Left Iliac Fossa Pain

Question 1

List the differential diagnosis for LIF pain.

Answer 1

Acute diverticulitis
Constipation
Inflammatory bowel disease
Ischaemic colitis
Pseudomembranous colitis
Leaking AAA
Locally perforated sigmoid colon
UTI
Ureteric colic
Pyelonephritis
IBS

Question 2

List some gynaecological causes of LIF pain.

Answer 2

Ectopic pregnancy 
Torsion/rupture/haemorrhage of an ovarian cyst/tumour
Mittelschmerz
Pelvic inflammatory disease 
Salpingitis

Question 3

List some causes of LIF pain that are unique to males.

Answer 3

Testicular torsion

Haemorrhage into testicular tumour

Question 4

Describe the pattern of pain in acute diverticulitis.

Answer 4

The pain will initially be midline colicky and poorly localised
It will then migrate to the LIF and become constant

Question 5

Describe the character and pattern of pain in ureteric colic.

Answer 5

severe colicky loin to groin pain

Question 6

List some possible causes of sudden-onset LIF pain.

Answer 6

Perforated viscus (e.g. locally perforated sigmoid colon)
Acute haemorrhage (e.g. ruptured AAA)
Torsion

Question 7

What alleviates pain caused by IBS?

Answer 7

Defecation

Question 8

Describe the time course of acute diverticulitis.

Answer 8

2-3 day history of LIF pain with a possible history of similar previous episodes

Question 9

List some causes of LIF pain that are associated with a change in bowel habit.

Answer 9

dicerticuli
IBS
IBD
Colorectal cancer

Question 10

List some causes of LIF pain that are associated with rectal bleeding.

Answer 10

Ulcerative colitis
Colorectal carcinoma
Ischaemic colitis
Pseudomembranous colitis

Question 11

List some gynaecological symptoms of pelvic inflammatory disease.

Answer 11

New vaginal discharge
Dyspareunia
Cyclical pattern with the period (Mittelschmerz)

Question 12

Why is it important to note whether the patient is on steroids?

Answer 12

Steroids can dampen the inflammatory response and mask symptoms

Question 13

Why is it important to note whether the patient is on antibiotics?

Answer 13

Antibiotics are a risk factor for the development of pseudomembranous colitis (C. difficile colitis)

Question 14

Describe the appearance and signs of a patient with generalised peritonitis.

Answer 14

Lying totally still
Taking shallow breaths
Looking pale
tender, rigid abdomen
No bowel sounds

Question 15

Describe the appearance of a patient with ureteric colic.

Answer 15

Writhing in pain and unable to stay still

Question 16

What is Troisier’s sign and what does it suggest?

Answer 16

GI malignancy

NOTE: Virchow’s node enlargement

Question 17

What causes of LIF pain may be palpable on rectal examination?

Answer 17

Pelvic abscess- post acute diverticulitis

Rectal tumour

Question 18

Which blood tests should be performed in patients with LIF pain?

Answer 18

FBC
U&Es
CRP
VBG

Question 19

Why is it important to do a VBG?

Answer 19

High lactate and metabolic acidosis would indicate ischaemia (e.g. ischaemic colitis)
It suggests that the patient is extremely unwell

Question 20

What form of imaging should not be performed in the acute phase of diverticulitis?

Answer 20

Colonoscopy
Barium enema
NOTE: this is because there is a risk of bowel perforation

Question 21

What is the imaging modality of choice for acute diverticulitis?

Answer 21

Abdominal CT with contrast

Question 22

What other forms of imaging may be useful?

Answer 22

Erect CXR- for pneumoperitoneum post perforated viscus
Abdominal X-ray- for bowel obstruction
Transabdominal/Transvaginal ultrasound (if gynaecological cause suspected)

Question 23

Describe the management of acute diverticulitis.

Answer 23

Analgesia
Bowel rest (only clear fluids) 
IV fluids
Antibiotics 
DVT prophylaxis 
Monitor 
Follow-up (offer colonoscopy or barium enema, offer surgery if indicated)

Question 24

Which organisms need to be covered by the antibiotics used in acute diverticulitis?

Answer 24

Gram-negatives

Anaerobes

Question 25

Describe the presentation of perforated diverticulitis.

Answer 25

Sudden-onset severe LIF pain following around 2-3 days of milder LIF pain The patient may subsequently become peritonitic = severe, sharp diffuse pain, worse on movement

Question 26

Describe the management of perforated diverticulitis.

Answer 26

``` Fluid resuscitation Oxygen (if low sats) Urinary output monitoring Analgesia Antibiotics Bloods (VBG, FBC, U+Es, CRP, Cross-match) CT ```

Question 27

What is Hartmann’s Procedure?

Answer 27

Proctosigmoidectomy with a rectal stump and end colostomy

Question 28

What is a primary anastomosis? What measure is taken to allow the anastomosis to heal?

Answer 28

Removal of the affected part of the bowel followed by the joining together of the two remaining ends To allow the anastomosis to heal, a loop ileostomy may be created

Question 29

Describe the typical presentation of IBS.

Answer 29

Long history of chronic abdominal pain with cramping, bloating and altered bowel habit

Question 30

In what demographic is IBS most common?

Answer 30

Young women

Question 31

Which other diagnoses should be considered in young patients presenting with altered bowel habit and vague abdominal pain?

Answer 31

Inflammatory bowel disease | Coeliac disease

Question 32

What are the diagnostic tests for coeliac disease?

Answer 32

``` Anti-endomysial antibodies Tissue transglutaminase (TTG) ```

Question 33

State the NICE criteria for clinical diagnosis of IBS.

Answer 33

More than 6 months of abdominal pain associated with bloating and altered bowel habit

Question 34

Describe the typical presentation of an ectopic pregnancy.

Answer 34

Sexually active young woman presenting with lower abdominal pain, vaginal bleeding amenorrhoea/late period

Question 35

Define pelvic inflammatory disease.

Answer 35

An acute or chronic condition in which the uterus, Fallopian tubes and ovaries are infected. It usually results from an infection ascending from the vagina.

Question 36

What are the two main causative agents in pelvic inflammatory disease?

Answer 36

Chlamydia trachomatis | Neisseria gonorrhoea

Question 37

Describe the typical presentation of pelvic inflammatory disease.

Answer 37

``` A sexually active young woman (with a new partner), experiencing acute lower abdominal pain new vaginal discharge vomiting fever adnexal tenderness on vaginal exam ```

Question 38

Which patients are offered an elective bowel resection after diverticulitis?

Answer 38

if they've had: - 2 proven episodes of diverticular disease requiring hospital admission or had obstructive symptoms of contrast leak on CT abdo

Question 39

List some of the potential complications of diverticulosis

Answer 39

- perforation - haemorrhage - abscess formation - fitulation - stricture formation => bowel obstruction

Question 40

What's the most common type of fistula in patients with diverticulosis and which sex is it more common in?

Answer 40

Colovesical fistulas | more common in med

Question 41

List some of the main risk factors for ectopic pregnancy

Answer 41

- previous ectopic pregnancy - Pelvic inflammatory disease - tubular procedures (sterilisation) - endometriosis - pelvic surgery - IVF - IUD

Question 42

Which classification system is used to classify peritoneal contamination in the context of acute diverticulitis?

Answer 42

Hinchey's classification

Question 43

What are the different stages of Hinchey's classification

Answer 43

1. Pericolic or mesenteric abscess 2. Walled-off pelvic abscess 3. Generalised purulent peritonitis 4. Generalised faecal peritonitis