Although we are taught in medical school and residency that appendicitis has a typical presentation like this:
Vague mid abdominal pain often several days after having a viral illness that progresses to right lower quadrant pain over 24 – 48 hours. Accompanied by fever, loss of appetite, and often vomiting, the pain often gets suddenly better indicating the patient has perforated. Subsequently they become very ill.
I have found this disease is another “great imitator” – ie it looks like something else a lot of the time. The whole “elevated White Blood Cell count” frequently does not happen and the above presentation probably occurs only a minority of the time. Very annoying. Why can’t people just read the book BEFORE they decide to get the disease and make our lives easier!!!!
Anyway, in the last week I have seen two very atypical presentations.
1. A 32 year old woman who was sent into the ER for severe abdominal pain by her gastroenterologist. He had see her three previous times over the last three months for the same symptoms – which included progressive lower abdominal pain and diarrhea over 3-5 days. With each episode , by the time the patient had come to the office, the symptoms were improving and her exam was very unimpressive. He had performed a colonoscopy and endoscopy (both normal) the first time, a CT scan of the abdomen (normal) the second time, and a small bowel series (normal) the third time. This time he said was the first time she presented to him with a very tender abdomen. She came to me with a very tender lower abdomen (both left and right sides), and normal pelvic exam, no fever but a slightly elevated white count. She looked very comfortable sitting there drinking her CT contrast. Results: perforated appendicitis with a large phlegmon.
2. A 29 year old woman (triathlete) who was sent in (would you believe by the same doctor!) for 3 weeks of intermittent crampy upper abdominal pain, episodic vomiting and diarrhea. She had already had a normal abdominal ultrasound and colonoscopy – presumptively diagnosed with IBS (irritable bowel syndrome – a nebulous disease which is not serious and probably has a psych component). Her exam was startling for how unimpressive it was – minimal periumbilical tenderness. Normal labs (no white count), no fever, normal pelvic. She got a CT because she kept saying she had such severe pain and had gotten 4 doses of IV morphine. Results: Appendicitis (not perforated yet).
These are cases some people might be tempted to send home without a CT – lawsuit galore. In the old days before CT they both would have gotten exploratory laparotomies I think and made our lives easier!
These atypical presentations make it difficult to decide on a course of action. There was a night when I had 5 abdominal pains in my section. Of all 5, one was screaming bloody murder and writhing on the bed, diaphoretic, vomitting and all that, had to drop an NG tube to get the contrast in her. The other 4 had vague complaints and were content after 20mg of pepcid, 30mg of Toradol, and 10mg of Reglan.
The doc had orders for all 5 pts to be CT scanned with contrast. The screaming pt ended up being discharged with instructions on how to deal with a stomach virus while three were admitted for bowel obstructions!! All three had complete bowel obstructions!! Amazing!
BTW the fifth pt signed out AMA after finding out she had to wait 2 hrs to get the CT scan, wonder if she ended up in another ED that night.
I had another kind of appendicitis presentation.
Abdominal cramping that persisted with no other symptoms for more than 24 hours, that eventually moved to the lower right and became tender.
No fever, no vomiting, no major discomfort, pain of maybe a 3 with cramps, 0 otherwise. I cleaned the house, made dinner, ate dinner, then went to urgent care on a triage nurse’s recommendation. Never took or requested any painkillers, slept comfortably at the hospital until surgery the next morning. Apparently when they took it out it was ready to blow at any second. Guess I was lucky.
I recently had a 50 y/o high maintenance female who was sent in by her doctor for evaluation of abdominal pain. She basically denied abdominal pain to me but rather complained of a fever and lower abdominal cramps. Pt admitted to waking at 5 am with cramps, had BM (suffered from chronic constipation). The Pt went back to bed, waking at 8 am with fever of 102.7. She denied other symptoms such as nausea, vomiting, uti symptoms, except a clear vaginal d/c. On exam: normal exam except very slight RLQ tenderness which pt had to put my fingers on where it hurt exactly, otherwise nontender. That spot was Mcburney’s point. I ordered a CT scan and labs and thought this lady has nothing. WBC count 19,000 and a ct result of an appendix that did not fill with contrast and no surrounding inflammatory changes. The surgical resident saw the patient and spoke to the surgeon who wanted a repeat CBC and a GYN consult. The repeat CBC was 24,000 and not having been seen by GYN yet I called the surgeon back, discussed the case and she showed up in the ER in about 15 minutes and took her to the OR for appendicitis.
The high maintenance female had to have everything explained to her 3 times. She had to personally review all her labs even though she had no idea what she was looking at. She wanted explanations about each and every irregularity. Why is my sodium 135- 136 being normal…..ETC. The Pt kept telling me that it did not hurt, except when you pushed on it.
That whole region of your belly can do bizarre things. I had a tubal ligation about 20 years before I got some kind of little infection in one of the tubes, causing it to rupture, which felt sooo much better when it went, I tell you, I got like 9 hours of sleep afterwards, and woke up REALLY sick. Go to the er, tell them I had no nausea, just pain radiating all the way down into my thigh, and start begging them to cut me and get whatever it is out. After running my blood, they do, because ultrasound is showing nothing and yet I’m falling down hard. They get in, find the tube, and it had caused the appendix to go bad and it was ready to blow too. And I was still refusing the morphine because I hate the way I can’t open my eyes but can hear everything going on, but can’t sleep either. Thank god the doc listened to me when I told him to get in there and take things out!
The weirdest appy presentation I ever saw was a middle-aged dude who presented with lower right-lung/flank area pleuritic chest pain. I can’t remember exactly what work-up they did, but it started as a PE/pneumonia work-up.
Bleh. I had an impaction that coincided with appendicitis. I had a high wbc but, but after the impaction was resolved (thanks to a barium enema), everything seemed fairly normal. A little generalized tenderness in my belly and chest, but I’d been dry-heaving continuously for the last eight hours (with the impaction.) They were going to send me home, actually. But decided to operate after my wbc just wouldn’t go down. Anyway, the appendix asploded as the surgeon was taking it out. So no pickled appendix for me.
The appy patients who are really sick and it’s obvious what’s wrong with them usually do really well. The ones with the vague complaints are the ones with the ruptures, stormy postop courses, procedures converted to open, etc.
I have known more than one person who had the typical appy symptoms and it turned out to be a ruptured ovarian cyst or some other painful pelvic condition.
There are several conditions that mimic acute appendicitis. Women can be more difficult then men to decide what is actually going wrong. Diverticulitis, a UTI, a kidney stone, retrocecal appendicitis, ovarian cyst, Pelvic inflammatory disease, hernia, cholecystitis, tumor, abdominal pain?? are just a few.
Whoever wrote the book on appendicitis never intended a CT scan to be more accurate than those famous signs and symptoms. Every abdominal pain that enters the ER should have appendicitis in your differential diagnosis.
Some surgeons will not take acute appendicitis to the OR without a confirmatory CT scan to confirm. It depends on the surgeon, what time of the day it is- IE- at 2 am, call a surgeon with a definite case of acute AP on story and elevated WBC count, then you need a CT scan. Call at 2 PM, and they may take to OR before dinner.
My son was 12 when he developed
severe, intermittent, very short-lived abdominal
pain. He would be running and jumping when the
pain would strike and it would drop him to the
floor, where he lay in fetal position for a few
moments until it passed. This lasted for about
3 months. He had no other symptoms, such as
fever, n, v, d. Nothing except that I did once
give him a little enema for what I thought was
constipation. He had a BM and got pain relief.
He went back to sleep that night and was fine for
a good long while, going to school and living a
normal life.
The pediatrician missed the DX the first 2 times
I took him to her. She has 30 years of
experience but somehow missed it.
One Sunday, my husband was with him while I was
at work. Hub called me and said he was worse. I
advised him go to ER if he felt it was needed.
They went. That doc missed the DX, too. He did
not do any imaging or even a flat plate, no blood
work, only HX and PE (I give him the benefit of
the doubt and ASSume he actually took some HX and
did some PE.)
Shortly after, we were back at the pediatrician
and I said we need to do at least an ultrasound,
if not a CT Scan or MRI. Why I had to be the one
to think of it, I don’t know but thank God I did
and thank God that she did order it, for it showed
appendicitis.
He was admitted, we were told he’d go to the OR in
about 2 hours. Well, 5 hours passed, at which time
I decided to stop being nice. I told the nurse that
I probably should either take him to the other
children’s hospital here in town or home to treat
it medically. Funny how the surgeon arrived to
his room in about 15 minutes. My lamb went to the
OR, where he was found to have a perforated organ.
Surprise, surprise.
I am so angry that 2 doctors missed it on 4
separate visits, angry that I had to think of
imaging, angry that he was kept waiting so
long, and this last event might have been the
cause of the perforation. I don’t know. Maybe it
was already ruptured.
The teaching scene, with 25 people wanting to poke
him – believe me, I did not let that happen; 1 got
to and if any more had tried, I swear I would have
pounced – inadequate pain med, an idiot nurse who
gave an antibiotic via an infiltrated IV, and kiss
A me, trying to be nice and not tell anyone how to
do their jobs, trying not to be intimidating to
any of the nurses, some of whom were my former
students (!) and who spread the word that I was a
nurse and Instructor and caused everyone to panic,
but it didn’t help my son, who was allowed to rup-
ture. All I can say is I’m thankful that he is
alive and well. This is despite all the screw
up’s, including the evil ministrations
of an interventional radiologist who was called in
to place a drain. I did not trust this man
because he would not look me in the eye but,
again trying to be nice, I let him work on my son
anyway, despite my misgivings and mistrust.
During this second trip to the OR, I was praying
anyway but felt a special burden to pray at a
certain point. When the procedure was over and
they were taking my son to Recovery, the CRNA was
all upset, told me there’d been a problem, said
she’d had to start a 2nd IV, and it was all due to
the radiologist. At the time, I was too thankful
that my son was alive and well to worry about what
she’d stated. But, one of these days, I will track
her down and see if she remembers anything. It’s
been lots of years.
So, another non-textbook appy story.
Yes they are fairly common. The thing is, that you can’t and shouldn’t image every child with abdominal pain – the newest studies show the radiation burden is quite high! Plus, as you could see with one of my cases above, sometimes the CT misses it – especially if it is very early. We have to accept that we will miss some cases. That is the nature of things unfortunately. Until we devise a better, safer method of diagnosis, it will continue to perplex us. As for the delay in going to the OR – that is another ongoing debate. Most cases can wait several or more hours – since most do not rupture, but as with your son, some do. Getting the OR cleared and staffed for an emergent case is a big production at a community hospital – it is only big teaching centres where there are staff just sitting around waiting for the next case. My opinion is that you should operate as soon as possible but there are studies out there saying you can wait 12 hours.
I just had my appy taken out last year after a rough course of chronic appendicitis. I was admitted 3 times last year with extreme nausea and vomiting which resulted with hypotension that required fluid resus and pressors. Never had an abnormal CBC other than a minimally elevated WBC. I’d get 1-2 days of fluids and abx and would magically be fine. 2 months later it happened again. Finally the 3rd time I was admitted I talked my surgeon into doing a lap ex-lap and he found it. I never had the slightest bit of abdominal pain and it never showed up on CT or Ultrasound.
There is a particular method of controlling various digestive ailments that involves the proper combining of different foods. It works very well if one can maintain the discipline of appropriate food mixtures without converting back to old habits of eating certain foods with others. The secret is in knowing which specific foods work well with others. Interesting topic.
I recently had an appendectomy in December due to my persistence. I had been at the ER two times with right lower quadrant pain. My WBC count was normal both times. I had numerous CT scans which showed something with the appendix, but the surgeon and doctors chose to ignore it and send me home with gastritis. I had lost alot of time at work and was threatened to be fired due to the loss of time at work. I went back to that same surgeon and explained to him what is going on again and that something has to be done. He decided to listen and did the surgery and removed the appendix along with some scar tissue. The pathological report showed that I had Chronic Appendicitis. I am so glad that I knew that there was something wrong and made sure something was done about it.
I had surgery on 02/14/09. Almost 2 yrs. of abdominal pain with periodic low grade fevers. Some days loose stools with blood in it. 1st. dr. said nothing wrong. 2nd Dr. told me that I had Ulcerative Colitis. I decided to get a third opinion as I continued to have severe abdominal pain and low grade fevers about every 2 months even while on a ton of medicine for ulcerative colitis. Saw the third Dr. Dec. 2008 about 5 days after my symptoms resolved. Had normal WBC count and normal CT abdomen. She saw me in Feb. 09, this time while all of my symptoms were “Active”. She ordered A C-Reactive protein which was very elevated and order an emergency Ct abdomen. By the time I left the hospital after the CT scan, she called me to come back to the hospital for emergency surgery. The CT scan showed that I had chronic appendicitis. After the Laproscopy, it was explained to me that I had chronic necrotizing appendicitis. The appendix had been rotting basically. After several days stay in the hospital on IV antibiotics. All of my symptoms have gone away. Feeling better than ever!
I endured Chronic Appendicitis for 3 years. I saw doctor after doctor (Normal practitioner, ER doctors, gastro Dr, and GYN.) had every test in the book done (inner/outer ultra sounds, live stomach/bowel movement xray, CT scans etc). I was in the ER every 4 or 5 months due to EXTREME stomach pain and severe vomiting over the course of hours.. (and of course, then dehydration). I would get fluids, have tests done, then was given pain medication. All tests would come back negative and I was wrongly diagnosed with IBS. The last time I was in the hospital, it finally showed on a CT scan. (I had had numerous CT scans before showing nothing). Following an appendectomy, I haven’t seen the inside of an ER room in 2 years!
My 18yr Daughter had stomach pain that caused her to be nauseated. We thought at first it was stomach flu. So Feb 3rd 2010 kept her out of school for the day. Next day(FEB 4th) she went to school and called her Dad said she was very sick and hurting. He took her to urgent care. First thought the Doc had was Appendix. But all test were normal. Told her if she got worse she would need to go to the ER. Had a whole lot of test ran all came back Normal.
But one and they didn’t tell us that her Emyzine’s were high. (Her Gallbladder was removed at age 15, it stop working)
Next morning she was seen by Family Doctor. He refered her to a Gastro doctor. Saw him on Feb 15th… He really didn’t want to see her because she was at that time one month from being 18. He saw her but didn’t want to do anything other than blood work and all again. We were to wait for 3 to 5 days on all the test he ran. And Daughters pain was terrible. So I called him to ask just what I could do to get her answers faster. So, I decided to take her 50 miles away to a childrens hospital ER to see if they could get answers. Gastro Doctor called down there and gave the ER doctor a line that we just wanted pain meds and attention. So all that was done there was Blood work and a Prego test. Then sent home.
Went to OBGYN to get answers the next day he sent her right to a surgeon. Who tells us that it is Mesntric Adinitius. Mimic of APPENDIX. He tells her he can put her in the hospital for a few days to see if she gets better. but she wanted to just go home. We read on the net that Mesentric only last for about 2 weeks and the only way to prove this dignoses is to do surgery.
In the middle of the night she got very sick and We called the surgeon on call and his first question was why hasn’t someone went in to take a look. By this time we were 3 and a half weeks in pain.
Oh also no school or anything for all this time just lying around hurting.
In the hospital they ran more test. and said she had a cyst on both ovaries. And they would call OBGYN back. They didn’t call him thru the whole weekend.
He came in on Sunday sent her home for 24hrs.cause pain wasn’t any better. and saw her in his office. He did and ultrasound and said no Cyst and he was going to go in and look.
It was Chronic Appendix.
I am so upset at all the other doctor’s … She hurt for a whole month and they did nothing.
But now they all want pay.
Any ideas please let me know.
HELP. We are not able to pay back all medical bills…
Just has a very sick kid.
Melenie, Chronic appendicitis is rare and hard to diagnose. If the CT is negative – or if it is suspicious for Mesenteric Adenitis (which new scanners can see), very few surgeons would just right away operate or “take a look” owing to the risks of surgery. Unless she had horrible lab work,persistant fever, or peritonitis on exam, observation is the best treatment until a firm diagnosis can be made. As in my case, often people with Chronic Appendicitis get multiple scans until someone makes the diagnosis.
And ovarian cysts are much more common.
Its been almost a year since the pain started. It started in July of 09 2 months after I had my son. I seen a gastro in August and went to the ER 4-8 times just that summer. They all said it was baby blues and IBS. The first gastro did a endoscopy with the tube down my throat showed nothing. I had one CT in July 09 that showed mild deteration on my appendix nothing to worry about my doctor said. In October I got a new primary care and a new gastro the new gastro said that I had IBS and depression and gave me a scribe of Hyomax for stomach pain. In November I was still complaining of stomach pain and going to the ER almost every 2 weeks. The gastro ordered a Ultrasound. 2 weeks later he told me my gallbladder was no good. He said there were no stones so I still have IBS. I went to the surgeon and they scheduled me one week later to have out my gallbladder. They told my parents in the waiting room that the gallbladder was worse then they thought there were 2 large stones and 10 little stones and it was chronic. I saw the surgeon and gastro and the ER since then and they all said you have IBS and need to deal with it. Even the primary does not believe in my pain and gave me zoloft 50mg. After Physical therpy ( I fell during my pregnancy in Jan. 09) my PT thought it may be a good idea to see a back doctor so I did. He wanted to make sure there was no cancer, cyst, or broken bones from falling so he ordered a CT. Well I went to the CT and it showed chronic appendictis. My primary care doctor called and said they made an appointment MONDAY with the surgeon and I had to go no if ands or butts. They suddnely believe that its not just IBS or in my head its REAL how nice. Its only been 10 months of living everyday in pain. Sometimes doctors just dont care its horrible and very sad but to get anything done you have to do it yourself. Now im going under general an. for the 3rd time in less then a year..not fair. Plus im only 24 years old first time mommy and my sons birthday is this week…his FIRST birthday and im going to miss it recovering from surgery again.
For 8 months I have been having debillitating stomach pains go on and off. everyday seemed different. sometimes there was no pain and then the next day would be awful. but always managable. then all of a sudden. one night everything went to shit and i couldn’t stand or sit or scream or really breathe. in the morning i went to see my GP who got me in to a cat-scan(the contrast is disgusting it should be served in jail as punishment).
well the cat-scan revealed i had appendicitis and i had an emergency appendectomy performed and this very moment im sitting in my bed recovering. Every doctor i had seem up to this point told me i had IBS, or celiac’s disease, or lactose intolerance, etc. but never did tests or looked into even referring me to a specialist. trust your intuition ladies and gents. i’d been screaming appendicitis from the start. and now i have the scars to prove it.
Urgh. That is terrible Kevin. Well, at least you have a completely and simply curable condition as opposed to IBS and all that other stuff.
irritable bowel is really a very annoying disease…;
This has been a very interesting and educating site. I’d like you to bear with me as I share with you my own story. I have had on again, off again pains in RLQ for years. Was told by one lovely female doctor many years ago whilst I was holidaying in a different state, that I had a ‘grumbling appendix’ and needed to get it looked at. These past 6 months it has become increasingly painful. (Even today I doubled up in the street whilst walking my dog….twice…the pain not walking the dog twice! Ha!) For the past year or so have had the nausea, low grade fever, diahorrea, rah rah rah. Doctors blame the anti-cholesterol tablets, tell me to take them at night to relieve the nausea. After 5 months, no difference. I can see a pattern in the nausea, then a day or so later a low grade fever then delightful ‘runs’ to the Ladies Room, with increase in the amount of ‘pinging pain’ as I like to call it.Though today I would refer to it as a Knight in the medieval days riding full bore on his horse jousting for my ovary! I’ve had every blood test, US, CT you name it. Get told it’s adhesions, ovary pain, endometriosis (I had an ultrasound yesterday, and no sign of any cysts, etc) Of course, none of these logical reasonings are the cause, once the other information is handed to the doctors. Most shrug their shoulders and say, “Oh but your WBC isn’t elevated..if anything it has gone down.”
Now I do appreciate, that doctors don’t know everything, and are going by the text books. I am well aware many things present as other things. But after so long I think I am going to opt to have the appendix removed regardless of their diagnoses and see if that helps! After all, that little digit off the intestine doesn’t seem to do much other than hang around like an extra toe or finger.
Seems to me that something about the human body is not as easily understood as a text book. My goodness, god forbid, if I DO have a ‘grumbling appendix’ and prove I am right!
Back in February I took myself to the ER with abdominal pain. I was in pain for about 48 hrs and it was progressively worse. At the hospital, they did blood test – elevated white cell count and x-ray. Doc said some stool and to take some fibre drink. Of course, I wasn’t constipated – already went twice that morning! I was also directed to go back next day for f/u blood work and ultrasound.
Blood tests still show elevated white cell count. Ultrasound showed golf ball size cyst on right ovary and a swollen appendix, with fluid in the pelvis. Surgeon didn’t want to remove appendix although I was diagnosed with appendicitis also. Said the pain was from the cyst. This day the pain was going.
Saw family doctor for follow up to this and rescheduled an ultrasound to check the cyst. This was in June – no cyst, but still have an inflammed appendix – slightly larger than in February.
I have a high pain threshold and don’t seem to show any real symptoms – except fatigue. I’m always exhausted and no longer find myself able to do what I used to do. I’ve put on 15lbs since this all began.
My fam doc has referred me to a surgeon – my consult is in mid-August…. go figure.
What irks me is that everyone knew the problem from the start and although I had other things going on at the same time, this did not mean a total disregard for my health.
Oh my goodness… I am going to my doctor tomorrow and demanding at minimum a laproscopic test be done for this. Reading these posts has been like reading the last 2 years of my life. I have had so many trips to the ER because of horrendous episodes of vomiting, right side pain and dehydration. My normal body temperature is low and I haven’t had a “fever” in over 20 years (I even had diagnosed strep throat twice with no fever). My blood work always comes back “normal” and I get sent home with a prescription for Phenergan and pain meds. This “cycle” of vomiting always appeared to occur just before my menstrual cycle. I had Really bad cycles (to the point of being anemic)so my doctors and I attributed the vomiting to hormonal influxes. I ended up having a hysterectomy after trying several other alternatives about 6 weeks ago. Since last Wednesday I have been to 2 doctors, had 3 major tests run, and still no answers. Wednesday I was told there were leukocytes and blood in my urine (thus leading to additional tests) and then Friday I was told my urine was clear….I found that very odd. I ended up in the ER yesterday for 5 hours, being subjected to another urine test (yet again showing leukocytes and blood???), a pelvic exam (OUCH!), 6 vials of blood, and IV antibiotic. Once again sent home with pain medicine and Phenergran (plus an antibiotic that I am not taking until I talk to my doc tomorrow). The pain in my right side has not gone away though the Delaudid helps for a few hours and Phenergan is keeping the vomiting away. First 2 doctors said no UTI; ER doctor swears it is a UTI. Because I had a CT Thursday that was “normal” they would not order one in the ER (I kinda understand that part). I called back last night because even with the pain meds I was awoken by the pain in my side. I asked if it was possible that I had appendicitis and the nurse who answered said nothing in my lab work showed that so I could come back and get more pain medicine but that was all they would do for me. I don’t WANT to have another surgery (I have major issues with anesthesia and antibiotics) but I have a feeling this week is going to prove VERY interesting. I’d be willing to bet my next dollar that this is definitely a case of chronic appendicitis. This time it’s not getting better. I am curious if my hysterectomy possibly caused the appendix to move into a different position. The DaVinci robot was used and the robotic arm is entered into the right side of the abdomen…. I am SO glad I found this page. I am praying that I will possibly have an answer finally!! THANK you all so much! Maybe I’ll get my life back now!
How about a case of 4-year long Chronic Appendicitis? Started in 1997. Severe abdominal pain lasting up to 8 hours, vomiting, weakness. Happened 3-4 times a year, each year. Go to the doctor. Ultrasound – nothing, blood tests – normal. Finally, in 2001, one of the ultrasounds showed possibility of Appendicitis (makes you wonder how good ultrasounds are,really). The surgeon removed the “thing” that was like 6in long, and an inch in diameter. It was so adhered to my abdominal wall, that the surgeon said she had to rip it off slowly, like a velcro. I had hematoma size of my palm for 2 months after.