right iliac fossa mass mass by, prof r.a.pandyaraj, ms, fics,fais,fmas(laproscopy). head of surgery...
TRANSCRIPT
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RIGHT IL IAC FOSSAMASS
By,Prof R.A.Pandyaraj, MS, FICS,FAIS,FMAS(Laproscopy).Head of surgery department,Govt. Royapettah Hospital.
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BOUNDARIES; TRANS TUBERCULAR LINE MIDCLAVICULAR LINE ILIAC CREST
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CONTENTS;•Appendix•Caecum•Mesoappendix•Terminal ileum• Retro peritoneal tissue • iliac nodes•iliac arteries
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APPROACH
•INSPECT•PALPATE•PERCUSS•AUSCULTATE•PV / PR•OTHER MASS
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PAIN
•Dullaching•Colicky•Continuous / intermittent
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CLASSIFICATION
RIF MASS
ANATOMICAL
PARIETALINTRA
ABDOMINAL
CLINICAL
SOLID CYSTIC
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ANATOMICAL
PARIETALINTRA
ABDOMINAL
1. LIPOMA
2. DESMOID TUMOR
3. PYOGENIC ABSCESS
4. INTRA ABDOMINAL ABSCESS
BURROWING THROUGH
1. ILIAC ABSCESS
2. APPENDICULAR ABSCESS
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ANATOMICAL
PARIETALINTRA
ABDOMINAL
INTRA PERITONEAL
1. APPENDICULAR MASS2. APPENDICULAR ABSCESS3. ILEOCAECAL TB4. CARCINOMA CAECUM5. MESENTRIC NODES6. ILIAC NODES7. TYPHILITIS8. CROHN’S DISEASE9. ACTINOMYCOSIS10. HUGE GALL BLADDER c LIVER11. INTUSSUSCEPTION12. AMOEBOMA
FEMALES1. OVARIAN CYST2. TUBO OVARIAN MASS3. FIBROID
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ANATOMICAL
PARIETALINTRA
ABDOMINAL
INTRA PERITONEAL RETRO PERITONEAL
NORMAL1. SARCOMA2. ANEURYSM3. PSOAS ABSCESS4. TUMOR FROM BONE/
CARTILAGE
ABNORMAL5. UNDESCENDED TESTIS6. UNASCENDED KIDNEY
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CLINICAL
SOLID CYSTIC•APPENDICULAR MASS•CARCINOMA CAECUM•ILEO-CAECAL TUBERCULOSIS•EXTERNAL ILLAC LYMPHADENITS•RETRO PERITONEAL SARCOMA•CROHN’S•UNASCENDED KIDNEY•ACTINOMYCOSIS
•APPENDICULAR ABSCESS
•PSOAS ABSCESS
•RT.OVARIAN CYST
•ILIAC ARTERY ANEURSYM
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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
STAGEFEVER HIGH GRADE LOW GRADE
RECURRENTAbsent
VOMITING ++ +++,IF OBSTRUCTED
++ IF
OBSTRUCTEDALTERED BOWEL
HABITUS- DIARRHOEA ALTERED
WITH CONSTIPATION+
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MASS CHARACTERISTICS
APPENDICULARMASS
ILEO-CAECAL TB CA.CAECUM
TENDER SOFT TO FIRM ILL DEFINED BORDERS IRREGULAR & FIXED TYMPANIC NOTE
NON-TENDERFIRM TO HARDHIGHLY PLACEDDOUGHY ABDOMEN
NON-TENDERHARDFIXEDASCITESHEPATOMEGALY
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INVESTIGATIONS• Blood HB , TC,DC,ESR • RFT • X-Ray – Chest,Abdomen Erect• Barium Enema • USG Abdomen • CT Scan Abdomen
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APPENDICULAR MASS
ILEO-CAECAL TB CA.CAECUM
PLAIN XRAY LOCALISED ILEUS MULTIPLEAIR-FLUID LEVELS CALCIFIEDTBNODES
_
BARIUM STUDY
NOT INDICATED PULLED UPCAECUM,NARROWED TERMINAL ILEUMWIDENING OF ILEO-CAECAL ANGLE
IRREGULAR FILLING DEFECT,APPLE CORE SIGN
USG MIXED ECHOGENIC LESION
DILATED ILEUMTHICKENED CAECUM
SOLID CAECAL MASS HEPATOMEGALY,ASCITIS
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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
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APPENDICULAR MASS
Approach A OSCHNER REGIMENInitial conservative treatment followed by interval appendicectomy six to eight weeks later
Approach BImmediate appendicectomy following inflammatory mass resolution
Approach CAn entirely conservative approach without interval appendicectomy in patients with appendiceal mass
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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
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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
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‐ 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
MUCINOUS CYSTADENOMA AND CYSTADENOCARCINOMA
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TREATMENT
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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
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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 )
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COBBLESTONE APPEARANCE
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ILEO-CACEAL TB
ABDOMINAL TUBERCULOSIS
INTESTINAL
ULCERATIVE HYPERPLASTIC STRICTOROUS MIXED
EXTRA INTESTINAL
PERITONEUM
ACUTE CHRONIC
MESENTRY SOLID ORGANS
GENITO-URINARY SYSTEM
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ABDOMINAL TUBERCULOSIS
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ABDOMINAL TUBERCULOSIS
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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
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TREATMENT
• CATEGORY I – ATT• IN CASE OF COMPLICATIONS
–LIMITED RESSECTION–RIGHT HEMICHOLECTOMY
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• CALCIFIED TB MESENTRIC NODES
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MESENTERIC-CYST
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CARCINOMA CAECUM
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• APPLE CORE APPEARANCE IN CA.CAECUM
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INTUSSUSCEPTION
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INTUSSUSCEPTION
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COMPLICATIONS
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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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THANK YOU