42 years, female presented to the emergency department with fever for 2 days along with acute onset pain in the right iliac fossa for the duration of 1 day associated with three episodes of bilious vomiting. She had underwent laparoscopic cholecystectomy 2 years back and two Cesarean section. Her menstrual periods were normal. On evaluation she was found to have tachycardia with tenderness in the right iliac fossa, no guarding or rebound tenderness. White cell counts 10,600 cells/mm3. CRP was not done. X- ray chest and ECG were normal. Ultrasound abdomen showed probe tenderness in RIF only.
Dear Professor,
The patient is 42 years old, if beta HCG is normal, I think that a CT scan of the abdomen represent a reasonable option.
Regards,
Giorgio Vasquez.
Thankyou,she had two casarens and Tubal ligation and menstrual periods are regular.
Rule out chronic appendicitis or CIBD (Crohn, Colitis ulcerosa, Colitis indeterminata,..) and if scaring is shown in the right lower quadrant on CT scans and inflammation is not present try to mobilize the scar with osteopathy (structural and visceral).
Dear Sir,
GIven the history of previous surgeries, adhesion colic maybe the provisional diagnosis as guided by normal normal TWC. Adequate pain management, hydration are the best management at the moment. If the pain and vomiting are still persistent more than 48 hours, it is suggestive to get a CT scan for her.
Medical history including previous history should be in more detail. We do not know about possible previous bouts of RLQ pain, diarrhea, weight loss.
If RLQ pain is recurrent/chronic laparoscopic appendectomy is reasonable. 70-90% of RQL pain is gone after this procedure.
If this is acute form, beta HCG, urinalysis (urocolic), plain abdominal X-ray.
Observation with next day repeated transabdominal ultrasound or the same day CT scan.
IT is always difficult to discuss the patient with RLQ pain without seeing and examining the patient.
Agreed with Dr Osama and Dr Goran,Plain abdominal x-ray was not done .U/S scan did not show any evidence of distension of Bowel.The role of Beta HCG with above history I am not sure .CECT was done showed normal Appendix,omental stranding in the Right Iliac fossa.small bowel appeared normal and no luminal mass in the caecum.
I would like to go with an aborted retrocaecal appendicitis.
Follow up and observation with conservative treatment is preferred.
In response to your title question, I would say "Clinically"!! Treat the patient, not the signs!
Hello, good evening. First, I agree with the clinical treatment with priority, according Surviving Sepsis Campagne criteria; then I think CT scan could be enlightening... X ray doesn't have accuracy for this, in my opinion.
Best regards
I agree that CT scan will add more value for the work up. If CT scan is negative and the pain is persistent then you can consider the option of diagnostic laproscopy.
Thanks to all,
CECT showed omental stranding in the Right iliac fossa ,appendicular lumen is normal and no signs of appendicular inflamation.Diagnostic Lap was done omental adhesions were seperated ,found to have solitary caecal diverticulum with gangrenous spot at it's tip.Stapled diverticulectomy was performed.Video clip will be posted shortly in medtube.net
Solitary cecal diverticulitis is characteristic for women of that age. More common in Asians and chronic constipation is common complaint. I had one case with diverticulitis without perforation. I did only laparoscopic lavage and drainage. The postoperative course was uneventful
Congrats Dr Reddy diagnostic lap and diverticulectomy preferably stapled is the trt of choice