai. Em una planilha electrónica foram incluídos os seguintes dados: sexo, idade, sintomatologia, achados físicos, exames solicitados, conduta tomada, achados intra-operatórios e complicações. Resultados: foram preenchidas 159 planilhas. Depois de uma avaliação primaria foram definidas dúvidas diagnósticas em 69 (43,4%) pacientes. Foram solicitadas TC a 29 (42%) pacientes; 78% dos pacientes com mais de 50 anos vs 18% dos pacientes com idades entre 15 e 29 anos. 13 (44,8% do total) tiveram laudo "normal", confirmando apendicite aguda em 4 (30,7%) durante cirurgia. Foram realizadas 29 LD nos casos com dúvida diagnóstica sem dos terços em pacientes de 15 a 29 anos. Em 22 (76%) casos foi possível definir um diagnóstico. Não se registraram complicações. Conclusões: a LD permitiu realizar diagnóstico e tratamento na maioria dos casos. A sensibilidade da TC foi baixa em comparação com dados internacionais. O algoritmo diagnóstico deve ser individualizado, baseado em protocolos adaptados aos recursos de cada instituição.

Apendicitis aguda asociada a masa palpable en fosa iliaca derecha / Acute appendicitis associated with palpable mass in the right lower quadrant

La apendicitis aguda es la primera causa de cirugía en pediatría. Su manejo es de urgencia. Como complicación del proceso inflamatorio local se puede producir un plastrón apendicular, siendo este la principal causa de masa en fosa iliaca derecha asociada a cuadro clínico compatible; sin embargo, se debe considerar la ocurrencia de otras causas de masa local. El abordaje quirúrgico inmediato prima en el estudio de una masa en fosa iliaca derecha asociada a dolor local cuando se requiere llegar al diagnóstico con precisión, prefiriéndose antes que el abordaje diferido o conservador, usados con frecuencia cuando la sospecha principal es masa de origen apendicular.

The acute appendicitis is the first cause of surgery in pediatric care. Its management is urgent. As a complication of the local inflammatory process, it can develops an appendicular abscess, being this the principal cause of right fossa iliac’s mass associated to clinic; nevertheless, it has to be considered other causes of local mass. The surgical approach goes first in the study of the right fossa iliac’s mass associated to local pain when it is required to have a diagnosis with accuracy, preferring this before the interval appendicectomy or conservative management, frequently used when the principal hypothesis is an appendiceal mass.

Angiostrongiliasis: Reporte de un caso / Angiostrongiliasis: Report of a case

Se presenta el caso de un niño de 9 años, costarricense, con angioestrongiliasis, el cual consultó por dolor abdominal de un año de evolución. La anamnesis demostró deficiencias en hábitos de higiene. El examen físico revela dolor en fosa iliaca derecha sin masas palpables. El examen serológico demostró la existencia de una importante eosinofilia, los análisis coproparasitoscópicos fueron negativos, presentaba anemia leve. La prueba de laboratorio test de Morera fue positiva.

The following is the case of a 9 yearoldCosta Rican male child withangiostrongyliasis, who consulteddue to an abdominal pain with yearof evolution. The medical history ofthe child demonstrated deficienciesin his hygiene habits. The physicalexamination revealed pain in theright iliac fossa without any palpablemass. The serological test showed theexistence of a relevant eosinophilia; the fecal stool analysis was negative.Yet, the boy suffered from anemia.The result of Morera Blood forangiostrongilos test was positive.