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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 20  |  Issue : 1  |  Page : 94-96

Unusual case of right iliac fossa pain: A case report


Center for Obesity and Digestive Surgery, Gamdevi, Mumbai, Institute of Minimal Access Surgical Sciences and Research Center, Saifee Hospital, Mumbai, Maharashtra, India

Date of Web Publication19-Feb-2015

Correspondence Address:
Aditi Agrawal
Centre for Obesity and Diabetes Surgery, Shiv Tapi Bldg, Ground Floor, End of French Bridge, Opposite Metro Motors (Mercedes Benz), Hughes Road, Mumbai - 400 007, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.151742

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  Abstract 

Right iliac fossa pain does not always mean acute appendicitis even though it is the most common etiology. We report a rare case where on clinical grounds patient was diagnosed to have acute appendicitis which on diagnostic laparoscopy turned out to be gangrenous small bowel secondary to a band causing constriction and compression.

Keywords: Appendicitis, congenital band, intestinal obstruction


How to cite this article:
Agrawal A, Govil A, Lakdawala M. Unusual case of right iliac fossa pain: A case report. J Mahatma Gandhi Inst Med Sci 2015;20:94-6

How to cite this URL:
Agrawal A, Govil A, Lakdawala M. Unusual case of right iliac fossa pain: A case report. J Mahatma Gandhi Inst Med Sci [serial online] 2015 [cited 2019 Jul 20];20:94-6. Available from: http://www.jmgims.co.in/text.asp?2015/20/1/94/151742


  Introduction Top


Right iliac fossa pain is a common surgical problem. The most common cause of pain in the right iliac fossa is acute appendicitis. Other causes could be right ovarian torsion, hemorrhage within right ovarian cyst, right ureteric colic or amoebic colitis etc.

A correct diagnosis can usually be made by a combination of accurate history and examination along with specific investigations. The diagnosis is straightforward most of the times. Occasionally, right iliac fossa pain can present as a diagnostic dilemma to the clinician.

Here, we report a case of right iliac fossa pain with acute intestinal obstruction. Diagnostic laparoscopy revealed a gangrenous ileal loop secondary to torsion over a fibrous band located in the right iliac fossa.


  Case Report Top


A 65-year-old male was referred to our center from another hospital with a 48-hour history of sudden onset, progressively increasing pain in the right iliac fossa accompanied with fever and two episodes of vomiting. He gave no history of surgery or similar episodes of pain. His hemogram revealed a white cell count of 16,000/dl and the ultrasound revealed dilated small bowel loops with probe tenderness and fat stranding in the region of the appendix. The contrast enhanced CT- scan of the abdomen showed fat stranding with arrow sign suggestive of acute appendicitis. He was recommended an exploratory laparotomy for acute appendicitis. The patient requested for a transfer to our facility which specializes in minimal access surgery.

When the patient presented to us, he had a pulse rate of 120/min and temperature of 38.6°C. The abdomen was distended with rebound tenderness, guarding and rigidity in right iliac fossa. On auscultation tingling peristaltic sounds were heard. There were no visible scars on the abdomen. A plain X-ray abdomen [Figure 1] showed centrally dilated small intestinal loops with multiple air fluid levels but no free gas under the diaphragm.
Figure 1: Plain abdominal radiograph showing multiple air fluid levels

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In view of persistent tachycardia, pain and an increasing WBC count (it was 20,000 at our facility), we proceeded with a diagnostic laparoscopy which revealed 50 cm of gangrenous, dilated ileum loop due to twisting and torsion across a fibrous band in the right iliac fossa [Figure 2]. The band extended from the lateral peritoneal wall to the base of the small bowel mesentry was divided and the gangrenous loop untwisted [Figure 3]. The gangrenous segment started 100 cm proximal to the Ileocecal junction. Despite warm saline lavage and 100% oxygen the bowel remained unchanged; hence, a laparoscopic resection of the ileal loop with a stapled side-to-side ileoileal anastomosis was done. Saline lavage was performed and a drain was placed in the right paracolic gutter. The patient had an uneventful post-operative course.
Figure 2: Gangrenous jejunal loop in the right iliac fossa

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Figure 3: Obstructive mesodiverticular band around the jejunum

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  Discussion Top


Varying degrees of intestinal obstruction are known to occur with acute appendicitis. [4],[5],[6],[7] In such cases the obstruction is either due to paralytic ileus, perforation or mechanical obstruction. Most frequently the inflammed appendix lies across the dilated ileum leading to obstruction.

Intestinal obstruction secondary to a band in the right iliac fossa mimicking acute appendicitis is a comparatively rare condition. Presence of bands without previous laparotomy and intraperitoneal inflammation are even rarer and is usually attributed to be congenital in nature. Touloukian was the first to describe congenital bands causing small bowel obstruction. [1] They are said to cause 3% of all intestinal obstruction and almost always lead to small bowel obstruction. [2] In adults they are rare and do not have any embryological or acquired basis. [3] Patients usually present with symptomatology mimicking acute appendicitis with or without features of intestinal obstruction and/or gangrene as in our case. Persistently increasing pain and high WBC counts despite conservative treatment warrant an early intervention to prevent gangrene. Obstructive symptoms are usually relieved with simple band excision alone in early cases.

A band is usually difficult to diagnose and cannot be detected by currently available radiological investigations. Plain radiographs of the abdomen can at best show multiple air fluid levels with dilated intestinal loops. Ultrasound and CT abdomen usually reveal dilated intestinal loops/fat stranding and/or an intra abdominal collection but fail to show any hard evidence of a band.

Pain in right iliac fossa with intestinal obstruction should be viewed with high suspicion and pathology other than acute appendicitis must be considered during evaluation. An early diagnostic laparoscopy with timely intervention is the best bet for such cases and may prove instrumental in the prevention of vascular compromise and gangrene in severe cases.

 
  References Top

1.
Ablow RC, Hoffer FA, Seashore JH, Touloukian RJ. Z-shaped duodenojejunal loop: Sign of mesenteric fixation anomaly and congenital bands. AJR Am J Roentgenol 1983;141:461-4.  Back to cited text no. 1
[PUBMED]    
2.
Perry JF, Smith A, Yonehiro EG. Intestinal obstruction caused by adhesions; a review of 388 cases. Ann Surg 1955;142:810-6.  Back to cited text no. 2
    
3.
Kumar A, Ramkrishnan TS, Sahu S. Large bowel obstruction by anomalous congenital band. MJAFI 2009;65;378-9.  Back to cited text no. 3
    
4.
Assenza M, Ricci G, Bartolucci P, Modini C. Mechanical small bowel obstruction due to an inflamed appendix wrapping around the last loop of ileum. G Chir 2005;26:261-6.  Back to cited text no. 4
    
5.
Harris S, Rudolf L. Mechanical small bowel obstruction due to acute appendicitis. Ann Surg 1966;164:157-61.  Back to cited text no. 5
    
6.
Gupta S, Vaidya M. Mechanical small bowel obstruction caused by acute appendicitis. Am Surg 1969;35:670-4.  Back to cited text no. 6
    
7.
Bose S, Talwar B. Appendicitis causing acute intestinal obstruction with strangulation. Aust N Z J Surg 1973;43:56-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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