Appendicitis is typically associated with pain in the right iliac fossa, but not all right iliac fossa pain indicates appendicitis. Various organs in this region can also present similar symptoms when inflamed, such as small bowel perforation, ovarian cyst torsion, or ectopic pregnancy…
Although the right iliac fossa is a small area, it houses several overlapping organs, including the appendix, cecum, ileum, ovaries, fallopian tubes (in females), right ureter, and pelvic floor muscles. Even experienced physicians must carefully evaluate to accurately diagnose atypical cases of right iliac fossa pain. Conditions that can cause pain in this area include:
Appendicitis: Always presents with pain in the right iliac fossa. The pain typically localizes at the junction of the outer third and inner two-thirds of a line drawn from the anterior superior iliac spine to the umbilicus, known as McBurney’s point. If the appendix is on the left side, the pain will also be on the left, which is rare. Patients often exhibit a fever ranging from 37-39 degrees Celsius, rapid heart rate, digestive disturbances, loss of appetite, and nausea. Blood tests will show elevated white blood cell counts, and pressing on the right iliac fossa increases pain, with abdominal rigidity. Emergency surgery is necessary in the early hours. Delays can lead to severe complications.
Small bowel perforation: Commonly encountered in typhoid fever or Crohn’s disease affecting the terminal ileum. In cases of typhoid, patients may have had fever for weeks, fatigue, delirium, and significant weight loss. A positive serological test for typhoid and abdominal distension is noted. Initially, pain is localized to the right iliac fossa and then spreads to the entire abdomen. In Crohn’s disease, perforation of the terminal ileum presents similarly to perforated appendicitis, requiring emergency surgery.
Meckel’s diverticulum: More frequently seen in males under 17 years of age. Symptoms include abdominal pain and bloody stools, with a pale appearance. Perforation of Meckel’s diverticulum can lead to peritonitis, often misdiagnosed as appendicitis, necessitating emergency surgery. Late diagnosis can lead to fatal outcomes.
Ovarian cyst torsion: Patients may occasionally notice a lump in the abdomen along with abdominal pain. Pain subsides when the lump disappears, and an ultrasound typically reveals the ovarian cyst. If the cyst is torsioned, the patient usually experiences severe, writhing pain. In such cases, exploratory surgery of the lower abdomen is required.
Ectopic pregnancy: Patients often present with delayed menstruation, pain in the right iliac fossa, and severe cramping. Signs of hypovolemic shock, reduced red blood cell count, and low blood pressure may occur. Upon vaginal examination, tenderness is noted in the posterior fornix, with slight bleeding. Failure to perform emergency surgery can lead to fatality due to blood loss.
Gastric-duodenal perforation: Patients usually have a history of gastric or duodenal ulcers. If the stomach perforates and gastric fluid spills into the right iliac fossa, the patient experiences pain and abdominal rigidity; pain initially encompasses the entire abdomen, later localizing to the right iliac fossa. This condition is easily mistaken for appendicitis-related peritonitis, requiring emergency surgery to address the perforation.
Pelvic floor abscess: Patients may also experience pain in the right iliac fossa, high fever, and elevated white blood cell counts. A key sign is the right leg being flexed; extending it causes pain. Draining the abscess can lead to recovery.
Salpingitis: Patients often report pain in the lower abdomen and both iliac fossae. In acute salpingitis, pain is typically felt in the right iliac fossa. Fever may reach 39-40 degrees Celsius, with high white blood cell counts. Non-surgical treatment with antibiotics can be effective for salpingitis.
Terminal ileal tuberculosis: Patients may present with weight loss, pallor, prolonged illness, and evening fevers ranging from 37-38.5 degrees Celsius, occasionally experiencing diarrhea or constipation. Upon examination, a mass may be palpated in the right iliac fossa, with tenderness upon palpation. Treatment with anti-tuberculosis medication usually results in recovery.
Right ureteral stones: Symptoms include pain radiating to the groin, hematuria, and urine tests showing red blood cells; fever is absent. The abdominal wall is soft, but deep palpation of the right iliac fossa elicits pain similar to that of appendicitis. Ultrasound or X-rays may reveal stones. Surgical intervention is required if stones cause obstruction.
Pneumonia – right pleurisy: Pain may be felt in the right iliac fossa, particularly in children. Patients exhibit fever, no vomiting, elevated white blood cell counts, and slight abdominal rigidity on the right side. Auscultation and X-rays will reveal pneumonia and pleural effusion.
Additionally, pain in the right iliac fossa can occur due to large omental torsion, fallopian tube torsion, bowel obstruction, or abdominal wall abscesses. When right iliac fossa pain is accompanied by fever and nausea, appendicitis should be the first consideration. However, there are instances where appendicitis may not present all the typical symptoms, so patients must thoroughly communicate with their doctors, maintain close monitoring, and undergo repeated examinations (every 1-3 hours). This approach prevents missing cases requiring emergency surgery, as delays can lead to extremely complex complications, even resulting in death.
