ISPUB.COM The Internet Journal of Surgery Volume 30 Number 4 S K Shetty, M Shankar Citation S K Shetty, M Shankar.. The Internet Journal of Surgery. 2013 Volume 30 Number 4. Abstract Background and Objectives A mass in the right iliac fossa is a common diagnostic problem encountered in clinical practice, requiring skill in diagnosis. A swelling in the right iliac fossa may arise from the structures normally present in that region or from structures, which are abnormally situated in the region. The mass could be intra-abdominal or extra-abdominal. The common swellings which occur in the right iliac fossa are appendicular lump, carcinoma of the cecum, ileocecal tuberculosis and Crohn s disease (common in the West). Rare swellings are actinomycosis, ameboma, psoas abscess and lymph node masses. A clinical diagnosis is often difficult due to other conditions such as obesity and guarding, with the mass being palpable only when patient is on the operating table. Methods Fifty patients with signs and symptoms of a right iliac fossa mass admitted to the hospital attached to Sri Deveraj Urs Medical College (South India) were included in the study. Gynecological, extra-abdominal or bony swellings, masses from abnormal structures and children of less than 10 years were excluded from the study. Results In our study, appendicular lumps (masses and abscesses) constituted 52%, ileocecal tuberculosis 22% and carcinoma of the cecum 16%, followed by iliopsoas abscesses in 8% (which all turned out to be of tubercular origin). Interestingly, one case turned out to be Non-Hodgkin lymphoma. Conclusion Appendicular lumps remain the most common mass in the right iliac fossa. Ileocecal tuberculosis is one of the most important differential diagnoses for chronic abdominal pain in the rural population. INTRODUCTION Patients with a mass in the right iliac fossa are often admitted in surgical departments. The mass can be due to intra- or extra-abdominal causes. Most of the causes need surgical intervention and are curable. A mass in the right iliac fossa mainly arises from appendix, cecum, terminal part of ileum, lymph nodes, iliopsoas sheath, and retroperitoneal connective tissue. An important differential diagnosis is between an appendicular lump, carcinoma of the cecum and ileocecal tuberculosis. Non-operative management of an appendix mass followed by elective appendicectomy is a 1 safe and effective method of management. Appendicitis can occur rarely with carcinoma of the cecum, particularly in elderly patients2. In India tuberculosis has been reported to be the cause in 3 to 20% of patients with intestinal obstructions. About 5 to 10 % of all gastrointestinal perforations (excluding appendix perforations) have been 3 reported to be due to tuberculosis. Cecal carcinoma is more common in people of the high socio-economic group who use less fibrous diet. Local control continues to be a significant problem in the management of retroperitoneal sarcoma5. AIMS AND OBJECTIVES The main intention of this study is to know the incidence, varying modes of presentation, different modalities of diagnosis, treatment and prognosis, and to identify factors which can help in better management of these cases. 1 of 11
MATERIALS AND METHODS Source of data (sample): Fifty patients with signs and symptoms of a right iliac fossa mass admitted to the hospital attached to Sri Devaraj Urs Medical College are included in this study. Method of collection of data: All patients with signs and symptoms of a right iliac fossa mass satisfying in the inclusion criteria were included in this study. A detailed clinical history was elicited and a careful general physical and systemic examination was carried out along with the necessary investigations. type of pathology. The postoperative period was monitored, intake-output charts and vital charts were maintained. Diagnosis was confirmed by histopathology reports. The patients were followed up for a variable period of time. OBSERVATIONS AND RESULTS In our study, 50 cases of mass in right iliac fossa were chosen over a period of two years. Table 1 Incidence of Various Conditions Inclusion criteria: Masses in right iliac fossa arising from the appendix, cecum, terminal ileum, retroperitoneal connective tissue and psoas abscesses were included in this study. Exclusion criteria: 1.Female patients with pathology related to uterus and its appendages. 2.Right iliac fossa masses secondary to extra-abdominal pathology. 3.Masses from structures which abnormally present in the right iliac fossa. 4.Bony swellings of the region. 5.Patients with right iliac fossa mass who are terminally ill. 6.Children less than 10 years of age. Mode of study: The detailed history and proper clinical findings were entered in a proforma case sheet.the required and routine investigations were done to establish the diagnosis. Patients were asked to present themselves for follow-up after a specific interval or at recurrence of symptoms. All patients received supportive treatment for correction of anemia and other nutritional deficiencies. Adequate bowel preparation with appropriate antibiotics and mechanical bowel wash was done wherever required. During laparotomy, intra-abdominal examination of all organs was made in addition to specific pathology. Relevant surgical procedures were done depending on the 2 of 11 In our study of 50 cases, 52% were related to appendicular pathology, either in the form of appendicular mass (32%) or of appendicular abscess (20%), 22% were ileocecal tuberculosis, 16% were carcinoma of the cecum and 8% were iliopsoas abscess. Interestingly, there was also one case of Non-Hodgkin lymphoma. Figure 1 Incidence of Various Conditions
Table 2 Age Incidence was more common in males (64%), females (63%) predominated males in carcinoma of the cecum. Iliopsoas abscess was more common in males (75%). Figure 3 Sex Incidence In our study, appendicular masses manifested most commonly in the 3rd and 4th decade, followed by the 2nd decade. Appendicular abscess was common in the 3rd and 5th decade. Ileocecal tuberculosis was common in the 4th decade. Carcinoma of the cecum was common in the 5th and 6th decade. Table 4 Duration of Symptoms (Abdominal Pain) Figure 2 Age Incidence Table 3 Sex Incidence In our study, appendicular mass (63%) and appendicular abscess (70%) were common in males. Ileocecal tuberculosis 3 of 11 In our study, almost all cases of appendicular mass presented within 30 days. In our series, the commonest presenting symptom was abdominal pain. In carcinoma of the cecum, two patients presented within 3 months and 6 patients within 3-6 months.
Figure 4 Table 6 Duration of Symptoms (Abdominal Pain) Symptoms (Abdominal Mass) Table 5 According to this study, mass per abdomen is the main symptom of cecal carcinoma. Symptoms (Fever, Vomiting, Loss of Weight) Table 7 Clinical Signs In the present study, 93% of appendicular masses presented with fever and 50% with vomiting. All cases of appendicular abscess presented with fever and 70% with vomiting; 91% of patients with ileocecal tuberculosis presented with fever and 36% with vomiting and all cases presented with weight loss; 25% of patients with cecal carcinoma presented with fever, 75% with vomiting and all cases presented with weight loss. Fever and weight loss are prominent symptoms of ileocecal abscess. Non-Hodgkin lymphoma presented with fever, vomiting and loss of weight. Figure 5 Symptoms (Fever, Vomiting, Loss of Weight) 4 of 11 All patients in this study had masses in the right iliac fossa; 92% had tenderness in the right iliac fossa. In 20% of patients, the mass was soft in consistency; these include all cases of appendicular abscess. Patients with masses firm in consistency mostly included all cases of appendicular mass, ileocaecal tuberculosis and iliopsoas abscess. Most of the cecal carcinomas were hard in consistency.
Table 8 Figure 7 Hemoglobin Percentage Erythrocyte Sedimentation Rate -ESR (mm/hour) Most of the patients with hemoglobin less than 10g% had either cecal carcinoma or ileocecal tuberculosis. Table 10 Mode of Treatment Figure 6 Hemoglobin Percentage Table 9 Erythrocyte Sedimentation Rate ESR (mm/hour) In our study, 47 patients were managed surgically. Most of the appendicular masses and appendicular abscesses were managed surgically. Nine cases of ileocecal tuberculosis were managed with surgery. All patients with carcinoma of the cecum were managed surgically followed by postoperative chemotherapy. All patients with iliopsoas abscess were managed surgically. Figure 8 Mode of Treatment Most of the patients with ileocecal tuberculosis had elevated ESR. 5 of 11
Table 11 Figure 10 Types of Surgical Treatment Complications (In %) All cases of appendicular mass were managed by O-S regimen initially and appendicectomy later. All 9 cases of ileocecal tuberculosis managed surgically underwent right hemicolectomy. One patient with cecal carcinoma underwent right hemicolectomy, the remaining ones underwent right radical hemicolectomy. All 4 cases of iliopsoas abscess underwent laparotomy and drainage. NonHodgkin lymphoma was managed with right hemicolectomy. Table 13 Follow-up Figure 9 Types of Surgical Treatment Two cases of cecal carcinoma were lost in follow-up. Figure 11 Patient with mass in the right iliac fossa Table 12 Complications Wound infection was most common postoperative complication in this study. 6 of 11
Figure 12 Operative findings of Non-Hodgkin lymphoma Figure 13 Non-Hodgkin lymphoma - specimen commencement of an acute appendicitis, a tender mass can frequently be felt in the right iliac fossa beneath some rigidity of the overlying musculature, with the other quadrants of the abdomen being free from rigidity or tenderness. In the present study, all patients had masses which were tender and firm. According to Skoubo-Kristensen et al.8, 55% of his cases experienced febrile episodes with a temperature >39 degree C. In the present series, 93% presented with fever and 50% with vomiting. In this study, 62% had hemoglobin values above 10g%. In all patients abdominal ultrasound was done to confirm diagnosis. In this study, 93% of patients were treated conservatively by Ochsner-Sherren (O-S) regimen followed by surgery. 9 According to Gahukamble et al., in situ delayed appendicectomy seems beneficial for all the patients who respond well to the initial management of appendicular mass. 8 Skoubo et al. say that conservative management of appendicular masses is successful in most cases and complication rates seem lower than with early operative treatment. In this study, cases managed conservatively were called back for appendicectomy 6-8 weeks later. The specimens of appendicectomy were sent for histopathological examination and all of them were reported as chronic appendicitis. Appendicular Abscess: DISCUSSION Apendicular Mass: In our study, appendicular masses accounted for 32% of cases. All patients came to the hospital for abdominal pain lasting less than one month. Fever was another prominent symptom (93%), and there was vomiting in about 50% of cases. The mean age for appendicular masses was 53.6 years6. In the present study, the maximum age incidence was in the 3rd (31%) and 4th (31%) decade, followed by the 2nd decade (18%). Appendicular masses were more common in males than in females (1.66:1). Only 2 patients complained of mass per abdomen. But on examination, all cases were found to have a mass in the right iliac fossa. According to 7 Mann, on the third day (rarely sooner) after the 7 of 11 Appendicular abscesses formed 20% of the present study group. Most of the cases were in the 3rd to 5th decade and 70% were males. All patients presented within one month of symptoms. According to Bradley et al.10, the mean age at which appendicular abscess occurred was 40.7+/- 2.7. Symptoms had been present on an average of 9.2+/-0.8 days prior to admission. All patients with appendicular abscess in this study group had abdominal pain and fever; 70% presented with vomiting. No patient complained of mass per abdomen, but all the cases were found to have a mass in the right iliac fossa which was tender and soft in consistency. In this study ultrasound was done in all patients for diagnosis. All cases were taken up for immediate extraperitoneal drainage of abscess and interval appendicectomy was done after 6-8 weeks. The histopathology reports showed chronic appendicitis. 11 According to Way et al., when the surgeon encounters an
unsuspected abscess during appendicectomy, it is usually best to proceed and remove the appendix. If the abscess is large and further dissection would be hazardous, drainage alone is appropriate. Appendicitis recurs in only 10% of patients whose initial treatment consisted of antibiotics or antibiotics plus drainage. have a mass in the right iliac fossa. According to Bhansali et al.15, 60% of chronic cases of ileocecal tuberculosis presented as mass in the right iliac fossa which may simulate either Crohn's disease, an appendix mass or a malignant lesion of the cecum or ascending colon. It could be due to hyperplastic tuberculosis or lymphadenitis. According to Bradley et al.10, the complication rate was significantly lower and the hospital stay shorter in patients managed expectantly than in those undergoing immediate appendicectomy. Patients who had diffuse peritonitis must undergo immediate appendicectomy, but other patients can be managed with intravenous antibiotics and percutaneous drainage of the abscess if suitable. After expectant management, interval appendicectomy can be offered in light of the significant risk that the appendicitis recurs and of the low morbidity rate associated with this procedure. The complication rates were 67% for immediate appendicectomy and 24% for expectant management. According to Prakash, 27% of cases had duration of symptoms below 6 months, 43% from 6 months to 3 years and the rest more than 3 years. In present the study, in 91% of cases the duration of symptoms was less than 6 months, in 16% it was less than 3 months and in 8% of cases it was more than 6 months. In this study group, 70% of patients had wound infection after extraperitoneal drainage. Ileocecal Tuberculosis: 12 Elhence et al. said, gastrointestinal tuberculosis, though rare in industrialized countries, continues to be a problem in developing countries. In India, tuberculosis has been reported to be the cause in 3 to 4% of patients with intestinal obstruction. About 5 to 7% of all gastrointestinal perforations (excluding appendix perforations) have been reported to be due to tuberculosis. In this study, 22% of masses in the right iliac fossa are due to tuberculosis. Most 13 cases belong to the rural area. According to Prakash et al., the highest incidence of this disease was found in the age group of 20-40 years. In our study, the maximum age incidence was in the 3rd and 4th decade (83%). The incidence was higher in males. Tuberculosis enteritis is commonest in the ileocecal region in series conducted by Prakash14. In this study, all the cases had involvement of cecum with associated involvement of ileum in few cases. According to Prakash, abdominal pain is the commonest symptom in both the obstructive and the non-obstructive group. In the latter, it may be colicky in nature, but it often vague, related to umbilicus and right iliac fossa. In this study, all patients complained of abdominal pain and weight loss, and 91% complained of fever. Only 16% of patients presented with mass in right iliac fossa. But on examination, all the patients were found to 8 of 11 16 According to Kelly et al., a high index of suspicion should be maintained for ileocecal tubeculosis in patients with appropriate clinical features, even if classical risk factors for 14 tuberculosis are absent. According to Prakash, more than 50% of cases had hemoglobin values below 10g% and an ESR >30mm/hour was noted in more than 50% of cases. In the present study, in 70% of cases hemoglobin was less than 10g% and in 83% ESR was >40mm/hour. According to Malik et al.17, ultrasound findings in proper clinical settings are diagnostic of tuberculosis. In this study, abdominal ultrasonography was done in all cases. Elhence et al.12 said that clinical and subjective improvement after surgery occurred after 2-6 months of anti-tuberculous treatment which may be because of surgical removal of basic tuberculosis. In this study, 84% of cases underwent definitive surgery and followed by this, the patients were put on antitubercular drugs. These patients responded well and had clinical improvement. The standard drug regimen used was: first 2 months of 4 drugs (which included Isoniazid, Rifampicin, Pyrazinamide and Ethambutol in the intensive phase), followed by 4 months of continuation phase with 2 drugs, which comprised Isoniazid and Rifampicin. 18 Bharati et al. performed a study of the pattern of surgical emergencies of abdominal tuberculosis, and they did right hemicolectomy in 4.5% of cases, limited resection in 6%, and stricturoplasties in 36%. In this study, 84% were managed surgically by right hemicolectomy. All resected specimens were proved histopathologically. Carcinoma of the Cecum: In the present study, carcinoma of the cecum formed 16% of cases; 87% were more than 40 years old. According to Amin
et al.4, in study of 20 cases, most of the patients were between the age of 45 and 65 years, the oldest patient being 80 years and youngest only 30 years old. In our study, the incidence was higher in females (63%). In the series done by 19 McDermott et al., 51% were males and 49% were females. In our study, duration of pain was longer than a month, all patients had weight loss and 37% had vomiting; 75% had a 20 hemoglobin value below 10g%. According to Goligher, in the majority of cases of cecal carcinoma constant but not very severe abdominal pain was experienced in right iliac fossa, subcostal region or epigastrium, often associated with local tenderness. In patients with growths of cecum, ascending colon and hepatic flexure, bowel symptoms were usually completely absent. In many instances the only manifestation will be deterioration of general health with loss of weight and anemia. In the present study, 75% of patients presented with a mass in the right iliac fossa. Barium enema examination reveals a bulky tumor that projects into the lumen of cecum or ascending colon, producing a filling defect with an irregular edge.19 In our study, contrast barium enema was done in two patients, which revealed a persistent short irregular filling defect in the cecum. Richardson et al.21 said that sensitivity, specificity and accuracy of abdominal ultrasonography in colonic tumors considered to be consistent with colonic carcinoma was 96%, 67% and 91%, respectively. In the present study, all patients were diagnosed accurately on ultrasonography. Colonoscopy was done in one case; 20 biopsy was taken. According to Goligher's experience with regard to growths of the cecum and ascending colon, he prefers to practice the more extensive right hemicolectomy except when the patients general condition is such as to compel restriction to the minimum that offers a reasonable chance of cure. In this series, the general condition of the patients was improved by giving high-protein diet and hematinics. Almost all the patients in this series needed blood transfusion, either in the preoperative period or in the peri/postoperative period. In 7 out of 8 cases, right radical hemicolectomy was done, followed by chemotherapy (5-FU based). In all of them adenocarcinoma was proved histopathologically. Iliopsoas Abscess: Psoas abscess is, as a rule, associated with detectable tuberculous disease of the vertebral column. However, the 9 of 11 osseous lesions may not be discernable clinico-radiologically in the initial stages22. Surprisingly, in our study 4 cases out of 50 turned out to have iliopsoas abscess. Clinically, all of them presented with abdominal pain and fever, 75% with weight loss, 25% with vomiting. On examination, they all had a mass in the right iliac fossa. Sonographically, differential diagnosis of appendicular abscess was considered. As conservative management failed, all cases underwent laparotomy and drainage. Histopathologically, they all proved to be of tubercular origin. One patient had a previous history of pulmonary tuberculosis. Non-Hodgkin Lymphoma: The gastrointestinal tract is the most common site for the development of non-hodgkin lymphoma, comprising approximately 30% of NHL, mostly from stomach (60%) and small bowel (30%) and rarely from colon. It may present as non-specific abdominal complaints, malabsorption, 23,24 obstruction or as palpable mass. In our study, interestingly, one case presented with a right iliac fossa mass clinically diagnosed as ileocecal tuberculosis, but at laparotomy it was an ileocecal mass with multiple firm lymph nodes. Histopathologically, it turned out be NonHodgkin lymphoma. CONCLUSION Diseases presenting as a mass in the right iliac fossa were common in the age group of 20 to 40 years. The overall incidence seems to be higher in males. Females had an increased incidence of cecal carcinoma. These diseases are more common in patients with low socioeconomic status. The commonest symptom was abdominal pain. The commonest presenting symptoms were pain in the right iliac fossa, fever, vomiting and loss of weight. Only 22% of patients complained of a mass in right iliac fossa. Tenderness was the prominent clinical sign (92%); 83% of ileocecal tuberculosis had high ESR. Appendicular pathology (mass/abscess) was the most common condition presenting as mass in the right iliac fossa. Ileocecal tuberculosis is the most common pathology in patients who present with chronic abdominal pain within the rural population, according to this study. All iliopsoas abscesses turned out be of tubercular etiology. There was no mortality in our study. Abdominal ultrasonography is the imaging modality of first choice in patients presenting with a right iliac fossa mass. Surgery is the mainstay of treatment and, when done with
adequate preparations, has good prognosis. Ileocecal tuberculosis is one of the most important differential diagnoses for chronic abdominal pain in the rural population. Non-Hodgkin lymphoma should be kept in mind as 10 of 11 differential diagnosis in long-standing mass lesions of the right iliac fossa in young patients. References
Author Information Sunil Kumar Shetty, Resident Department of General Surgery Devaraj Urs Medical College M Shankar, Associate Professor Department of General Surgery Devaraj Urs Medical College 11 of 11