Caecal mass unusual finding during appendectomy Ppt Powerpoint Presentation slides DR.Fiaz maqbool Fazili Medical Slideshow SAXually Explicit Images: Finding Unusual Shapes

Caecal mass unusual finding during appendectomy

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Slide 1 :

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Management of cecal massesDr Fiaz Maqbool FaziliAcute Care Surgeon

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Unexpected inflammatory or neoplastic cecal mass of uncertain etiology encountered during surgery for presumed appendicitis poses a dilemma to the surgeon when deciding the appropriate operative management.

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Differential diagnosis of Ileocecal mass Appendix mass Appendix abscess Carcinoma of the caecum Crohn’s disease (terminal ileitis) Cecal diverticulitis Ileo-cecal Tuberculosis Iliac lymph nodes Twisted ovarian cyst, uterine fibroids Tubo-ovarian abscess

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Rare causes Pelvic kidney (congenital or after KTx) Iliac artery aneurysm Psoas abscess Chondroma of the ilium Ruptured epigastric artery Malignant change in an undescended testis Carcinoid Actinomycosis Ileocecal intussusception Appendicular tumors Endometriosis Colonic malakoplakia

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Clinical evaluation

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Appendicular mass History. The patient complains of a period of central abdominal pain followed by a pain in the right iliac fossa, with malaise, loss of appetite. Examination. There is a tender, indistinct mass, dull to percussion, fixed to the iliac fossa posteriorly. The patient will have a persistent fever and tachycardia.

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Appendicular abscess History. This is the same as for appendicitis, with the additional symptoms of an abscess such as fever, rigors, sweating and increased local pain. Examination. There is a tender mass, which may fluctuate and be associated with oedema and redness of the overlying skin. The patient will have a swinging, intermittent fever and an increasing tachycardia.

Slide 9 :

CT abdomen with appendicular abscess

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Appendicular mucocele

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Ultrasound of inflamed appendix

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Abdominal X-ray showing appendicolith

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Carcinoid tumor of the appendix

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Tuberculosis The mass consists of the inflamed ileocaecal lymph nodes and parts of the caecum and terminal ileum. History. The patient often has a vague central pain for months, with general ill-health, loss of weight & night sweats. The pain becomes intense and settles in the iliac fossa. Examination. The mass is firm, tender. The surface and the edge are difficult to define.

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Ileocecal TB

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Ileocecal TB

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Carcinoma of the cecum History. Often there is no acute pain, just a dull discomfort in the right iliac fossa. Some patients present with anaemia, diarrhoea, or intestinal obstruction. Examination. The mass is firm, distinct and hard. Sometimes it is fixed to the posterior abdominal wall. It is not tender and does not resolve with observation. The patient’s temperature and pulse are normal. Occult blood in stool & barium enema can give clues to diagnosis.

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Cecal carcinoma

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Cecal tumor

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Cecal carcinoma

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Right hemicolectomy specimen

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Cecal carcinoma

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Crohn’s disease (terminal ileitis) History. There is recurrent episodes of pain in the RIF, general malaise, loss of weight and, sometimes, episodes of diarrhoea and melaena. Examination. The swollen terminal ileum forms an elongated sausage-shaped mass which is rubbery and tender. It lies in a transverse position and often slips up and down on examination. ESR usually high & contrast follow through shows string sign of Kantor.

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Crohn’s disease

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Enlarged iliac lymph nodes History. symptoms depend on the cause. There may be a generalized disease, or local lesion in the limb, perineum or genitalia. Examination. Enlarged iliac lymph nodes form an indistinct mass, with no clear contours, which follows the line of the iliac vessels. The mass can bulge forwards just above the inguinal ligament and be easy to feel, or be no more than a fullness in the depths of the iliac fossa.

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Iliac artery aneurysm History. The patient may present with pulsating mass or an aching pain in the right iliac fossa. Examination. Aneurysm is more common in CIA than the EIA, so the smooth, distinct mass with expansile pulsation is usually felt in the upper medial corner of the iliac fossa.

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Psoas abscess History. The patient usually have felt ill for some months and had night sweats and loss of weight. He may also complain of back or abdominal pain. Examination. The iliac fossa is filled with a soft, tender, dull, compressible mass. There may be a fullness in the lumbar region which is accentuated by pressing on the mass in the iliac fossa. The swelling may extend below the groin and it may be possible to empty the swelling below the groin into the swelling above, and vice versa. Back movements may be painful and limited.

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Chondroma of the ilium Chondromata and chondrosarcomata occur in the iliac bones. They grow slowly and may bulge into the iliac fossa. They are large, hard, not tender and fixed to the skeleton. They often lie out in the lateral part of the iliac fossa, more so than the intra-abdominal causes of a right iliac fossa mass.

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Actinomycosis This invariably develops as a complication of appendicitis, but may present de novo as a mass in the iliac fossa with a number of discharging sinuses. It is rare and due to infection with the anerobic actinomyces israeli.

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Endometriosis Endometriosis is the presence of ectopic endometrium-like tissue outside the mucosal lining of the uterus. Affect 5-10% of women of child-bearing age. The GIT is the most common extrapelvic site of involvement. Symptoms include vomiting, diarrhea, constipation, cramps or a cecal mass.

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Ruptured epigastric artery This occurs as a result of straining or coughing. The haematoma tracks beneath the abdominal wall, extraperitoneally, to produce a mass in the iliac fossa. It is diffuse and with skin discoloration. It is the only RIF mass which is attached to anterior abdominal wall, but as it is on its deep surface it becomes impalpable when the muscles contract. Contraction of the abdominal muscles is usually painful.

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Malakoplakia This is a rare granulomatous disease involving urinary tract, colon or stomach. Histologically characterized by the presence of histiocytes It is due to acquired abnormality of macrophage phagocytosis. It is usually found incidentally in elderly debilitated individuals and can only be diagnosed by histological examination of the bowel.

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Malignant change in an undescended testis This is a rarity but is easily suspected from history and on examining the scrotum.

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Management

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Pre-operative management of a cecal mass depend on presumptive diagnosis that we have reached based on clinical evaluation, laboratory investigation and imaging studies.

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Pre-operatively The preferred management of appendiceal mass/abscess is CT/US guided drainage and iv antibiotics (against aerobic G-ve & anerobic bacteria) Surgery in such situations is hazardous, it can: Disseminate infection Injure inflamed or edematous bowel or require more extensive procedures (ileocecal resection or right hemicolectomy)

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Pre-operatively Other inflammatory processes are treated conservatively with the appropriate antimicrobials i.e ileocecal TB, Crohn’s disease, cecal diverticulitis Surgery is usually reserved to complications: intestinal obstruction, perforation or bleeding. If malignancy is pre-operatively suspected, an extensive work-up has to be carried out to confirm diagnosis to stage the tumor & to assess operability of the tumor.

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Intra-operatively A five-year retrospective study was performed to review the management of this problem. Thirteen patients were identified who had had right hemicolectomy performed for unexpected mass in which neoplasm, diverticular disease, or inflammatory bowel disease could not be differentiated from severe appendicitis at laparotomy.

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Seven patients (group 1) had a final pathologic diagnosis of appendiceal phlegmon. The other patients (group 2) had Crohn's disease, typhlitis, or neoplasm. Right hemicolectomy was performed with a morbidity of 7% and mortality of 7% in all patients. The study recommended the procedure of right hemicolectomy for unexpected cecal mass.

Slide 40 :

Poon et al, have another retrospective study performed to review the pathology and surgical management in 3224 patients who had emergency surgery for a diagnosis of acute appendicitis between January 1990 and December 1997, a group of 52 patients (1.6%) underwent either ileocecal resection or right hemicolectomy for an inflammatory cecal mass of uncertain etiology.

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The final pathologic diagnosis was cecal diverticulitis in 26 patients (50%). appendiceal phlegmon or abscess in 21 patients (40%). cecal carcinoma in 3 patients (6%). tuberculosis in 1 patient (2%) schistosomiasis in another patient (2%).

Slide 42 :

34 patients underwent ileocecal resection, and 18 patients underwent right hemicolectomy. There was no mortality in either group

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The study concluded that most inflammatory cecal masses are due to benign pathologies and could be managed safely and sufficiently with ileocecal resection. Careful intraoperative assessment including examination of the resected specimen is essential to exclude malignancy, which would require right hemicolectomy.

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If frozen section unavailable and there is high index of suspicion regarding malignancy i.e hard mass with enlarged hard lymph nodes particularly in elderly patient, right hemicolectomy is a prudent choice and this include removal of the retroperitoneal fat to ensure safe margins.

Slide 45 :

If intra-operative findings suggest a benign mass, management depend on age of the patient and nature & extent of the lesion ranging from drainage (appendicular mass/abscess), diverticulectomy (cecal diverticulitis) or ileocecal resection in more extensive lesions.

Slide 46 :

Thank you

	fiazfazili 1 Years ago. Category: Surgery

Tags:	Surgery

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