Analytical Study of Right Iliac Fossa Masses Clinical Features and Management

INTRODUCTION: Right Iliac Fossa Mass is quite commom in our part of country. The mass has varied origin and requires versatility in its management. This is because the mass may range from benign to most aggressively malignant lesion and touch upon various specialities of surgery, like genitourinary surgery, vascular surgery, gynecological surgery, and colorectal surgery. Hence a detailed study of the variouscauses of Right Iliac Fossa Mass will help in analyzing the different types of presentation and the management. Right Iliac Fossa Mass has 8 anatomical entities, and six other organs in the neighbourhood whose pathology may extend into this region. Right Iliac Fossa region has Appendix, Cecum, Terminal Ileum, Lymphnodes, Iliac artery and vein, Retroperitoneal connective tissues, Iliopsoas muscle, and Iliac bone. Neighbouring organs and their pathologies which might extend into this region are Kidney, Gallbladder, Uterus, Urinary Bladder, Testis, and Pelvic abcess. Hence, this study has been initiated with a view to analyse: 1. Incidence of different types of Right iliac fossa masses. 2. Variable clinical presentstion and investications most helpful for each case. AIMS OF THE STUDY: 1. To evaluate a) The incidence of various causes of Right iliac fossa masses and the commonest causes. b) Various modes of presentations of Right iliac fossa masses. c) Most helpful investigations for aiding in diagnosis of Right iliac fossa masses. 2. To determine the management of right fossa masses whether by emergency surgery or by conservative measures. MATERIALS AND METHODS: Over a period of time from 2004 to 2006 all the patients admitted in the surgical wards were examined and patients who had a lump in the right iliac fossa were grouped for the study. In this study total of fifty patients were taken up for study over the previous two and half years duration. pediatric cases were not included in this study group. Routine thorough history was elicited, and detailed clinical examination was performed. Routine hematological and biochemical investigations were done. Radiological examinations, X-rays chest PA view was taken to all patients, along with X-ray abdomen plain view for correlation and contribution to the diagnosis. Specific investigations were also performed, considering the merits of the individual case. USG – abdomen was performed for all cases. Depending on the requirement of individual case presentation Barium meal series or Barium Enema evaluation was performed. Colonoscopy was not done as this facility was not available at this centre. CT Scan abdomen contrast study also done. CONCLUSION: 1. Appendicular mass is the commonest of all right iliac fossa masses, 46%, followed by ileocecal TB,Ca.cecum, ovarian cyst. The frequency of unusual cases is difficult to assess in a small study like this. 2. In younger age group, inflammatory masses like appendicular mass, iliocecal TB predominate and ovary mass in young females is an important cause of right iliac fossa mass. Ca.cecum and appendicular abscess are more common in the older age group. 3. USG abdomen as a preliminary investigation in the right iliac fossa masses has been found to be useful in deciding further investigations and planning management. 4. Appendicular mass presents with short duration of pain. In about 20% of patients consevative treatment has to be abondened in favour of surgical intervention. 5. Ileocecal TB is more common in males in this small study. Barium enema is the investigation of choice for patients with chronic symtoms. about 45% of cases of ileocecal TB presented acutely and needed emergency laparatomy for diagnosis and treatment. 6. Ca.Cecum fecal occult blood loss and weight loss are almost and always present. 7. A complicated ovarian cyst should be always thought of in young females, with acute abdominal pain and right iliac fossa mass

Ileal neuroendocrine tumor in a patient with sclerosing mesenteritis: Which came first?

Objective: Unusual clinical courseBackground: Jejunoileal neuroendocrine tumors (JI-NETs) are rare tumors that can be associated with mesenteric fibrosis. This case report is of an incidental finding of a JI-NET in a patient who was previously misdiagnosed with sclerosing mesenteritis.Case Report: A 42-year-old man was admitted to our institution with diffuse abdominal pain and clinical and radiographic signs of bowel obstruction. He had a previous diagnosis of sclerosing mesenteritis, which had been histologically diagnosed after an exploratory laparoscopy performed in 2009 for recurrent acute abdominal pain. He was also annually monitored through computed tomography scans for an incidentally discovered, gradually enlarging mesenteric mass for which a "wait and watch" management approach was adopted. After a period of fasting and observation, the patient underwent an urgent exploratory laparotomy because of his worsening condition. Intraoperatively, an ileocecal resection was performed, along with excision of the known mesenteric mass. The pathology report revealed an ileal NET with nodal metastases within the mesentery and mesenteric tumor deposits (pT3N1).Conclusions: JI-NETs are rare entities, which are usually encountered as incidental findings or in patients with unspecific abdominal pain. Our case represents a probable delayed diagnosis of JI-NET in the context of sclerosing mesenteritis; therefore, a possible association between these 2 conditions should be investigated

Schwannoma extending from the umbilical region to the mid-thigh, compressing the major vessels of the right leg: A case report and review of the literature

Schwannomas are benign, usually encapsulated, nerve sheath tumours derived from Schwann cells. They commonly arise from the cranial nerves as acoustic  schwannomas and are extremely rare in the pelvis and retroperitoneal area (<0.5% of reported cases) unless they are combined with Von Recklinghausen disease (type 1 neurofibromatosis). We report the case of a 23-year-old woman with a mass extending from the umbilical region in the abdomen to the upper two-thirds of the thigh. As this tumour is so rare, and in order to ensure optimal treatment and survival for our patient, a computed tomography-guided biopsy was performed before en bloc tumour excision. Because of the possibility of malignancy, complete excision of the mass was performed, with pelvic blunt dissection. Histological examination showed a benign neoplasm, originating from the cells of peripheral nerve sheaths; the diagnosis was a schwannoma. Abdominal schwannomas are rare neoplasms that can be misdiagnosed. Laparoscopy is a safe and efficient option for approaching benign pelvic tumours and may offer the advantage of better visualisation of structures owing to the magnification in laparoscopic view, especially in narrow anatomical spaces. However, in our case laparoscopy was not considered owing to the size and anatomical location of the tumour

Huge adenomyotic cyst in pregnancy

Adenomyotic cyst is a rare variant of adenomyosis. It is believed to arise from repeated focal haemorrhages resulting in cystic spaces filled with altered blood products. We present a rare case of a huge adenomyotic cyst in a 27-year-old primigravida, who was in her first trimester, complaining of sudden lower abdominal pain. Diagnostic laparoscopy performed to rule out other cause of acute abdomen. Her pregnancy went on smoothly. She delivered a baby girl of 2.82 kg via vaginal delivery at 39 weeks. Diagnosis and management of this rare clinical entity were reviewed and discussed

UWOMJ Volume 25, Number 4, November 1955

Schulich School of Medicine & Dentistryhttps://ir.lib.uwo.ca/uwomj/1169/thumbnail.jp

Ovarian juvenile granulosa cell tumors with Ollier’s disease in children with IDH1 gene somatic mutation

ObjectiveThe aim of this study was to explore the symptoms, treatment, and pathogenesis of ovarian juvenile granulosa cell tumors with Ollier’s disease in children.MethodsFrom October 2019 to October 2020, clinical data were retrospectively analyzed for one case of ovarian juvenile granulosa cell tumors with Ollier’s disease. Whole-exome sequencing and Sanger sequencing were used to detect gene mutation in ovarian tumor and chondroma tissue. NADP-dependent isocitrate dehydrogenase-1 (IDH1) and S6 ribosomal protein expression levels in cells transfected with wild-type or mutant plasmid were analyzed by Western blot.ResultsThe 4-year-old female showed multiple skeletal deformities, bilateral breast development with chromatosis, and vulvar discharge. Sex hormone assay suggested that estradiol and prolactin were elevated, and the x-ray of limbs suggested enchondroma. Pelvic ultrasound and abdominal CT revealed a right ovarian solid mass. Pathologic examination of the right ovarian solid mass showed a juvenile granulosa cell type. A c.394C>T (p. Arg132Cys) mutation of the IDH1 gene was detected in both the ovarian juvenile granulosa cell tumors and enchondroma. Transfection of HeLa cells with either WT or Mut plasmid caused 4.46- or 3.77-fold overexpression of IDH1 gene compared to non-transfected control cells, respectively. R132C mutation inhibited the phosphorylation of S6 ribosomal protein, which is central to the mTOR pathway. Postoperatively, estradiol and prolactin levels fell to values normal for her age and bilateral breast gradual retraction.ConclusionThe incidence of ovarian juvenile granulosa cell tumors with Ollier’s disease in children may be caused by generalized mesodermal dysplasia; IDH1 gene mutation may play a facilitated role in this process. Surgical operation is the main treatment. We suggest that patients with ovarian juvenile granulosa cell tumors and Ollier’s disease should undergo regular investigation

Various Clinical Entities Presenting as Intraabdominal Right Iliac Fossa Mass: A Comparison of the Sensitivities of the Clinical, Radiological and Histopathological Diagnoses

INTRODUCTION: There are many abdominal conditions that present clinically as palpable lumps in the abdomen. The site and clinical characteristics of the lump as elicited by examination helps to get a diagnosis in most of these cases. However many require investigations like imaging to confirm clinical clues and some will need intra operative/pathological analysis for a definitive diagnosis. The abdomen is traditionally divided into 9 regions for description by 2 vertical and horizontal lines. The 2 vertical lines are extensions of the midclavicular lines and extend to the midinguinal points. The upper horizontal line is a transpyloric line passing midway between the umbilicus and the xiphisternum. The lower transtubercular line connects the 2 of the tubercles of iliac crest. The 9 regions are; 1. Right hypochondrium, 2. epigastrium, 3. Left hypochondrium, 4. Right lumbar, 5. Umbilical region, 6. Left Lumbar, 7. Right Iliac Fossa, 8. Hypogastrium, 9. Left iliac fossa. The anatomic structures occupying the right iliac fossa are the caecum, appendix, the terminal ileum. Retroperitoneally the iliac vessels, right ureter, lymphnodes, psoas muscle are situated. Pathologically enlarged ovaries, uterus, cysts can come to lie in the right iliac fossa. The common pathologic conditions giving rise to a palpable lump in the right iliac fossa are; 1. Appendicular mass, 2. Carcinoma of the Caecum, 3. Ileocecal Tuberculosis, 4. Psoas abscesses, 5. Intussuceptions, 6. Ovarian tumors. This dissertation aims to know the clues in the patient history and findings on examination that will help to arrive at a particular clinical diagnosis and then compare the sensitivity of the clinical diagnosis with diagnosis at imaging. The accuracy of clinical diagnosis and imaging diagnosis is then compared with intra operative and histopathologic findings. AIMS AND OBJECTIVES: 1. To study the various clinical entities presenting as Right Iliac Fossa mass and their incidence. 2. To compare the sensitivity of clinical diagnosis with radiological diagnosis using imaging modalities like Ultrasonography and CT scan. 3. To compare the sensitivity of clinical and radiological diagnoses with the intraoperative diagnosis in cases where surgical exploration is undertaken and the final histopathological report. MATERIALS AND METHODS: 50 Patients presenting to the general surgery department with clinically palpable right iliac fossa mass over a period of 6 months were included in the study. Pediatric patients and patients with only right iliac fossa pain but no mass were excluded. Study Centre: Department Of General Surgery, Madras Medical College And Rajiv Gandhi Government General Hospital, Chennai-600003 The patients were studied over a period of 6 months from June 2012-Dec 2012. All patients were examined by me and history and physical examination findings were noted based on the proforma enclosed. All patients underwent Ultrasonography of the abdomen and CT scan abdomen was taken for in patients who had a diagnosis other than appendicular mass. 35 cases underwent surgery and 33 of these cases had specimens removed and their histopathological report was compared with the pre operative clinical and radiological diagnosis CONCLUSIONS: 1. Appendicular mass is the commonest condition presenting as right iliac fossa mass. 2. Clinical diagnosis and imaging diagnosis is in concordance only in 50% cases of appendicular mass. 3. Clinical diagnosis is accurate in only 50% cases of appendicular Mass. 4. Imaging diagnosis is accurate in 86% cases of appendicular mass. 5. Ileocecal tuberculosis is the 2nd most common condition presenting as right iliac fossa mass. This is unlike in western populations where Crohn’s disease and malignancy of the caecum are commoner causes. 6. There was a female preponderance in the incidence of ileocecal tuberculosis. Female: Male ratio was 62.5 : 37.5 in this study. This is in concurrence with other studies from the Indian subcontinent. 7. Clinical diagnosis and imaging is highly accurate in diagnosing ileocaecal tuberculosis. There was 100% concurrence between both clinical diagnosis and imaging diagnosis. Also both clinical diagnosis and imaging diagnosis were in 100% agreement with histopathologic result. 8. Past history of tuberculosis is present in 75 % of cases of ileocecal tuberculosis. 9. Clinical impression was more accurate than imaging result in case of Carcinoma caecum. In this study clinical diagnosis agreed with final histopathology report in 100% of cases while imaging was accurate only in 75% of cases. 10. Carcinoma of caecum was found only in males in this study. 11. Clinical assessment and imaging were 100% accurate in diagnosing Psoas abscess. 12. Clinical assessment and imaging were 100% accurate in diagnosing Ovarian tumors. 13. Clinical assessment and imaging were 100% accurate in diagnosing intussusception. 14. In this study both cases of intussusception were due to small bowel polyps