Left Iliac Fossa Pain

Question 1

What are the surgical emergencies in a 76yo lady presenting with left iliac fossa pain?

Answer 1

Acute diverticulitis
Leaking AAA
Locally perforated sigmoid carcinoma
Pyelonephritis

Question 2

What are the differentials in a 76yo lady with left iliac fossa pain that aren’t surgical emergencies?

Answer 2

Constipation
IBD
Ischaemic colitis
Pseudomembranous colitis
UTI
Ureteric colic
IBS
Shingles
Rectus sheath haematoma
DKA

Question 3

Pain that is initially poorly

localized, midline, and colicky but which then migrates to the LIF and becomes constant is highly suggestive of what?

Answer 3

Acute diverticulitis

Question 4

Pain that migrates down the left flank and iliac fossa suggests what?

Answer 4

Migration of a ureteric stone

Question 5

What does sharp iliac fossa pain suggest?

Answer 5

Haemorrhage, perforation or torsion

Question 6

What questions should you ask with someone with LIF pain?

Answer 6

SOCRATES

Nausea & Vomiting - Acute diverticulitis/PID
Fever
Change of bowel habits
Rectal bleeding
Bloating - Characteristic of IBS
Weight loss
Gynaecological symptoms

Question 7

Why are colonoscopy and double-contrast barium enema contraindicated in the acute setting of LIF pain?

Answer 7

Risk of perforating the acutely inflamed colon

Question 8

How is acute diverticulitis managed in the acute phase?

Answer 8

Analgesia

Bowel rest

IV fluids

Antibiotics

Monitor

Question 9

What are the main complications of diverticulitis?

Answer 9

Perforation

Abscess formation

Fistulation

Chronic inflammatory strictures resulting in bowel obstruction

Haemorrhage

Question 10

Are colovesical fistulas more common in men or women? Why?

Answer 10

Men

Thought to be because the uterus sits between the sigmoid and the bladder, forming a barrier to colovesical fistula formation

Question 11

What is the most common type of fistula formation caused by diverticulitis?

Answer 11

Colovesical

Question 12

What are the main risk factors for ectopic pregnancy?

Answer 12

Previous ectopic pregnancy
PID
Tubular procedures eg sterilization
Endometriosis
Pelvic surgery
IVF
Intrauterine contraceptive device

Question 13

What is Hinchey’s classification?

Answer 13

This classification represents an assessment of peritoneal contamination at the time of surgery in the context of acute diverticulitis

As such, it may be used as a guide to the suitability for primary anastomosis following resection

I - Pericolic or mesenteric abscess
II - Walled-off pelvic abscess
III - Generalised purulent peritonitis (~5% mortality)
IV - Generalised faecal peritonitis (~35% mortality)