Reddy Venkatapuram M.1, Sreeram S.2, Prasad Reddy G. V. V.3

Clinico pathological study of right iliac fossa masses and their management

Reddy Venkatapuram M.1, Sreeram S.2, Prasad Reddy G. V. V.3

1Dr. V. Mahidhar Reddy, Associate Professor, 2Dr. Sreeram Sateesh, Professor, 3Dr. Prasad Reddy G.V.V, Post Graduate, all authors are affiliated with Department of General Surgery, Narayana Medical College, Nellore, Andhra Pradesh, India.

Corresponding Author: Dr. Sreeram Sateesh, Professor of Surgery, Department of General Surgery, Narayana Medical College, Nellore, Andhra Pradesh. Mail id: mahiesweb@gmail.com


Abstract

Aim: The present study aims to study causes, modes of presentation, investigations of choice and management of right iliac fossa masses. Materials and Methods: A prospective study was undertaken on 50 patients presenting with mass in right iliac fossa to surgery outpatient department during the period august 2015 to October 2017. All cases were investigated and managed as per protocol and their data recorded. All the demographic variables were tabulated as per percentage among total cases. Results: In this series out of 50 patients, 23 patients (46%) diagnosed to have Appendicular mass followed by Ileocaecal TB (20%), Appendicular abscess (16%), CA Caecum (12%) and psoas abscess (6%). Appendicular pathology is more common in 3rd decade, Ileocaecal TB in 4thdecade, CA Caecum and Psoas abscess in 6th decade.In total of 50 patients, 28 (56%) were males and 22 (44%) were females. In the present study pain was the commonest symptom of presentation seen in all cases, fever was present in 78% cases, vomiting was present in 42% cases, loss of weight and appetite was present in 24% cases, constipation was present in 16% cases, diarrhea was present in 8% cases, mass per abdomen was present in 26% cases. Conclusion: The common cause of right iliac fossa mass is of appendicular pathology followed by lleocaecal TB, Carcinoma caecum and psoas abscess in that order, with male preponderance and most of cases falling in 3rd decade.

Keywords: Appendicular mass, ileo-caecal tuberculosis, carcinoma caecum, Crohn’s disease, amoebic typhlitis, cold abscess


Manuscript Received: 20th March 2018 Reviewed: 30th March 2018 

Author Corrected: 6th April 2018 Accepted for Publication: 10th April 2018

Introduction

Mass per abdomen has always been considered to be temple of wonders or Pandora’s magic box. Mass in the right iliac fossa is a common entity which is frequently encountered in clinical practice requiring skill for diagnosis [1]. The varied etiology of these conditions presents a diagnostic challenge to the surgeon, as appropriately said by Sir Hamilton Bailey “A correct diagnosis is the hand maiden of a successful operation”. Right Iliac Fossa Mass is a common clinical entity encountered in surgical practice [2]. The mass has varied anatomical and etiological origin and requires versatility in its management.

This is because the mass may range from benign to most aggressively malignant lesion and touch upon various specialities of surgery like genitourinary surgery, vascular surgery, gynaecological surgery and colorectal surgery [3,4].

Right Iliac Fossa has 8 anatomical entities and six other organs in the neighbourhood whose pathology may extend into this region. Right Iliac Fossa region has Appendix, Caecum, Terminal Ileum, Lymph nodes, Iliac artery and vein, Retroperitoneal connective tissues, Ilio psoas muscle, and Iliac bone. Neighbouring organs and their pathologies which might extend into this region areKidney, Gallbladder, Uterus, Ovaries, Urinary Bladder and Testis.

Diagnosis of abdominal mass mainly depends on clinical examination and investigations.The patients are subjected to radiological and pathological investigations [5,6].                     

Differential diagnosis of mass in the RIF: Parietal Swelling: Parietal swellings are less common in this area. Infrequently, desmoid tumors and burrowing iliac abscess/ appendicular abscess through the abdominal wall into the parietal area are also noticed [7].

Intra-abdominal swelling from structures in the RIF:

·   Appendicular mass                                        

·   Appendicular abscess                                    

·   Hyperplastic ileocaecal TB [8,9]                 

·   CA caecum      

·   Crohn’s Disease              

·   Lymph node enlargement                            

·   Iliac abscess

·   Ilio psoas cold abscess [10]

·   Amoebic typhilitis

·   Actinomycosis of caecum and ilium                                    

From structures invading fromneighboring regions:

·   Unascended Kidney

·   Dropped kidney

·   Hydrops gall bladder with enlarged liver                                                    

·   Tubo-ovarian mass                                                                        

·   Pyosalpinx

·   Cyst and abscess of broad ligament           

·   Fibroid of uterus, ovarian cyst                                                                                     

·   Huge diverticulum of urinary bladder

·   Undescended testis developing malignancy.

The most common differential diagnosis encountered by surgeons are Appendicular mass, Appendicular abscess, Ileocaecal TB, Right ovarian mass,CA caecum,Right ectopic kidney, Rectus sheath hematoma, Psoas abscess and Amoeboma.               

In subcontinents, TB has been the main cause of intestinal obstruction and perforation. A set of investigations are ordered to reach a definite diagnosis. These include: CBC, USG Abdomen which are done in all cases. Additional tests like CECT Abdomen, Colonoscopy and biopsy, Diagnostic Laparoscopy, Tumour markers may be needed [11,12,13,14].

Appendiceal phlegmon, are commonly managed by conservative treatment till the mass resolves and at a later date interval appendicectomy is done if needed [15,16,17,18].

Ileocaecal tuberculous masses are one of the common causes of intestinal obstruction and perforation in subcontinent. they are usually managed by hemicolectomies and resection anastomosis of involved segment [19, 20].

Materials and Methods

Place of Study: Narayana Medical College and Hospital, Nellore.

Type of Study: Prospective study.

Study Period: August 2015 to October 2017.

Sampling method: a cross-sectional study was done with convenient sampling.

Sample collection: 50 cases were selected from surgical OPD which fulfilled the below criteria.

Statistical methods: Results were shown in tables, comparing their numbers and percentages. We used chi-quare association test and the Z test forproportions.

Inclusion Criteria

·   All cases of age more than 12 years that presented during the study period having mass in RIF.

·   Patients of both Sex

·   Patients who have also been found to have mass in RIF incidentally on examination and by investigations are included in the study.

Exclusion Criteria

·   Patients having mass in RIF due to gynaecological conditions are excluded.

·   Patients with debilitating illness like CRF, ARF, CAD, Liver failure etc are excluded from the study.

Observation and Results

The results of the study are discussed as following

Table-1: Causes of Right iliac fossa swellings.

Diagnosis

No. of Cases

Percentage

Appendicular Mass

23

46%

Ileocaecal TB

10

20%

Appendicular Abscess

8

16%

CA Caecum

6

12%

Psoas Abscess

3

6%

Total

50

100%

In this series out of 50 patients, 23 patients (46%) diagnosed to have Appendicular mass followed by Ileocaecal TB (10 cases, 20%), Appendicular abscess (8 cases, 16%), CA Caecum (6 cases, 12%), psoas abscess (3 cases, 6%).

Table-2: Age Wise Distribution of Causes

Age in years

Appendi -cular mass

Ileocae -cal TB

Appendicular abscess

CA Caecum

Psoas abscess

Total no cases

percentage

12-20

5

0

2

0

0

7

14%

21-30

13

1

4

0

0

18

36%

31-40

3

7

1

0

0

11

22%

41-50

1

2

1

2

1

7

14%

>50

1

0

0

4

2

7

14%

Total

23

10

8

6

3

50

100%

In this series age varies from 14 years to 60 years. Appendicular pathology is more common in 3rd decade, Ileocaecal TB in 4thdecade, CA Caecum and Psoas abscess in 6th decade.

Table-3: Diagnosis of RIF Masses.

Sex

Appendicular mass

Ileocaecal TB

Appendicular abscess

CA Caecum

Psoas abscess

Total no of cases

Percentage

Male

12

8

4

2

2

28

56%

Female

11

2

4

4

1

22

44%

Total

23

10

8

6

3

50

100%

In total of 50 patients, 28 (56%) were males and 22 (44%)were females

Table-4: Presenting symptoms diagnosis wise

SL No

Diagnosis

Pain

Fever

Vomiting

Loss of

appetite and weight loss

Constipation

Diarrhea

Mass

1

Appendicular mass

23

18

15

0

0

2

5

2

Ileocaecal TB

10

10

6

6

6

0

3

3

Appendicular abscess

8

8

6

0

0

2

2

4

CA caecum

6

0

0

6

2

0

3

5

Psoas abscess

3

3

0

0

0

0

3

Total

50

39

21

12

8

4

13

In the present study pain was the commonest symptom of presentation seen in all cases, fever was present in 78% cases, vomiting was present in 42% cases, loss of weight and appetite was present in 24% cases, constipation was present in 16% cases, diarrhea was present in 8% cases, mass per abdomen was present in 26% cases

Table-5: Endoscopy and Imaging as per diagnosis

Sl.No

Diagnosis

USG

Colonoscopy

CT Scan

Diagnostic Laparoscopy

1

Appendicular Mass

23

0

0

0

2

Ileocaecal TB

10

0

0

2

3

Appendicular Abscess

8

0

0

0

4

CA Caecum

6

6

6

0

5

Psoas Abscess

3

0

0

0

Total

50

6

6

2

In the present study Usg abdomen is done in all cases. Colonoscopy is done in all cases of CA Caecum and multiple biopsies are taken. CECT Abdomenis done in all case of CA Caecum for tumor staging. Diagnostic laparoscopy isdone in 2 case (20%) of Ileocaecal TB.

Table- 6: Treatment as per diagnosis

Diagnosis

No. of cases

Conservative management

Surgery

Appendicular Mass

23

23

0

IleocaecalTB

10

4

6(limited resection+ileo-ascending anastomosis)

Appendicular Abscess

8

0

8(Intr/extra peritoneal drainage)

CA caecum

6

0

6(radical right hemicolectomy +ileo-transverse anastomosis)

Psoas Abscess

3

0

3(aspiration/drainage)

Total

50

27

23

In the present study 27 cases (54%) are managed conservatively and 23 cases (46%) are treated surgically. All the cases of appendicular mass are managed conservatively. 4 cases of Ileocaecal TB are managed by medical management and rest all the cases are treated surgically.

Table-7: HPE report of the resected specimens

Preop diagnosis

No of surgeries

Surgery

HPE report

Appendicular pathology

15

Interval appendectomy

Appendicitis

Ileocaecal TB

6

Limited resection with ileo-ascending colon anastamosis

Ileocaecal TB

CA. Caecum

6

Right radical hemicolectomy

Well differentiated adenocarcinoma

All patients who underwent interval appendectomy, HPE report came as chronic appendicitis. All patients of CA Caecum underwent right radical hemicolectomy and               HPE report came as well differentiated adenocarcinoma. 6 cases of Ileocaecal TB underwent limited resection ileo- ascending colon anastomosis and HPE report of resected specimens are suggestive of Ileocaecal TB.

Discussion

The present study was carried out to evaluate various diseases presenting as mass in the right iliac fossa.  Several variables like age, sex, incidence, clinical presentation, type of investigation needed, mode of treatment and histopathology of resected specimens etc. were studied in all the selected cases.

About 50 patients who presented with right iliac fossa mass were selected for this study during the period August 2015 to October 2017 at Narayana medical college and hospital Nellore.

After detailed history, thorough clinical examination and relevant investigations a proper diagnosis was arrived at. Whether it was conservative or surgical,a standard treatment was given depending upon the diagnosis. following are the observations and inferences which we concluded.

In our study appendicular pathology (appendicular mass and abscess) was the most common disease encountered followed by Ileo-caecal tuberculosis, carcinoma caecum and Psoas abscess in that order. The same observation was found in a study conducted at victoria hospital affiliated to Bangalore Medical college and research institute by shashikala V et al [21].

In the present study Pain abdomen, followed by fever and vomiting were the predominant symptoms. According to S K Shetty, M Shankar, pain abdomen was present in almost all cases, fever in 93% of cases and  vomiting in about 50% of cases[22].

In the present study 8 cases (16%) are diagnosed asappendicular abscess. The highest number of cases are found in third decade (50%). The patients age ranged from 14 to 41 years, with male to female ratio being 1:1. According to Edward L. Bradley and James lsaacs, age ranges from 4-83 years (40.7 +- 2.7yrs), male to female ratio of appendicular abscess is 1.26:1[23,24].

According to Philip Abraham and Ferosh P. Mistry, tuberculosis of gut is common in the ileocaecal region (55.85% of cases) and the prevalence is approximately equal in males and females. In the present study 10 cases (20%) are diagnosed as Ileocaecal Tuberculosis [25,26,27]. The highest number of cases are found in third decade (70%), with male to female ratio being 4:1. According to S. K. Bhansali, 2/3rd of patients were in 4th -5th decades [28]. According to Prakash et al.the highest incidence of this disease was found in the age group of 20-40 years[29].

In the present study 6 patients arediagnosed to have CA Caecum, the highest number of cases are found in 6th decade (66.67%) followed by 5thdecade (33.33%), 4 patients (66.6%) are females and 2 patients (33.3%) are males with male: female ratio being 1:2 [30,31].S K Shetty et alreported 87% cases of CA Caecum were more than 40 years of age and more common in females[32].According to the studies of Smiddy and Goligher (1957) and D Gomez et al (2004), the incidence of carcinomas in the right colon (caecum and ascending colon) is 25 – 31%, and in the left colon (descending colon and sigmoid) is 50 - 69%[33,34].

Conclusion

Appendicular pathology continues to be the most common cause of right iliac fossa masses followed by ileocaecal TB, Carcinoma caecum and psoas abscess in that order, at least in this geographical location. Majority of the patients involved are in 3rd decade followed by 4th decade with slight male predominance. conservative treatment for appendicular masses and extra peritoneal drainage for appendicular abscesses are found to be effectiveprocedures.

What this study contributes

Results of our study strongly concur with the existing knowledge of right iliac fossa masses in particular appendicular phlegmon, in several of its factors. our study emphasizes the successful role of conservative treatment in the management of appendicular phlegmon.

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How to cite this article? 

Reddy Venkatapuram M, Sreeram S, Prasad Reddy G. V. V. Clinico pathological study of right iliac fossa masses and their management. Surgical Update: Int J surg Orthopedics.2018;4(4):133-138.doi:10.17511/ ijoso.2018.i4.01.

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