RIF pain…an unusual RIF pain…an unusual suspect suspect
Jan 31, 2016
RIF pain…an unusual RIF pain…an unusual suspectsuspect
HS.HS.
84 year old gentleman 84 year old gentleman 7/52 history of right iliac fossa pain7/52 history of right iliac fossa pain ‘‘Tightness’ at RIFTightness’ at RIF ConstantConstant Non radiatingNon radiating Worse on hip flexion and movement Worse on hip flexion and movement No fevers/night sweats/rigorsNo fevers/night sweats/rigors No nausea/vomiting/altered bowel habitNo nausea/vomiting/altered bowel habit
HistoryHistory
Past Medical HistoryPast Medical History NIDDMNIDDM MI – ’98MI – ’98 Right inguinal hernia repairRight inguinal hernia repair Vit B12 deficiencyVit B12 deficiency
MedicationsMedications MetforminMetformin AspirinAspirin AtorvastatinAtorvastatin
PantoprazolePantoprazole
HistoryHistory
Social HistorySocial History– Non smokerNon smoker– No C2H5OHNo C2H5OH
Family HistoryFamily History– NIDDMNIDDM
Systems reviewSystems review– NADNAD
ExaminationExamination
BP 118/66, PR 90, Temp 36.5, Sats 96% on BP 118/66, PR 90, Temp 36.5, Sats 96% on RARA
Abdomen softAbdomen soft Tender at RIFTender at RIF Guarding on deep palpation at RIFGuarding on deep palpation at RIF No distension No distension Bowel sounds present and normalBowel sounds present and normal DRE- NADDRE- NAD
InvestigationsInvestigations
BloodsBloods
Hb Hb 12.712.7 WBC WBC 7.177.17 Neut Neut 4.934.93 ESR ESR 3535 CRP CRP 66 U&E U&E normal normal LFTs LFTs normalnormal
RadiologyRadiology
PFA PFA – density projected density projected
over Right renal over Right renal pelvis (7X5mm), ?pelvis (7X5mm), ?renal calculus. renal calculus. Bowel within Bowel within normal limits.normal limits.
CXR CXR – NADNAD
Intra-operativeIntra-operative
LaparoscopyLaparoscopy Laparoscopic mobilisation of ceacumLaparoscopic mobilisation of ceacum Findings:Findings:
– hard appendiceal masshard appendiceal mass Converted to laparotomyConverted to laparotomy Right hemicolectomyRight hemicolectomy
HistologyHistology
Diffuse large B cell lymphoma, appendix, Diffuse large B cell lymphoma, appendix, germinal centre typegerminal centre type
Margins and lymph nodes free.Margins and lymph nodes free.
Post operative coursePost operative course
Wound infectionWound infection Oncology reviewOncology review CT Thorax, abdomen, pelvisCT Thorax, abdomen, pelvis
Discharged on POD 17 with po Discharged on POD 17 with po AntibioticsAntibiotics
Follow up Follow up – 1/12 in our OPD1/12 in our OPD– 3/12 in oncology OPD 3/12 in oncology OPD
Appendiceal TumoursAppendiceal Tumours
BackgroundBackground
Gastrointestinal tract Gastrointestinal tract – is the most frequently involved extranodal site of is the most frequently involved extranodal site of
Non Hodgkins lymphoma (30-45%). Non Hodgkins lymphoma (30-45%). – 4-20% of all Non Hodgkins lymphoma.4-20% of all Non Hodgkins lymphoma.
Incidence of primary lymphomas of appendix Incidence of primary lymphomas of appendix – estimated as 0.015% of all gastrointestinal estimated as 0.015% of all gastrointestinal
lymphomas. lymphomas. 1% of all appendectomy specimens contain a 1% of all appendectomy specimens contain a
neoplasm. neoplasm.
PresentationPresentation
Acute appendicitisAcute appendicitis Weight loss Weight loss AnorexiaAnorexia Palpable lower quadrant massPalpable lower quadrant mass Obstruction/constipationObstruction/constipation Nausea/vomitingNausea/vomiting Diagnosis- histologicalDiagnosis- histological
InvestigationInvestigation
HistoryHistory– similar to appendicitis.similar to appendicitis.
Examination Examination – tender RIF +/- masstender RIF +/- mass
Bloods Bloods – Normal/Raised inflammatory markersNormal/Raised inflammatory markers
Radiology (pre op)Radiology (pre op)– CXR/PFA – perforation/obstructionCXR/PFA – perforation/obstruction– CT ABDOMEN – massCT ABDOMEN – mass
HistologyHistology Radiology (post op)Radiology (post op)
– CT TAP - metsCT TAP - mets
ManagementManagement
Early detection + high suspicion – Early detection + high suspicion – essential.essential.
Surgery Surgery – Appendectomy Appendectomy – +/- Right hemicolectomy +/- Right hemicolectomy – +/- lymph node dissection+/- lymph node dissection
TypesTypes
Divided into 2 major groupsDivided into 2 major groups– Carcinoid Carcinoid
occurs at tip of appendix.occurs at tip of appendix.
– Non-carcinoid Non-carcinoid originate at the epithelial lining of originate at the epithelial lining of
appendix.appendix. Produce a thick gelatinous material Produce a thick gelatinous material
known as mucin.known as mucin.
CarcinoidCarcinoid
Most common form (>50% cases)Most common form (>50% cases)F>MF>MOccur in 4Occur in 4thth decade of life. decade of life.Symptoms Symptoms
similar to appendicitis.similar to appendicitis.Carcinoid syndrome – flushing, SOB, Carcinoid syndrome – flushing, SOB,
diarrhea, Right sided heart valve diarrhea, Right sided heart valve disease.disease.
Tx- appendectomy + Right hemicolectomy + Tx- appendectomy + Right hemicolectomy + lymph node dissection.lymph node dissection.
85% 5-year survival rate.85% 5-year survival rate.
B cell lymphomaB cell lymphoma
non-Hodgkin's B-cell lymphoma non-Hodgkin's B-cell lymphoma usually present in second to third usually present in second to third
decade of life.decade of life. SymptomsSymptoms
– Like appendicitisLike appendicitis TreatmentTreatment
– Appendectomy + Right Appendectomy + Right hemicolectomyhemicolectomy
AdenocarcinomaAdenocarcinoma
F=MF=M Occurs 6Occurs 6thth decade of life decade of life Rarer but more aggressive type.Rarer but more aggressive type. Occur in the epithelial lining of the appendix – obstructive Occur in the epithelial lining of the appendix – obstructive
symptoms.symptoms. SymptomsSymptoms
– Abdominal pain, constipation, N+V.Abdominal pain, constipation, N+V. TreatmentTreatment
– Appendectomy + right hemicolectomy.Appendectomy + right hemicolectomy. Prognosis – poorer than carcinoid.Prognosis – poorer than carcinoid. 5 yr survival. 5 yr survival.
– Duke’s A – 94Duke’s A – 94– Duke’s B – 83%Duke’s B – 83%– Duke’s C – 44%Duke’s C – 44%
Pseudomyxoma Pseudomyxoma peritonei (PMP)peritonei (PMP) Presence of acellular mucin within abdominal cavity.Presence of acellular mucin within abdominal cavity. Usually has metastased at time of presentation.Usually has metastased at time of presentation. SpreadSpread
– directdirect– rarely through bloodstream or lymphatics.rarely through bloodstream or lymphatics.
SypmtomsSypmtoms– Bowel obstructionBowel obstruction– Increase in abdominal sizeIncrease in abdominal size– Pelvic discomfortPelvic discomfort– Ovarian masses Ovarian masses
TreatmentTreatment– debulking surgery.debulking surgery.
SummarySummary
Appendicitis should be the top of your Appendicitis should be the top of your differential for anyone with RIF pain.differential for anyone with RIF pain.
Appendiceal cancer is a rare (and Appendiceal cancer is a rare (and usually an incidental) findingusually an incidental) finding
Should be suspected in any elderly Should be suspected in any elderly person presenting with appendicitis person presenting with appendicitis like symptoms and signslike symptoms and signs
Histology of Histology of ALLALL patients post patients post appendectomy should be checkedappendectomy should be checked
http://www.ajronline.org/cgi/content/full/178/5/1123 (histology (histology pictures)pictures)
http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2008;volume=51;issue=3;spage=392;epage=394;aulast=Radha (indian case) (indian case)
http://www.mdanderson.org/patient-and-cancer-information/cancer-http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/appendix-cancer/index.htmlinformation/cancer-types/appendix-cancer/index.html
www.medscape.com/viewarticle/431119_3 (normal CT appendix)www.medscape.com/viewarticle/431119_3 (normal CT appendix) http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic)http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic) www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on
adenocarcinoma)adenocarcinoma) http://www.aboutcancer.com/http://www.aboutcancer.com/
appendix_cancer.htm (graph)appendix_cancer.htm (graph) http://www.thedoctorsdoctor.com/http://www.thedoctorsdoctor.com/
diseases/appendix_adenoca.htm - diseases/appendix_adenoca.htm - Appendiceal tumors: retrospective clinicopathologic analysis Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. Connor of appendiceal tumors from 7,970 appendectomies. Connor SJ, Hanna GB, Frizelle FASJ, Hanna GB, Frizelle FA