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RIF pain in the ED

read this first: abdominal pain in ED

right iliac fossa pain:

differential diagnosis:

initial Mx in ED:

  • urgent pregnancy test if not already known to be pregnant
    • if pregnant & significant iliac fossa tenderness, Mx as per suspected ectopic pregnancy:
      • ie. FBE, HCG, Gp & Hold, IV access (16G if severe pain), urgent US, senior consult
  • examine inguino-scrotal region to exclude hernia/testicular torsion
    • if child with very tender testes, contact paed. surgeon ASAP (within minutes)
    • if adult with tender testes, consider US & epididymo-orchitis vs testes torsion (young adults mainly)
      • if epididymo-orchitis then decide whether most likely UTI-based or STD-based as this will decide choice of anti's (see antibiotic guidelines online).
  • FWT urine:
    • if microhaematuria only (BUT absence of microhaematuria does not exclude renal colic), suspect renal colic if Hx fits
      • don't do a KUB Xray (these are only really useful for ongoing monitoring of radio-opaque calculi)
      • consider CT-KUB that day or next day IF pain not settling - avoid unnecessary CT scans, particularly if clinical picture is clear and pain settling
      • consider admission to SSU for pain control
    • US is usually preferred imaging modality unless elderly or obese and not pregnant and not a child, in which case contrast CT scan may be considered.
  • if paediatric, blood tests not usually needed, consider US if female over age 8-10yrs
  • if adult then:
    • FBE + HCG if female aged 13-50yrs.
    • if possible pelvic inflammatory disease (PID) (usually gradual onset pain) then Cx swabs for Chlamydia PCR & m/c/s
    • if possible ovarian cyst or torsion of ovary (usually sudden onset pain) then pelvic US
    • if it seems more likely to be appendicitis, contact surg. reg
      • pain initially epigastric and migrated to RIF with anorexia, nausea +/- low grade fever
      • max. tenderness over McBurney's point
      • +/- Rovsing's sign - rebound tenderness LIF
      • +/- psoas sign (pain on passive extension of the right hip) - esp. likely in retrocaecal appendicitis
      • +/- obturator sign (pain on passive internal rotation of the flexed right thigh) - esp. pelvic appendicitis
      • remember, pelvic appendicitis may have few abdo signs and present with diarrhoea
    • if more likely to by gynae and pain not settling then contact O&G reg.
  • if age > 50yrs, consider diverticulitis:
    • suspect if change in bowel habit, tenesmus, esp. if fever but remember WCC only raised in 36%
    • consider CT abdomen with contrast but check renal function first and ensure not on metformin before using iv contrast
  • if sudden severe lower abdo. pain, becoming generalised with toxicity/peritonitis consider erect CXR to exclude perforated bowel secondary to diverticulitis
  • if working Dx is diverticulitis, then Amoxyl + Flagyl, liquid diet for 48hrs, if more than mild, will need admission.
  • if female and post-partum or post gynae surgery then consider pelvic vein thrombosis:
    • pelvic color doppler US +/- CT abdomen
abdopain_rif.txt · Last modified: 2022/05/24 08:01 by gary1

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