14 year old with RIF pain and mild tenderness but otherwise stable. Negative urine dipstick and febrile. Last menstrual period was 2 weeks ago and pregnancy test is negative. What is the most likely diagnosis?
Mittleschmerz
(Mid cycle pain following follicular cyst rupture sometimes with scanty bleeding which is irritating and mimics appendicitis)
Intussusception- Paediatric
- Telescoping of bowel produces mucosal ischaemia and bleeding may occur leading to redcurrant jelly stools.
- Recognised causes - Polyps, lymphadenopathy, cystic fibrosis, meckels diverticulum,
- Commonest variant is ileo-ileal(ileocaecal valve and terminal ilium). Other variant is ileo-colic.
- Diagnosis by USS
- Treatment
-Laparotomy for unstable cases, small bowel intussusception, impending perforation
-Pneumatic reduction under fluoroscopic guidance is the usual treatment for stable/well children.
Calot’s triangle
-Relevant in cholecystectomy.
-Cystohepatic triangle bordered by inferior surface of liver(superior), cystic duct(lateral), and common hepatic duct(medial)
-Contains cystic artery, right hepatic artery, cystic lymph node of Lund.
Eponymous Abdominal Signs
- Murphy’s sign - Cholecystitis (RUQ tenderness exacerbated by inspiration)
- Boas sign- Cholecystitis (right infra scapular hyper-aesthesia around 12th rib region)
- Rovsing’s sign - Appendicitis (increased RIF pain upon LIF palpation)
- Cullen’s sign - Pancreatitis/intra-abdominal haemorrhage (peri-umbilical ecchymosis)
- Grey Turner’s sign - Pancreatitis/retro-peritoneal haemorrhage (abdominal flank bruising)
Gynaecological causes of abdominal pain
- PID - Lower abdominal pain associated with vaginal discharge. Dysuria may be present.
RUQ pain + Fever >38 degrees =Fitz Hugh Curtis syndrome(disseminated chlamydia) - Mittleschmerz - Mid cycle pain(RIF/LIF). Often sharp onset. Recurrent. Settles after 24-48 hours.
- Endometriosis - 25% asymptomatic//25% associated with other pelvic organ pathology//50% may have menstrual irregularity, pain, and deep dyspareunia. Recurrent episodes are common.
- Ovarian torsion - Usually sudden onset, deep seated colicky abdominal pain. Associated with vomiting and distress. Vaginal exam may reveal adnexial tenderness.
- Ectopic gestation - Symptoms of pregnancy without intra-uterine gestation. Present as emergency with evidence of rupture or impending rupture.
Meckel’s diverticulum
-Congenital abnormality resulting in incomplete obliteration of vitello-intestinal duct (attachment to yolk sac should disappear by 6 weeks gestation)
-Tip is free in majority of cases. 2% of population//2 inches long//2 feet from ileocaecal valve.
-Typically lined by ileal mucosa but gastric mucosa can occur with risk of peptic ulceration. Jejunal or pancreatic mucosa can occur.
-Associated with enterocystomas, umbilical sinuses, and omphalo-ileal fistulas.
-Normally asymptomatic or incidental finding. Removal if symptomatic or narrow neck(wedge excision or formal small bowel resection and anastomosis)
-Complications are the result of obstruction, ectopic tissue, or inflammation.
Femoral canal
- It lies medial to the femoral sheath(fascial tunnel containing by the femoral artery and vein).
-It allows the femoral vein to expand to increase venous return from lower limbs.
-It contains lymphatic vessels and Cloquet’s lymph node.
- Borders of the femoral canal:
Lateral = femoral vein
Medial = lacunar ligament
Anterior = inguinal ligament
Posterior = pectineal ligament
-Potential space for femoral hernias with high risk of strangulation.
