How should an adult with right iliac fossa pain be treated with Meftal Spas (mefenamic acid and dicyclomine)?

Meftal Spas for Right Iliac Fossa Pain

Meftal Spas (mefenamic acid combined with dicyclomine) should not be used as primary treatment for right iliac fossa pain in adults, as the priority must be accurate diagnosis through imaging before administering analgesics that may mask peritoneal signs and delay recognition of surgical emergencies like appendicitis.

Why Analgesics Should Not Be First-Line

The fundamental issue with using Meftal Spas or any analgesic for undifferentiated right iliac fossa (RIF) pain is that it can obscure critical clinical findings needed for diagnosis:

• Appendicitis remains the most common surgical cause of RIF pain (27-39% of cases), but presents with classic symptoms in only 50% of patients 1
• Pain with guarding and rebound tenderness are key physical examination findings that predict appendicitis in 96% of cases when combined with fever >38°C and leukocytosis 2
• Masking these peritoneal signs with analgesics before establishing a diagnosis can lead to delayed recognition of perforation or other surgical emergencies 1

The Correct Diagnostic Approach

CT abdomen and pelvis with IV contrast must be obtained before symptomatic treatment in adults with RIF pain, as it has sensitivity 85.7-100% and specificity 94.8-100% for identifying surgical pathology 1, 3, 4:

• In patients over 50 years, CT scanning should be mandatory unless contraindicated, as this population has higher prevalence of colonic diverticulitis (10%) and neoplasia (15%) that require identification before any intervention 5
• CT has 97% sensitivity based on operative findings and prevents unnecessary surgery while identifying alternative diagnoses 5
• Do not delay imaging for oral contrast administration—IV contrast alone provides equivalent diagnostic accuracy without treatment delay 3, 4

Essential Pre-Imaging Evaluation

Before ordering imaging, document these specific findings that predict surgical pathology:

• Temperature >38°C (rectal), RIF guarding, and white blood cell count >10,000/mm³ predict appendicitis in 96% of cases 2
• Anorexia, tachycardia, or rebound tenderness significantly predict appendicitis 6
• Duration of symptoms: patients with perforated appendicitis have median 50 hours of pre-hospital symptoms versus 17 hours for simple appendicitis 6
• Mandatory pregnancy test (β-hCG) in all reproductive-aged women before CT 4

When Observation Without Analgesics Is Appropriate

For patients with atypical presentation and no peritoneal signs:

• Hospital observation with serial clinical and laboratory examinations over 36 hours can avoid 22% of unnecessary appendectomies 2
• This approach is only appropriate when peritoneal signs are absent and imaging is not immediately available 2
• Repeated physical examinations during observation are more valuable than masking symptoms with analgesics 2

Critical Differential Diagnoses That Require Imaging First

Beyond appendicitis, RIF pain has a wide differential that cannot be distinguished clinically:

• Colonic pathology: Diverticulitis (10% in older patients), inflammatory bowel disease, neoplasia (15% over age 50) 5, 4
• Gynecological emergencies: Adnexal torsion, ruptured ovarian cyst, pelvic inflammatory disease 4
• Urological causes: Nephrolithiasis, pyelonephritis 4
• In immunocompromised patients with pancytopenia: Typhlitis, hepatosplenic candidiasis, or bowel ischemia 3

Common Pitfalls to Avoid

• Never administer analgesics before establishing whether peritoneal signs are present, as this can delay recognition of surgical emergencies requiring immediate intervention 1
• Do not rely on clinical scoring systems (Alvarado, AIR) alone—they have lower accuracy than CT imaging for definitive diagnosis 7
• Recognize that 15-20% of patients with nonspecific abdominal pain may have normal-appearing appendices that are pathologically abnormal on histology 1
• In patients over 50, six patients who underwent surgery without CT required intraoperative changes in planned procedures due to unexpected findings 5

The Role of Symptomatic Treatment

Only after surgical pathology has been excluded by imaging should symptomatic treatment with agents like Meftal Spas be considered for confirmed nonspecific abdominal pain (which accounts for 15-26% of RIF pain cases) 2, 5, 7.