A 21 year old female presented by severe pain in right iliac fossa since 3 days

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Bunni Sadhguna 

Roll no. 25

A 21 year old female ,student by occupation, resident of Badrachalam came with chief complaints of pain in right iliac fossa since 3 days.

History of present illnesses 

Patient was apparently asymptomatic 1 day back then developed pain in the infraumbilical region which was radiated ti right iliac fossa.

History of past illness 

No previous surgical history 

Treatment history 

No diabetes 

No hypertension 

No asthma 

No blood transfusions 

No surgery 

Personal history

 She is Unmarried, student by occupation,  loss of appetite, Non vegetarian, bowels and micturition is normal with no allergies. 

Family history 

Not affected by any disease. 

Vital examination 

Temperature:  afebrile

Pulse rate : 90bpm

Respiration rate: 22/ min

Bp: 90/60

Grbs: 84mg%

General examination 

Positive to Pallor                         

No icterus

No Cyanosis     

No Clubbing

No pedal edema

no ascites 

Systemic examination 

Normal cardiovascular, respiratory system,tenderness is found in right iliac fossa, not palpable liver and spleen, positive to rebound tenderness is abdomen, CNS system is normal. 

Clinical findings 

Appendix measures 6mm

Thickened caecal wall,terminal ileum with surrounding inflammatory changes and enlarged lymphnodes with 12mm 

Few lymphnodes shows necrosis and one of the lymphnode is adjacent to Appendix 

Medication 

What is the anatomical location of patient's problem?

Terminal end of ileum and wall of caecum

The infective etiology is likely ileocaecal tuberculosis 

What is ileocaecal tuberculosis?

The most common site of gastrointestinal involvement is the ileocecal region which is involved in 64% of cases of gastrointestinal TB and is thought to be due to the abundant lymphoid tissue and the stasis of the stools around that segment.

79% successfully completed treatment or were cured.

Abdomen is the most common extra-pulmonary site of TB involvement. The clinical presentation is often unspecific, and imaging plays an important role in establishing the diagnosis of abdominal TB, with peritoneal disease and lymph node involvement being the most commonly encountered manifestations . When involving the bowel, TB has a predilection for the ileocaecal region due to its profusion of lymphoid tissue . The most common finding is that of mural thickening of the caecum and terminal ileum, which may be concentric or eccentric. Findings more specific for TB tend to be seen in advanced disease, with either eccentric thickening of the medial wall of the caecum, or in some cases of an inflammatory soft tissue mass extending from the caecum to envelop the terminal ileum . In advanced disease there may also be stricturing of the bowel leading to obstruction. The accessory finding of enlarged intra-abdominal lymph nodes is also very common, and nodal involvement tends to have a characteristic appearance of heterogeneous or peripheral enhancement caused by central caseating necrosis. This corresponds with the central low density within the affected nodes.
Ileocaecal TB is relatively rare in comparison to other pathologies affecting the ileocaecal region. Disease cause thickening of the caecum and terminal ileum, although the degree of thickening tends to be greater with ileocaecal TB. The involved lymph nodes in ileocaecal TB are also usually larger and are more likely to demonstrate caseating necrosis . Ancillary findings such as peritoneal involvement and loculated peritoneal fluid strongly support the diagnosis of abdominal TB . She received treatment on the working diagnosis of ileocaecal TB, and made good progress.

DIFFERENTIAL DIAGNOSIS LIST

Ileocaecal tuberculosis

Typhlitis

Crohn’s disease

Caecal carcinoma

FINAL DIAGNOSIS

Ileocaecal tuberculosis