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!
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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!