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RIF pain…an unusual suspect

RIF pain…an unusual suspect. HS. 84 year old gentleman 7/52 history of right iliac fossa pain ‘Tightness’ at RIF Constant Non radiating Worse on hip flexion and movement No fevers/night sweats/rigors No nausea/vomiting/altered bowel habit. Past Medical History NIDDM MI – ’98

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RIF pain…an unusual suspect

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  1. RIF pain…an unusual suspect

  2. HS. • 84 year old gentleman • 7/52 history of right iliac fossa pain • ‘Tightness’ at RIF • Constant • Non radiating • Worse on hip flexion and movement • No fevers/night sweats/rigors • No nausea/vomiting/altered bowel habit

  3. Past Medical History NIDDM MI – ’98 Right inguinal hernia repair Vit B12 deficiency Medications Metformin Aspirin Atorvastatin History • Pantoprazole

  4. History • Social History • Non smoker • No C2H5OH • Family History • NIDDM • Systems review • NAD

  5. Examination • BP 118/66, PR 90, Temp 36.5, Sats 96% on RA • Abdomen soft • Tender at RIF • Guarding on deep palpation at RIF • No distension • Bowel sounds present and normal • DRE- NAD

  6. Bloods Hb 12.7 WBC 7.17 Neut 4.93 ESR 35 CRP 6 U&E normal LFTs normal Radiology PFA density projected over Right renal pelvis (7X5mm), ?renal calculus. Bowel within normal limits. CXR NAD Investigations

  7. Intra-operative • Laparoscopy • Laparoscopic mobilisation of ceacum • Findings: • hard appendiceal mass • Converted to laparotomy • Right hemicolectomy

  8. Histology • Diffuse large B cell lymphoma, appendix, germinal centre type • Margins and lymph nodes free.

  9. Post operative course • Wound infection • Oncology review • CT Thorax, abdomen, pelvis • Discharged on POD 17 with po Antibiotics • Follow up • 1/12 in our OPD • 3/12 in oncology OPD

  10. Appendiceal Tumours

  11. Background • Gastrointestinal tract • is the most frequently involved extranodal site of Non Hodgkins lymphoma (30-45%). • 4-20% of all Non Hodgkins lymphoma. • Incidence of primary lymphomas of appendix • estimated as 0.015% of all gastrointestinal lymphomas. • 1% of all appendectomy specimens contain a neoplasm.

  12. Presentation • Acute appendicitis • Weight loss • Anorexia • Palpable lower quadrant mass • Obstruction/constipation • Nausea/vomiting • Diagnosis- histological

  13. Investigation • History • similar to appendicitis. • Examination • tender RIF +/- mass • Bloods • Normal/Raised inflammatory markers • Radiology (pre op) • CXR/PFA – perforation/obstruction • CT ABDOMEN – mass • Histology • Radiology (post op) • CT TAP - mets

  14. Management • Early detection + high suspicion – essential. • Surgery • Appendectomy • +/- Right hemicolectomy • +/- lymph node dissection

  15. Types • Divided into 2 major groups • Carcinoid • occurs at tip of appendix. • Non-carcinoid • originate at the epithelial lining of appendix. • Produce a thick gelatinous material known as mucin.

  16. Carcinoid Most common form (>50% cases) F>M Occur in 4th decade of life. Symptoms similar to appendicitis. Carcinoid syndrome – flushing, SOB, diarrhea, Right sided heart valve disease. Tx- appendectomy + Right hemicolectomy + lymph node dissection. 85% 5-year survival rate.

  17. B cell lymphoma • non-Hodgkin's B-cell lymphoma • usually present in second to third decade of life. • Symptoms • Like appendicitis • Treatment • Appendectomy + Right hemicolectomy

  18. Adenocarcinoma • F=M • Occurs 6th decade of life • Rarer but more aggressive type. • Occur in the epithelial lining of the appendix – obstructive symptoms. • Symptoms • Abdominal pain, constipation, N+V. • Treatment • Appendectomy + right hemicolectomy. • Prognosis – poorer than carcinoid. • 5 yr survival. • Duke’s A – 94 • Duke’s B – 83% • Duke’s C – 44%

  19. Pseudomyxoma peritonei (PMP) • Presence of acellular mucin within abdominal cavity. • Usually has metastased at time of presentation. • Spread • direct • rarely through bloodstream or lymphatics. • Sypmtoms • Bowel obstruction • Increase in abdominal size • Pelvic discomfort • Ovarian masses • Treatment • debulking surgery.

  20. Summary • Appendicitis should be the top of your differential for anyone with RIF pain. • Appendiceal cancer is a rare (and usually an incidental) finding • Should be suspected in any elderly person presenting with appendicitis like symptoms and signs • Histology of ALL patients post appendectomy should be checked

  21. http://www.ajronline.org/cgi/content/full/178/5/1123 (histology pictures) • http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2008;volume=51;issue=3;spage=392;epage=394;aulast=Radha (indian case) • http://www.mdanderson.org/patient-and-cancer-information/cancer-information/cancer-types/appendix-cancer/index.html • www.medscape.com/viewarticle/431119_3 (normal CT appendix) • http://www.dmvsurgerycenter.com/Portals/0/gensurg.gif (surgery pic) • www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed.section.24834 (info on adenocarcinoma) • http://www.aboutcancer.com/appendix_cancer.htm (graph) • http://www.thedoctorsdoctor.com/diseases/appendix_adenoca.htm - Appendiceal tumors: retrospective clinicopathologic analysis of appendiceal tumors from 7,970 appendectomies. Connor SJ, Hanna GB, Frizelle FA

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