International Journal of Health & Allied Sciences

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 8  |  Issue : 1  |  Page : 33--37

Pelvic ultrasonographic findings in patients with acute right iliac fossa pain


Moawada Burai1, Moawia Bushra Gameraddin2, Ali Suliman1, Awadia Gareeballah1, Fathelrehman Alagab2, Maisa Elzaki1,  
1 Department of Diagnostic Radiology, Faculty of Radiological Sciences and Medical Imaging, Al Zaiem Alazhari University, Khartoum, Sudan
2 Department of Radiology, Faculty of Applied Medical Sciences, Taibah University, Al-Munawarah, Al-Madinah, Kingdom of Saudi Arabia

Correspondence Address:
Dr. Moawia Bushra Gameraddin
Department of Radiology, Faculty of Applied Medical Sciences, Taibah University, Al-Munawarah, Al-Madinah
Kingdom of Saudi Arabia

Abstract

BACKGROUND: Pain in the right iliac fossa (RIF) is considered the most common presentation of the patients in the emergency department (ED). OBJECTIVE: The objective of this study was to assess various etiologies of acute pain in the RIF using ultrasonography. MATERIALS AND METHODS: This was a cross-sectional study conducted in Khartoum North Teaching Hospital and Alrebat University Hospital from January 2016 to July 2016. A total of 100 patients presented to the ED with acute pain in the RIF. The patients were investigated with ultrasound (US) using 3.5- and 5-MHz transducers. The exclusion criteria included chronic illness, known cancer, and women in late pregnancy. RESULTS: A total of 100 cases who presented with pain in the RIF had been examined clinically and sonographically. A number of 26 cases (26%) showed no findings, whereas 19% were with appendicitis, ovarian cysts represented 17%, right lower ureteric stone represented 16%, and pelvic inflammatory disease represented 12%. Gender and age were the significant factors affecting the distribution of diseases that cause pain in the RIF (P = 0.04). CONCLUSION: In addition to appendicitis, there were a variety of abnormalities that cause pain in the RIF. Ovarian cysts and lower ureteric stone were the most etiologies of pain in the RIF following appendicitis. US of the pelvis is essential before proceeding with any surgery for acute pain in the RIF, especially in young women.



How to cite this article:
Burai M, Gameraddin MB, Suliman A, Gareeballah A, Alagab F, Elzaki M. Pelvic ultrasonographic findings in patients with acute right iliac fossa pain.Int J Health Allied Sci 2019;8:33-37


How to cite this URL:
Burai M, Gameraddin MB, Suliman A, Gareeballah A, Alagab F, Elzaki M. Pelvic ultrasonographic findings in patients with acute right iliac fossa pain. Int J Health Allied Sci [serial online] 2019 [cited 2019 May 22 ];8:33-37
Available from: http://www.ijhas.in/text.asp?2019/8/1/33/252453


Full Text



 Introduction



Pain in the right iliac fossa (RIF) is considered one of the most common manifestations of the patients who referred to the emergency department (ED).[1] The differential diagnosis of the patients presenting with acute pain in the RIF is not always correct, and some pathologies may be responsible for pain in this region. However, the first diagnosis to be considered is acute appendicitis, which is undoubtedly the most common finding referred to a surgical emergency.[2] However, there are many etiologies of RIF pain that the ultrasound (US) is capable of demonstrating such as lower ureteric stone, appendicitis, pelvic inflammatory disease (PID), and ruptured ectopic pregnancy. Acute RIF pain is one of the most common surgical presentations. The presentation is often nonspecific and includes a wide differential, which creates a diagnostic challenge.[3]

US plays an effective role in the evaluation of several pathologies that cause pain in the RIF. It is sensitive, accurate, safety, noninvasive imaging modality that has biological effects. In this study, US is used to evaluate a variety of pathologies that cause pain in the RIF. In the diagnosis of acute appendicitis, the sensitivity of US varies between studies and reaches 98% to 100%.[4],[5] In previous studies, appendicitis was reported to be the most common disease that causes pain in the RIF. In our study, we found appendicitis is not the only etiology of pain in the RIF. Ovarian cysts and lower ureteric stone were also common findings which cause pain in the RIF. However, in acute appendicitis, 10% of the patients' symptoms and signs subside spontaneously 12–48 h after the onset and then reappear later on.[6],[7] The sonographic features of acute appendicitis are the visualization of a peristaltic, thick-walled, blind-ending, tubular structure with a diameter >6 mm with compression.[3] Another cause of pain in the RIF is ovarian cysts. The cause of pain is due to hemorrhage or rupture.[8] Hemorrhagic cysts appear as avascular complex cystic lesions, with a thin wall, fluid-detritus levels with hyperechogenic areas about coagulated blood.[8] The study demonstrated various pathologies in the RIF with different sonographic features in correlation with age and gender.

Most of the previous reports demonstrated appendicitis as the most common finding that causes pain in the RIF without focusing on other causes that contribute to causing pain in the RIF. Therefore, the study aims to determine a variety of abnormalities that cause pain in the RIF using US. This study is very useful for clinicians and surgeons in differential diagnosis since there is a long list of medical and surgical problems involving the RIF.

 Materials and Methods



This was an observational cross-sectional study. A total of 100 patients with pain in the RIF who presented to the ED participated in the study. They were investigated with US using a 3.5 MHz probe. Clinical examination was done by clinicians and surgeons. The patients were 41 male and 59 female. The mean age was 29 ± 8 years. The demographic data were collected from the patients' records. The study was conducted in the Khartoum State of Sudan at Khartoum Teaching Hospital and Alrebat University Hospital from the period of January 2016 to July 2016. The exclusion criteria included patients with a history of cancer, previous pelvic surgery, and women in late pregnancy. Informed consent was obtained from the patients to participate in the study. The study was approved by the Institute Ethical Committee.

Sonographic procedure

Pelvic US was performed using Sonyance (model A5, China /2013) and Toshiba (Model: xario XG, Japan/2008) equipped with 3.5-MHz (convex array) and 5-MHz transducers (endocavitary and linear probes). Patients were investigated in the supine position with the transducer placed on the suprapubic region in both transverse and longitudinal planes. The pelvis was scanned in the parasagittal scan plane and then transversally to evaluate the ovaries and appendix and to explore the lower right ureter for stones.

Statistical analysis

The data were analyzed using SPSS for Windows (Version 16.0. Chicago, SPSS Inc., USA). Data were presented as means and percentage. Spearman test was used to make a correlation between gender and age with sonographic findings in the RIF. P< 0.05 was considered statistically significant.

 Results



A total of 100 patients with pain in the RIF who presented to the ED were evaluated by this study. The mean of patients was 29 ± 8.4 years. They were 41 male and 59 female [Figure 1]. The age distribution of the participants and sonographic findings is shown in [Table 1]. It was observed that appendicitis was common in the age group of <20 years, whereas ovarian cysts were common in age groups of 20–29 years and 30–39 years. The patients were investigated with US machines with transducers of 3.5 MHz and 5 MHz. The type and frequency of transducers are shown in [Table 2]. The sonographic finds of the RIF are demonstrated in [Table 3]. It was noted that 26% of the patients who came with RIF pain showed negative results and no sonographic findings. The incidence of appendicitis was slightly higher than ovarian cysts and lower ureteric stone; appendicitis (19%), ovarian cysts (17%), and lower right ureteric stone (16%). The incidence of PID was 12%. [Figure 2] and [Figure 3] are sonograms selected from the cases of the study demonstrating the sonographic features of appendicitis. [Figure 4] reveals a transvaginal sonogram demonstrating hemorrhaging cyst in a 22-year-old female with right lower abdominal pain.{Figure 1}{Table 1}{Table 2}{Table 3}{Figure 2}{Figure 3}{Figure 4}

There was a significant statistical association between age and gender with the sonographic findings, P = 0.04 for each [Table 4]. This indicates that age and gender were significant risk factors of pathologies affecting the RIF.{Table 4}

 Discussion



Acute pain localized in the RIF is the central point that meets between general surgeons, gastroenterologists, urologists, nephrologists, gynecologists, and internists.[9] RIF pain is commonly diagnosed as appendicitis. In this study, we demonstrated a variety of pathologies that cause pain in the RIF in the ED.

In the present study, we found appendicitis as the most common cause of pain in patients attending the ED. In previous reports, appendicitis was considered to be the most common surgical emergency.[2] Our finding was consistent with Bhutta et al.,[10] who demonstrated the role of high resolution in the diagnosis of acute appendicitis.

The current study revealed that ovarian cysts were the second cause of RIF pain. Although appendicitis is more frequent than ovarian cysts, the difference is 2% (19% vs. 17%, respectively). However, acute pelvic pain in women is the primary reason for ED admission. It was observed that 17% of RIF fossa pain was diagnosed with ovarian cysts. Page et al.[11] reported that gynecological causes of acute pain were adnexal torsion, ectopic pregnancy, and hemorrhagic ovarian cyst rupture. This finding is consistent with our study; this study reported that ovarian cysts were the most common frequent cause of pain in women. However, appendicitis is misdiagnosed in 33% of nonpregnant women in the reproductive age. The most frequent misdiagnoses are PID, followed by gastroenteritis and urinary tract infection.[12] In these cases, US is important and accurate for differential diagnosis. The US differentiates ovarian cysts from appendicitis. Therefore, it is the first line to investigate young women' pelvis to confirm the diagnosis.

In the present study, it was observed that lower ureteric stone and PID were the third and fourth etiologies of RIF pain, respectively. Moodi reported that the incidence of the lower ureteric stone was 16%.[13] These results agree with our findings. All these findings supported the fact that various etiologies caused RIF pain and were not attributed to appendicitis only.

The present study revealed that there was a statistically significant correlation of sonographic findings of the RIF with age and gender of the patients. This indicates that the incidence of appendicitis, ovarian cysts, PID, and right lower ureteric stones varies with age and gender. Salö et al.[14] studied appendicitis in children from a gender perspective. They reported that there are some gender differences in children with appendicitis. This supported that incidence in appendicitis is different between boys and girls. This result agreed with our finding that supported gender as a significant factor for the prevalence of RIF pain. On the hand, age was another significant predictor factor associated with etiologies of RIF pain. In this study, it was observed that the incidence of appendicitis was common in the age group of 20–29 years. This is consistent with Ceresoli et al. who studied the epidemiology of acute appendicitis and reported that the mean age was 24.51 ± 16.17 years.[15]

Regarding the other causes of RIF pain, it was observed that the incidence of ovarian cysts was common in the age groups of 20–29 years and 30–39 years. Jone reported that the prevalence of ovarian cysts was common in the age group of 38 years.[16] This result agrees with our finding that the majority of ovarian cysts affect women in the age group 20–39 years old. All these findings supported that age and gender were significant factors affect the incidence of pathologies that cause RIF pain.

 Conclusion



A variety of gastrointestinal, urological, and gynecological pathologies can present as acute pain in the RIF. Hence, US of the pelvis is mandatory before proceeding for any surgery for severe pain at RIF. Gender and age are considered to be significant factors when assessing RIF pan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Williams N. Peritoneal aspiration cytology as a diagnostic aid in acute appendicitis. Br J Surg 1994;81:1083-4.
2Primatesta P, Goldacre MJ. Appendicectomy for acute appendicitis and for other conditions: An epidemiological study. Int J Epidemiol 1994;23:155-60.
3White EK, MacDonald L, Johnson G, Rudralingham V. Seeing past the appendix: The role of ultrasound in right iliac fossa pain. Ultrasound 2014;22:104-12.
4Rybkin AV, Thoeni RF. Current concepts in imaging of appendicitis. Radiol Clin North Am 2007;45:411-22, vii.
5Del Cura JL, Oleaga L, Grande D, Farina MA, Isusi M. Comparison of ultrasonography and computed tomography in the diagnosis of acute appendicitis. Radiología 2001;43:175-86.
6Puylaert JB. Ultrasonography of the acute abdomen: Gastrointestinal conditions. Radiol Clin North Am 2003;41:1227-42, vii.
7Cobben LP, de Van Otterloo AM, Puylaert JB. Spontaneously resolving appendicitis: Frequency and natural history in 60 patients. Radiology 2000;215:349-52.
8Quillin SP, Siegel MJ. Color Doppler US of children with acute lower abdominal pain. Radiographics 1993;13:1281-93.
9Florin S, Bogdan M, Cristian C. Right iliac fossa pain syndrome. Genico 2014;10:48-9. Available from: http://www.gineco.eu/system/revista/25/48-49.pdf. [Last accessed on 2017 Jun 08].
10Bhutta A, Nawaz F, Mustafa J. The role of high resolution ultrasonography in the diagnosis of acute appendicitis. Rawal Med Coll 2004;8:87-9.
11Pages-Bouic E, Millet I, Curros-Doyon F, Faget C, Fontaine M, Taourel P, et al. Acute pelvic pain in females in septic and aseptic contexts. Diagn Interv Imaging 2015;96:985-95.
12Craig S. Appendicitis Differential Diagnoses. Drugs & Diseases > Emergency Medicine. Available from: http://www.emedicine.medscape.com/article/773895-differential. [Last accessed on 2017 Aug 19].
13Modi BJ. A study of causes of right Iliac fossa pain with comparison of operative vs conservative management. Int J Med Health 2015;1:22-4..
14Salö M, Ohlsson B, Arnbjörnsson E, Stenström P. Appendicitis in children from a gender perspective. Pediatr Surg Int 2015;31:845-53.
15Ceresoli M, Zucchi A, Allievi N, Harbi A, Pisano M, Montori G, et al. Acute appendicitis: Epidemiology, treatment and outcomes – Analysis of 16544 consecutive cases. World J Gastrointest Surg 2016;8:693-9.
16Jones KD. The prevalence and age distribution of ovarian cysts among women attending a London teaching hospital. J Obstet Gynaecol 2001;21:70-1.