Colon and Small Bowel—RLQ Pain
Concept
Wide variety of pathologies can contribute to RLQ pain.
Much can be gathered by H+P. Plan out a DDx in your head and ask appropriate questions. In OR, be prepared for what to do if the appendix is negative.
Way Question May be Asked?
“21 y/o female evaluated in the ED for RLQ pain. Her temperature is elevated and she has peritoneal signs. You explore the pt through a RLQ transverse incision and find a normal appendix. What do you want to do?” Will likely be placed in the position of taking patient to the OR and finding a normal appendix and asked what to do next.
How to Answer?
History
Character of pain GI/GU symptoms Previous surgery Appetite
Menstrual history (if female) FHx IBD
Physical Exam
Abdominal exam (tenderness, guarding, rebound, mass (pulsatile?))
Rectal exam
Pelvic exam (if female)—don’t trust someone else’s exam!
Look for hernia
Data
Full lab panel (including amylase and pregnancy test) U/A
Abdominal series
EKG/CXR (depending on pt age) CT scan (in equivocal cases)
U/S—transvaginal helpful in female to r/o gynecologic process
It would be acceptable if unsure to admit pt overnight for observation (no antipyretics or antibiotics!)
Surgical Treatment
(1) Appendicitis
Describe typical resection If base necrotic, partial cecectomy
If abscess, CT guided drain followed by interval appen- dectomy
If comes back carcinoid, right hemicolectomy for→ carcinoid > 1.5 cm
located at base of appendix serosal involvement
+ lymph nodes (2) Ectopic pregnancy
Unruptured→salpingotomy, evacuate contents, repair
Ruptured→salpingectomy (preserve ovary) (3) TOA→
Appendectomy (so no confusion in future) Lavage, drain
Salpingo-oopherectomy if necrotic
Can treat with antibiotics (Ceftriaxone and Doxycycline) if only PID
(4) Meckel’s
If negative appy, make sure to examine last 2 feet of terminal ileum
Wedge resection of diverticulum, may need segmen- tal resection with primary anastomosis depending on inflammation
Always do appendectomy before closing!
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If incidental finding, remove if pt < 18 years of age or a narrow neck to diverticulum
(5) Terminal ileitis
Do appendectomy if base of appendix is free of dis- ease
Treat medically with Azulfidine, Prednisone, Flagyl Surgery only for obstruction, bleeding, perfora-
tion, non-healing fistulas, failure of medical management
(6) Solid ovarian mass
(a) Postmenopausal—resect with full staging for ovarian cancer (washings, biopsies, omentectomy, para-aortic LN sampling, TAH/BSO)
(b) Premenopausal—washings, biopsies, frozen section after incisional biopsy, if malignant, unilateral salpingo-oophorectomy
(7) Cystic ovarian mass
(a) Postmenopausal—ovarian cancer staging procedure
(b) Premenopausal—treat as “6b” above if > 5 cm, otherwise follow with U/S and refer to Gyn for follow-up
Common Curveballs
Any one of a variety of diagnoses, none of which are appendicitis
Be prepared for scenario to switch right after you describe how to deal with one problem (after answer- ing for Meckel’s, expect an examiner to ask a ques- tion like “OK, what if the terminal ileum is inflamed?”)
Changing scenarios is common here
Inflammatory mass RLQ and can’t identify appendix
Other causes not listed above:
Giadiasis Renal stone
Diverticulitis (right or left sided +/− abscess) Leaking AAA (take to OR immediately) Acute mesenteric ischemia
Incarcerated hernia
Testicular torsion/ovarian torsion Ruptured ovarian cyst
Pt will be pregnant (appendix may not be in pelvic depending on trimester)
Pt will be HIV + (CMV enteritis, TB, lymphoma) Mesenteric lymphadenitis
There will be no problem in RLQ except bile staining and mass in RUQ (perf duodenal ulcer!—changing scenario)
Strikeouts
Describing complicated laparoscopic procedures Not looking for Meckel’s or into pelvis when appendix
normal
Not knowing what to do for Carcinoid or Crohn’s disease Fumbling with the change in scenarios (can happen
anytime)
Forgetting pregnancy test in females of child-bearing age Forgetting pelvic exam in females
Not doing rectal exam
Getting CT scan showing appendicitis and discussing admission, Abx, and interval appendectomy
Not having broad DDx
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