A 20 yr female with 2 months amenrrohea came to casuality with severe pain in left iliac fosa, no history of fever and vomiting . What is probable diagnosis?
Answers
Left iliac fossa (LIF) pain may occur due to a self-limiting condition but may also be a sign of a medical/surgical emergency. It is less common than right iliac fossa (RIF) pain. The two share a considerable number of differential diagnoses but some conditions are more likely, or only likely, on one side. LIF pain is common in and tends to affect an older population more than RIF pain.
Parietal pain occurs when there is noxious stimulation of the parietal peritoneum because of ischaemia, inflammation or stretching. It is sharp, intense, discrete, localised and aggravated by coughing/movement.
Visceral pain occurs when noxious stimuli affect a viscus. Hindgut structures (eg, large intestine) cause lower abdominal pain.
Referred pain is pain felt in remote areas supplied by the same dermatome as the diseased organ.
Causes of acute LIF pain
Gastrointestinal causes
Gastroenteritis: however, this commonly causes more generalised abdominal pain. It is the most common cause of abdominal pain in children with viral causes being most frequent. Care should be taken as gastroenteritis specifically causing LIF pain should be a diagnosis of exclusion.
Constipation: acute constipation usually has an organic cause (eg, gastroenteritis). Again, it should be a diagnosis of exclusion.
Diverticulitis: the majority of diverticular disease involves the sigmoid colon and therefore diverticulitis most commonly presents with LIF pain.
Volvulus: sigmoid volvulus is the most common type of colonic volvulus. It can lead to large bowel obstruction and can have an insidious onset in elderly patients.
Left inguinal/femoral hernia: an incarcerated left inguinal or femoral hernia may present as LIF pain. There will be tenderness and an irreducible swelling over the hernial orifice, and symptoms and signs of bowel obstruction. Cough impulse is lost if hernia is incarcerated. Requires urgent surgical referral.
Appendicitis: rarely, this can present as LIF pain, particularly in patients with redundant and loosely attached caecum.
Gynaecological causes
Ectopic pregnancy in the left Fallopian tube: pain rather than vaginal bleeding is the prominent feature. If in doubt, admit. When rupture occurs bleeding is profuse and two or three litres can be lost in a short space of time with consequent hypovolaemic shock.
Threatened or complete miscarriage: if a pregnancy test is positive and there is a history of bleeding, always refer for an ultrasound scan to exclude an abortion. If there is associated pain, an ectopic pregnancy needs excluding by immediate referral to secondary care.
Causes of LIF pain in later pregnancy: premature labour, placental abruption, uterine rupture.
Pelvic inflammatory disease (PID)/salpingitis/pelvic abscess: typically, vaginal discharge is present. More common if there have been multiple sexual partners, or a history of PID and if an intrauterine device is in situ.
Mittelschmerz (ovulation pain): this is a sudden onset of mid-cycle pain.
Ovarian torsion: this usually happens when an ovary is enlarged by a cyst. Diagnosis can be difficult. There may be adnexal tenderness. Ultrasound scan may show the abnormal ovary.
Fibroid degeneration.
Pelvic tumour.
Other causes
Abdominal aortic aneurysm: this can present with atypical symptoms resembling renal colic or diverticular disease rather than the classic back or flank pain. Do not forget this differential diagnosis. Look for a pulsatile abdominal mass. Many patients with a ruptured abdominal aortic aneurysm are misdiagnosed initially.
Situs inversus: here, the differential diagnosis for LIF pain is that for RIF pain. Only half of those with dextrocardia have total situs inversus.
Herpes zoster: usually a characteristic rash. Before the rash appears the skin can be tender.
Pelvic vein thrombosis.