eSurgery

This is written with the aim of helping my medical students and doctors in training go through my thought process in the outpatient clinic. This list is not meant to be all comprehensive but rather a practical guide in coming to a diagnosis quickly.

1. Ask the patient how long this pain has been there for – acute ie recent onset – most likely abscess or chronic(?coccydynia) or intermittent(recurrent pilonidal abscess)
2. Examine the patient: Look at the lump ?red, swollen, discharging pus, tender(abscess); any pits/sinus in the midline in the natal cleft(pilonidal sinus)
3. If no pits/sinus openings and the red tender lump is away from the midline – think of other differentials: fat necrosis(has the patient been sitting a lot eg cycling long distances), abscess arising from folliculitis. If the abscess is near the anus low in the natal cleft – then consider a perianal abscess.
4. Always keep at the back of the mind other differentials which are much rarer but as a specialist one has to be aware of:
(i) Skin cancer in the area – BCC, SCC, melanoma
(ii) Other types of soft tissue tumour and sacral tumours
(iii) Dermatitis – ?chronically scratching the area
5. Less commonly – infected/inflammed sebaeceous cyst can also occur there

Management:
If pilonidal sinus abscess – I would do a small operation to drain the abscess through the pits/sinus by making a small incision around the sinus opening, putting in an artery to remove the hair and drain the pus, swiping the cavity with Betadiene soaked gauze. This can be done with LA infiltration around the area if the patient is tolerant or in theatre under Local anaesthesia & sedation in lateral position(easier for the anaesthetist and safer). I would normally treat with oral antibiotics for a week. Review again next week. (In the long term, if recurrent infections, to consider operation with lower recurrence rate namely Modified Karydakis surgery)

History:
Most important symptom is abdominal pain – pain in the right lower abdomen. History of central(around belly button), intermittent pain moving to the right side of the abdomen(and the pain becoming constant). Patients may give history of being sore to move, of feeling all the bumps in the drive to hospital.
Other symptoms:
1. Loss of appetite – but beware, a young patient who has not eaten for some time can still say they feel hungry even with appendicitis
2. Nausea and vomiting – usually the vomiting is mild
3. Loose bowel action, abdominal pain on urinating(if inflammed appendix tip is sitting on the bladder)
4. Fever

Examination findings:
Patient lying still in bed, sore to move around
Vital signs – may have fever and tachycardia
Abdominal examination : Tender in right iliac fossa, rebound tenderness , crossed tenderness
(note: the tenderness can only be mild if the inflammed appendix is sitting behind the caecum – ie retrocaecal appendicitits)

Ix:
Imaging – an increasingly used modality, helps reduce incidence of negative appendicectomy; Ultrasound can show a swollen appendix(but may not pick up an early appendicitis, also dependent on sonographer and body habitus) CT abdomen – can be helpful but the disadvantage is the radiation exposure
Blood test – elevated white cell count in particular neutrophilia with left shift, elevated C-reactive protein(an inflammatory marker)..but there are cases of appendicitis where the blood test is normal early on

Treatment:
Nil by mouth
Intravenous antibiotics as soon as diagnosis is suspected(why wait?)
Surgery – Appendicectomy : through short incision if diagnosis is confirmed on CT/US, Laparoscopy if uncertain eg in females ?ovarian pathology ?endometriosis or other pathology

Differentials – other diseases that can mimic appendicitis:
1. Diverticulitis – ie if long redundant sigmoid colon, esp in elderly
2. Cancer of caecum
3. Inflammatory bowel disease involving the caecum or terminal ileum
4. Meckel’s diverticulitis
5. Gynaecological – ovarian cyst rupture, Mittelschmerz, torsion of ovary, ectopic pregnancy
6. Worms – eg pin worm
7. Torsion of fat around right colon
8. Low lying inflammed gallbladder

1. Peptic ulcer disease / Gastritis/ Duodenitis
This pain is usually located in the centre of the upper abdomen(in the epigastric area). The pain is usually relieved by antacids if due to gastritis/duodenitis alone. Sometimes the pain can be referred to the back. Rarely the pain can be generalised and very severe if the peptic ulcer has perforated(ie the patient has peritonitis – this can be associated with a high fever. And classically on the CXR one can see gas under the diaphragm) However, perforated peptic ulcer is rare these days due to the increasing use of proton pump inhibitors(ie Losec, Nexium, Somac). Often this is associated with a Helicobacter pylori infection of the lining of the stomach. This can be diagnosed at gastroscopy through a biopsy of the stomach lining. Alternatively a breath test can be performed.

• Can duodenitis cause back pain on the right side?
  YES – one can get back pain from a duodenal ulcer on the posterior wall of the duodenum.

2. Gallstones – Biliary colic : the pain is usually upper abdomen and to the right. Sometimes the pain is felt all the way round in the back as well. In the initial stages it is usually common not to be able to find any comfortable position at all. A fatty meal can sometimes trigger an attack. This pain can last from minutes to a few hours.
If the stone remains stuck in the gallbladder neck, the pain may persist and the gallbladder becomes acutely inflammed(Acute cholecystitis). At this stage, the pain in constant and the one has to lie still to be comfortable. If the stone remains stuck at the end of the bile duct, one can become jaundiced or develop acute pancreatitis(a serious condition in which the pancreas is inflamed and can potentially be life threatening)

3. Appendicitis - the pain is initially central and then moves to the right side of the abdomen above the groin(the location is called the Right Iliac fossa – it is often abbreviated to RIF in medical notes). There is also often a loss of appetite and nausea. This is also associated with fever. One is tender in to the RIF on palpation. However if the appendix is behind the caecum(ie retrocaecal) the pain may not be as severe and the tenderness may be mild. This is why a retrocaecal appendix is hard to diagnose.

4. Gynaecological pathology (eg Retrograde menstruation, bleeding ectopic pregnancy, torsion of the ovary, rupture of an ovarian cyst/follicle, pelvic inflammatory disease, endometriosis) – the pain can be in either right or left iliac fossa but it is usually lower down and closer to the groin crease that the pain from an appendix (if on the right side to).

5. Urological pathology – Infection of the urinary tract (eg bladder) besides causing a stinging pain when passing urine may also cause pain above the pubic bone and also in the loin(if the infection spreads to the kidneys). Kidney stones can also cause pain in the loin going around into the groin. Testicular problems/trauma may also cause pain to be felt around the belly button!

6. Diverticulitis – the pain is usually in the left iliac fossa. This is usually associated with fever. Diverticular disease itself can also cause a milder pain or discomfort. Sometimes if the sigmoid colon is very loopy, the pain can be felt on the right side and mistaken for an appendicitis!

7. Bowel blockage / obstruction (eg from adhesions, bowel cancer or stuck hernia) – typically the pain comes and goes in waves, usually central or just above the pubic bone. This is associated with nausea, vomiting, abdominal distension, inability to pass flatus and constipation. (the last three symptoms being more for obstruction of the large bowel)

8. Complicated hernia – a hernia with its contents becoming stuck can become painful when the blood supply to the contents(eg fat or bowel) becomes compromised. It is important to check the groin for any inguinal or femoral hernia in anyone with abdominal pain. Rarely a hiatus hernia can cause pain(this is if the stomach becomes strangulated above the diaphragm – this is associated with an inablilty to swallow saliva and not being able to pass down a nasogastric tube)

9. Pain referred from elsewhere and other medical causes – Pneumonia affecting the lower lobes of the lungs, heart attack, metabolic causes (eg very high blood calcium levels, severe diabetes – diabetic ketoacidosis), back problems, shingles, Familial Mediterranean fever, vasculitis, sickle cell anaemia. In young children, mesenteric adenitis(inflammation of the lymph glands in the abdomen) can also cause abdominal pain. This is associated usually with a cold and high fever.

10. Pancreatitis – inflammation of the pancreas (usually from either alcohol or gallstones). This can cause pain in front going through to the back. Often associated with vomiting which tends to relieve the pain.

11. Coeliac disease – this is a hereditary condition that is quite common(about 1 in 100 Australians suffer from it although majority are undiagnosed. Often, there may not be a known family history. Coeliac disease can cause a wide range of symptoms including abdominal pain.

• Can coeliac disease cause pain in upper right abdomen?
  Coeliac disease can cause nonspecific abdominal pain. It can cause pain in the upper right abdomen but there are other pathology that can cause pain there too such as gallstones and hepatitis. It is important to see a doctor to discuss this further.

12. Inflammatory Bowel Disease – Ulcerative colitis, Crohn’s disease. They can present as abdominal pain(ie toxic megacolon, terminal ileitis). The pain in the right iliac fossa may also mimic appendicitis.

13. Infection of the bowel – eg Pseudomembranous colitis(often have diarrhoea, and is associated with prior antibiotics use and often in frail elderly hospitalized patients), Yersinia gastroenteritis(associated with diarrhoea and bleeding).

14. Cancer / Malignancy – This can occur in any abdominal organ. The common ones are colon cancer, stomach cancer, oesophageal cancer, liver cancer and pancreatic cancer. Generally cancer does not cause pain until it is quite advanced.

Sometimes though no cause of abdominal pain can be found despite numerous investigations.

It is important that one sees a doctor urgently especially if the pain is severe.