right iliac fossa mass

1. RIGHT ILIAC FOSSA
MASS

2. RIGHT ILLIAC FOSSA
•
Abdomen is divided into
9 regions
2 Horizontal planes:
Upper/Transpyloric
Lower/Transtubercular
2 Vertical planes:
one on either side
through the midpoint
between ASIS &
symphysis pubis.

3. RIF
Abdominal wall Intra abdominal Retroperitoneal

4. RIF mass
Structures
Normally present
Anterior Abdominal wall
GIT
Mesentery
Blood vessels
Lymphatics
Nerves
Bones
Posterior abdominal muscles
Structures from adjoining areas
Kidneys(unascended,
transplanted)
Testis(undescended),
Gallbladder,
Uterus & its Appendages,
Urinary bladder

5. Abdominal wall
• Haemotoma
• Abscess
• Incisional hernia ( post appendicectomy)
• Tumours
Benign
Lipoma, Fibroma, Neurofibroma and fibromatosis.
Malignant tumours (rare)
Desmoid tumour, Soft tissue sarcomas
(fibrosarcoma , dermatofibrosarcoma , liposarcoma).

6. Intra peritoneal
• Appendicular mass
• Appendicular
abscess,
• Ileocaecal tuberculosis
• Carcinoma caecum
• Mesentric lymph nodes
• Amoebic typhylitis
• Crohn’s disease
• Actinomycosis
• Intussuception
• Mesentric cyst
• Diverticulosis.

7. Retroperitoneal
• Soft tissue sarcoma
• Aneurysm
• Iliopsoas abscess
• Tumor from bony or
cartilage of ilium
• Undescended Testis
• Retroperitoneal lymph
nodes, (tuberculosis or
filariasis,lymphoma,
Secondaries)
• Transplanted kidney
• Unascended Kidney

8. Miscellaneous
• loose bodies
• foreign body
• ovarian mass/tubo-ovarian mass
• Uterine mass

9. APPENDICULAR MASS
complication of acute appendicitis.
 Mass consists of greater omentum with oedematous caecal wall
& loops of distal small intestine with inflammed appendix in
centre,
natural phenomenon to contain spread of infection
Firm , tender, irregular mass in RIF ,with localised guarding &
rigidity & systemic manifestations
 USG and CECT –helpful in assessing the nature & size of mass

10. 1.Conservative(Ocshner-Sherren regimen)
 pulse and temperature monitoring
Monitoring the size of mass
I.V Fluids & I.V Antibiotics
Interval-Appendicectomy after 6 weeks
2.Emergency Surgery
Rising pulse rate & temperature
persistant vomiting
Increasing abdominal pain
Increase in size of the mass,

11. APPENDICULAR ABSCESS
 Complication of acute appendicitis
 Pt. is toxic ,with high grade fever & tachycardia.
 tender mass with indistinct borders , guarding &
rigidity
 USG/CT for size of abscess
 Treatement
conservative( < 4 cms)
USG guided aspiration( > 4 cms )
surgical drainage ( failure of other modes )
Interval appendicectomy after 12 weeks

12. Neoplasms of the appendix
Carcinoid tumour (argentaffinoma)
arise from Kulchitsky cells of the crypts of Lieberkühn
vermiform appendix is the most common site
 most common neoplasm of the vermiform appendix
 it’s commonly a incidental finding / painless well defined
firm to hard mass
carcinoid syndrome(flushing & diorrhoea) in liver
metastases

13. Investigations
24 hrs urine 5HIAA,
 sr.chromogranin A ,
USG ,
CECT ,
SOMATOSTATIN RECEPTOR SCINTIGRAPHY
Treatment
< 1 cm – appendicectomy
>1 cm – right hemicolectomy
metastases – metastasectomy

14. Mucocele of the appendix
• retained mucous secretions / tumour
• mimicks sub acute appendicitis, infection leads to
empyema.
• Rupture causes pseudomyxoma peritonei.
• USG / CT
• benign – appendicectomy
• psuedomyxoma peritoni - cytoreductive surgery/
- intra-peritoneal chemotherapy

15. Adenocarcinoma
• Rare
• presents as painless hard mass
• USG / CECT / colonoscopy
• Right hemicolectomy

16. abdominal tuberculosis
abdominal
tuberculosis
intestinal
ileo-caecal
1.ulcerative
2.hyperplastic
3.sclerosing
ileal
stricture
diffuse
colonic
peritoneal
acute chronic
1.ascitic
2.loculated
3.adhesive
4.purulent
others
1.mesenteric
2.omental
3.ano-rectal
& sigmoid
4.miliary
5.gastro-
duodenal
6.retro-
peritoneal

17. ILEOCAECAL- TUBERCULOSIS
Site : ileum, proximal colon and peritoneum are commonly
affected
Etiology ; mycobacterium tuberculosis
Mode of spread:
1.Ingestion of food contaminated with tubercle bacilli
2.Ingestion of infected tubercle bacilli containing sputum
3.Haematogenous spread from pulmonary tuberculosis.
4.Lymphatic spread through tuberculous cervical adenitis.
5 .Retrograde spread through genitourinary tract in females
Types: 1. ulcerative. 2. hyperplastic 3. mixed

18. Mass in abdominal TB
• mesenteric TB
• Hyperplastic type of ileocaecal TB
• Peritoneal TB (loculated ascities )

19. Hyperplastic type :
less virulent infection, good host resistance
 intermittent abdominal pain, diarrhoea,
 steatorrhea, anemia and wt.loss , low grade fever
 intestinal obstruction (acute / sub-acute)
 irregular firm non-tender mass
 investigations
CXR, AXR, USG, CECT, colonoscopy , D-lap , mantoux ,
ELISA , PCR
 Treatement
umcomplicated - ATT
complicated - ileocaecal resection

20. ILEOCAECAL TB

21. CROHN`S DISEASE
Can involve any part of GIT . ileocoloic region most common site
skip lesions
 (cobblestone appearance) Mucosal ulceration with oedema of
mucosa between the ulcers
 Transmural inflammation leading to adhesions & inflammatory
masses formation with mesenteric abscess & fistula formation into
adjacent organs.
 Serosa is opaque,with mesenteric thickening &enlarged mesenteric
lymph nodes.
 CECT , Barium meal follow through , colonoscopy & biopsy
 uncomplicated - steroids , anti-inflammatory, immunosupressants
Complicated – resection & ostomy/ reconstruction

22. CROHN`S DISEASE

23. CARCINOMA CAECUM

24. CARCINOMACAECUM
3rd common site for colonic carcinoma
 unexplained anemia is the common presentation
Altered bowel habits , obstruction , perfotation
 hard, nontender, fixed mass

25. • Aetiology ;
• 1. DIET -Red meat, saturated fat and cholesterol
• 2.Alcohol and smoking
• 3.Radiation
• 4. Post-cholecystectomy and ileal resection and
ureterocolostomy status
• 5.Genetic causes
Familial Adenomatous polyposis coli.
Gardner's syndrome and Turcot’s syndrome.
Peutz jeger’s syndrome and Juvenile polyposis syndrome.
HNPCC , Lynch syndrome1, Lynch syndrome 2
Aspirin and other NSAIDs, calcium are protective
against large bowel cancers

26. Types
1.Polypoidal
2. Ulcerative,
3.Annular,
4.Mucinous.
Investigations-stool for occult blood,
Barium meal follow through-irregular filling defect in caecum
& normal terminal ileum
Colonoscopy & Biopsy
Treatement - Right hemicolectomy, chemotherapy (FOLFOX)

27. ACTINOMYCOSIS
 anaerobic gram positive branching filamentous fungal
like bacterium Actinomycosis israeli (‘Ray fungus.’)
Types : 1. cervicofascial 2. thoracic ,
3.Abdominal actinomycosis (rare)
 fixed indurated mass in right iliac fossa with abscess
and multiple sinuses , discharging sulphur granules
 No intestinal luminal narrowing or lymph node
involvement
Treatement: high dose penicillin or co-trimoxazole

28. Actinomycosis

29. AMOEBOMA
Entamoeba histolytica (trophozoite)
 feco-oral route
 flask shaped ulcers in ileum and large bowel
 Blood and mucus diarrhoea , pain abdomen , mass abdomen
 stool examination , colonoscopy & biopsy , PCR
Treatement : metronidazole 800mg tds for 7-10 days.
Diloxanate furoate, Paromomycin
and Iodoquinol.
surgery for complications like obstruction

30. MESENTRIC CYSTS
1.chylolymphatic cysts
congenital maldeveloped lymphatic system
commonest type
enucleation
2.enterogenous cysts
duplication or diverticulum of adjacent bowel
contains all layers of bowel
tillaux triad
resection and reconstruction
3.congenital remnant cysts
4.teratomatous dermoid cyst
5.traumatic mesenteric haematoma and cyst formation
6.mesenteric cold abscess formation
7.hydatid cyst of mesentery.

31. INTUSUSCEPTION

32. INTUSUSCEPTION
Cause:
Children : Hyperplasia of peyer’s patches
Adult : polyps, submucosal lipoma, tumour, prolonged fasting
Types: ileo-ileal , ileo-colic , Colocolic common in adults
Pathology
3 parts
Entering or inner tubes ( blood supply is commonly impaired)
Returning or middle part,
sheath or outer tube(Intessuscipiens)

34. o acute / sub-acute
o colicky abdominal pain ,bilious vomiting , abdominal lump
freely mobile , becomes firm on palpation , intestinal
obstruction , guarding & rigidity ( gangrene )
o red current jelly stool
o emptiness on the RIF(sign de dance)
o investigations
AXR – absent caecal gas / multiple air-fluid levels
barium enema – claw sign
USG – psuedokidney sign/ bull’s eye sign
CECT
o treatment
hydrostatic reduction
resection and reconstruction
.

35. ILIOPSOAS ABSCESS

36. PSOAS ABSCESS
It’s a cold abscess due to Tuberculosis of Thoracolumbar spine
(Pott`s disease)
 caseating pus from vertebra gravitates via medial arcuate ligament
underneath psoas sheath
 psoas sign - Thigh is in fixed flexion position due to
psoas muscle spasm
 Cross fluctuation – pus tracks below inguinal ligament
into thigh
 Spinal tenderness/Gibbus can be demonstrated.
 X-ray of spine ,CT , MRI
 Treatment –Image guided aspiration / I & D
ATT
spinal support with bed rest

37. Retroperitoneal tumours
• painless ill-defined masses , restricted mobility , doesn’t
fall on knee-elbow position
• USG , CECT , MRI , biopsy
• benign – excision
• sarcoma – wide local excision / chemoradiation
• lymphoma – chemo–radiation
• Secondaries – palliative therapy

38. Aneurysm
• well defined fusiform pulsatile mass
• may present with distal ischemia
• USG ,duplex , Angiography
• stenting / resection & reconstruction

39. OTHER CAUSES
ROUND WORM BOLUS MASS
soft tender mass in RIF.
With H/O of passing round worms in Stools.
Most common in children in endemic areas,causing intestinal
obstruction.
TUMOURS OF ILIAC CREST
Osteochondroma,hard fixed bony swelling .

40. RARE CAUSES
• KIDNEY- Unascended kidneys/mobile normal kidneys
• TESTIS- Undescended testis
• GALL BLADDER- Huge distended GB
• UTERUS & APPENDAGES-Tubo-ovarian
mass,ovarian cyst,fibroid uterus
• URINARY BLADDER DIVERTICULUM