Clinico pathological study of right iliac fossa masses and their management

Aim: The present study aims to study causes, modes of presentation, investigations of choice and management of right iliac fossa masses. Materials and Methods: A prospective study was undertaken on 50 patients presenting with mass in right iliac fossa to surgery outpatient department during the period august 2015 to October 2017. All cases were investigated and managed as per protocol and their data recorded. All the demographic variables were tabulated as per percentage among total cases. Results: In this series out of 50 patients, 23 patients (46%) diagnosed to have Appendicular mass followed by Ileocaecal TB (20%), Appendicular abscess (16%), CA Caecum (12%) and psoas abscess (6%). Appendicular pathology is more common in 3 decade, Ileocaecal TB in 4decade, CA Caecum and Psoas abscess in 6 decade.In total of 50 patients, 28 (56%) were males and 22 (44%) were females. In the present study pain was the commonest symptom of presentation seen in all cases, fever was present in 78% cases, vomiting was present in 42% cases, loss of weight and appetite was present in 24% cases, constipation was present in 16% cases, diarrhea was present in 8% cases, mass per abdomen was present in 26% cases. Conclusion: The common cause of right iliac fossa mass is of appendicular pathology followed by lleocaecal TB, Carcinoma caecum and psoas abscess in that order, with male preponderance and most of cases falling in 3 decade.


Introduction
Mass per abdomen has always been considered to be temple of wonders or Pandora's magic box. Mass in the right iliac fossa is a common entity which is frequently encountered in clinical practice requiring skill for diagnosis [1]. The varied etiology of these conditions presents a diagnostic challenge to the surgeon, as appropriately said by Sir Hamilton Bailey "A correct diagnosis is the hand maiden of a successful operation".
Right Iliac Fossa Mass is a common clinical entity encountered in surgical practice [2]. The mass has varied anatomical and etiological 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, gynaecological surgery and colorectal surgery [3,4]. Right Iliac Fossa has 8 anatomical entities and six other organs in the neighbourhood whose pathology may extend into this region. Right Iliac Fossa region has Appendix, Caecum, Terminal Ileum, Lymph nodes, Iliac artery and vein, Retroperitoneal connective tissues, Ilio psoas muscle, and Iliac bone. Neighbouring organs and their pathologies which might extend into this region areKidney, Gallbladder, Uterus, Ovaries, Urinary Bladder and Testis. Diagnosis of abdominal mass mainly depends on clinical examination and investigations.The patients are subjected to radiological and pathological investigations [5,6].
Differential diagnosis of mass in the RIF: Parietal Swelling: Parietal swellings are less common in this area. Infrequently, desmoid tumors and burrowing iliac abscess/ appendicular abscess through the abdominal wall into the parietal area are also noticed [7]. The most common differential diagnosis encountered by surgeons are Appendicular mass, Appendicular abscess, Ileocaecal TB, Right ovarian mass,CA caecum,Right ectopic kidney, Rectus sheath hematoma, Psoas abscess and Amoeboma. In subcontinents, TB has been the main cause of intestinal obstruction and perforation. A set of investigations are ordered to reach a definite diagnosis. These include: CBC, USG Abdomen which are done in all cases. Additional tests like CECT Abdomen, Colonoscopy and biopsy, Diagnostic Laparoscopy, Tumour markers may be needed [11,12,13,14]. Appendiceal phlegmon, are commonly managed by conservative treatment till the mass resolves and at a later date interval appendicectomy is done if needed [15,16,17,18]. Ileocaecal tuberculous masses are one of the common causes of intestinal obstruction and perforation in subcontinent. they are usually managed by hemicolectomies and resection anastomosis of involved segment [19,20].

Materials and Methods
Place of Study: Narayana Medical College and Hospital, Nellore.

Type of Study: Prospective study.
Study Period: August 2015 to October 2017.
Sampling method: a cross-sectional study was done with convenient sampling.
Sample collection: 50 cases were selected from surgical OPD which fulfilled the below criteria.

Statistical methods:
Results were shown in tables, comparing their numbers and percentages. We used chiquare association test and the Z test forproportions.

Inclusion Criteria
 All cases of age more than 12 years that presented during the study period having mass in RIF.  Patients of both Sex.  Patients who have also been found to have mass in RIF incidentally on examination and by investigations are included in the study.

Exclusion Criteria
 Patients having mass in RIF due to gynaecological conditions are excluded.  Patients with debilitating illness like CRF, ARF, CAD, Liver failure etc are excluded from the study.

Observation and Results
The results of the study are discussed as following  In this series age varies from 14 years to 60 years. Appendicular pathology is more common in 3 rd decade, Ileocaecal TB in 4 th decade, CA Caecum and Psoas abscess in 6 th decade. In total of 50 patients, 28 (56%) were males and 22 (44%)were females In the present study pain was the commonest symptom of presentation seen in all cases, fever was present in 78% cases, vomiting was present in 42% cases, loss of weight and appetite was present in 24% cases, constipation was present in 16% cases, diarrhea was present in 8% cases, mass per abdomen was present in 26% cases   All patients who underwent interval appendectomy, HPE report came as chronic appendicitis. All patients of CA Caecum underwent right radical hemicolectomy and HPE report came as well differentiated adenocarcinoma. 6 cases of Ileocaecal TB underwent limited resection ileo-ascending colon anastomosis and HPE report of resected specimens are suggestive of Ileocaecal TB.

Discussion
The present study was carried out to evaluate various diseases presenting as mass in the right iliac fossa. Several variables like age, sex, incidence, clinical presentation, type of investigation needed, mode of treatment and histopathology of resected specimens etc. were studied in all the selected cases.
About 50 patients who presented with right iliac fossa mass were selected for this study during the period August 2015 to October 2017 at Narayana medical college and hospital Nellore.
After detailed history, thorough clinical examination and relevant investigations a proper diagnosis was arrived at. Whether it was conservative or surgical,a standard treatment was given depending upon the diagnosis. following are the observations and inferences which we concluded. In our study appendicular pathology (appendicular mass and abscess) was the most common disease encountered followed by Ileocaecal tuberculosis, carcinoma caecum and Psoas abscess in that order. The same observation was found in a study conducted at victoria hospital affiliated to Bangalore Medical college and research institute by shashikala V et al [21]. In the present study Pain abdomen, followed by fever and vomiting were the predominant symptoms. According to S K Shetty, M Shankar, pain abdomen was present in almost all cases, fever in 93% of cases and vomiting in about 50% of cases [22].
In the present study 8 cases (16%) are diagnosed asappendicular abscess. The highest number of cases are found in third decade (50%  26,27]. The highest number of cases are found in third decade (70%), with male to female ratio being 4:1. According to S. K. Bhansali, 2/3rd of patients were in 4th-5th decades [28]. According to Prakash et al.the highest incidence of this disease was found in the age group of 20-40 years [29].
S K Shetty et alreported 87% cases of CA Caecum were more than 40 years of age and more common in females [32].According to the studies of Smiddy and Goligher (1957) and D Gomez et al (2004), the incidence of carcinomas in the right colon (caecum and ascending colon) is 25 -31%, and in the left colon (descending colon and sigmoid) is 50 -69% [33,34].

Conclusion
Appendicular pathology continues to be the most common cause of right iliac fossa masses followed by ileocaecal TB, Carcinoma caecum and psoas abscess in that order, at least in this geographical location. Majority of the patients involved are in 3rd decade followed by 4th decade with slight male predominance. conservative treatment for appendicular masses and extra peritoneal drainage for appendicular abscesses are found to be effectiveprocedures.

What this study contributes
Results of our study strongly concur with the existing knowledge of right iliac fossa masses in particular appendicular phlegmon, in several of its factors. our study emphasizes the successful role of conservative treatment in the management of appendicular phlegmon.