Cannot Miss Diagnosis

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Acute Appendicitis
Cannot Miss Diagnosis No.2

Section Editor: Prof. T.K. Partha Sarathy

A 13 year old boy was sent back home from school because he complained of abdominal pain and vomiting. The anxious mother took him to her family physician. On going over the history the boy said that from that morning he did not have any appetite and did not feel like eating. He felt nauseated and vomited twice and developed pain around the umbilicus and epigastric area. The pain was getting gradually worse in the last few hours. The boy denied any similar episode in the past and has always been healthy and active. He has had all childhood immunizations; and could not recall any history of injury while playing.

As he was talking to the doctor he started to retch and vomited a small amount of bilious material. He had not taken any food in the last 8 hours. He denied any difficulty in passing urine and there were no symptoms of frequency or dysuria. There was no history of cough, cold, headache or fever. The past history and family history were essentially non contributory. He said that the pain was more towards his right side of the abdomen and he pointed to the right iliac fossa where he felt the maximum pain.


The family physician examined the boy from head to foot. His neck was supple. Examination of head, neck, ear, nose and throat were normal. His temperature was 100.2o F with a pulse rate of 88/mt and BP of 110/70 mmHg. Cardiovascular system and respiratory system were entirely within normal limits.

Physical examination of the abdomen revealed that it was essentially soft and scaphoid. There was appreciable direct tenderness over the right iliac fossa and in particular over the McBurney’s point. The costovertebral angles were non-tender. There was no suprapubic tenderness. There was no true rigidity in the abdomen. Some voluntary guarding was present, particularly over the right lower abdomen. The liver and spleen were not palpable and no mass was felt in the abdomen. Bowel sounds were heard.

After reassuring the boy, a careful rectal examination was done which revealed some tenderness towards the right side of the wall of the rectum. No masses were felt. The examination of the scrotum and genitalia were within normal limits. Gross neurological examination was within normal limits.

The first clinical impression that the Family Practitioner entertained was that it could a case of acute appendicitis. With this in mind, he did additional testing for rebound tenderness, Rovsing’s sign, Psoa’s sign and obturator-sign. Except for evidence of rebound tenderness in the right iliac fossa, no other sign was positive. The physician ordered a complete blood count and urinalysis and requested a surgical consultation. The urinalysis was essentially normal except for presence of ketones. The white blood cell count was 14,500 with 89 polymorphous and 11 lymphocytes.

The surgeon who examined the patient agreed with the clinical impression of the family practitioner. On the basis of the history of anorexia, nausea, vomiting and abdominal pain and the signs of direct right lower quadrant tenderness and rebound tenderness, with an elevated white blood cell count and acetone in urine indicating dehydration, he was convinced that this patient has “acute appendicitis”.

The patient was started on I.V. fluids and after explaining the possibility of appendicitis, to the parents and the need for emergency surgical care, for which the parents agreed, the boy was taken to surgery and under general anesthesia through a right lower quadrant, transverse incision appendectomy was performed. The appendix was acutely inflamed although intact and not perforated. Post operatively the boy returned to normalcy rapidly and was discharged on the third post operative day in good general condition; eating normal with normal bowel habits.

The above is a classical presentation of acute appendicitis and the diagnosis which was made entirely on clinical grounds was possible because patient was a young male who had acute onset of symptoms typical of acute appendicitis. The findings were undisputed. The right lower quadrant tenderness that was appreciated by the family practitioner was reproducible during the surgeon’s examination. The focal point tenderness at the McBurney’s area and the rebound tenderness further confirmed the diagnosis. The elevation of white count (WBC) with a left shift speaks in favour of acute inflammation secondary to infection consistent with acute appendicitis. There was no other alternative diagnosis to consider on this patient and so an easy diagnosis was made and patient benefited from the same.

However, a positive diagnosis of acute appendicitis is by no means a simple one like this and circumstances and presentation may be subtle and vary under different situations. Although it is true that early operation for acute appendicitis offers the best cure and prevents serious complications, it does not warrant routine exploration of every abdomen just because the patient has some pain in the right side, which happens frequently. In many quality oriented hospitals, stringent criteria are enforced through the tissue review committees to make sure that not more than 10 to 15% of appendix removed are found normal by the pathologists. In other words, surgery is performed on patients for removal of acute appendicitis with nearly 85% to 95% accuracy.

Is it possible to make that kind of accurate diagnosis? Yes, it is certainly possible and has to be pursued with a sense of commitment to avoid unnecessary surgery on people.

Let us look at some other circumstances, where diagnosis of acute appendicitis may not be this straightforward:
  • A 23 year old recently married young female having persistent right lower quadrant abdominal pain

  • A pregnant lady having right iliac fossa pain

  • A 2 year old infant probably crying of abdominal pain, presenting with abdominal distension

  • A 75 year old senile male not able to communicate his problems having right lower abdominal tenderness

  • A paralysed person having episodes of vomiting, fever, elevated white count with no sign of peritonitis.

All the above situations are challenges that surgeons frequently encounter and it does involve a careful evaluation, reevaluation, work-ups and in select cases operative approach.

Let us take the first scenario of a 23 year old lady who complains of right lower quadrant abdominal pain. Women could have abdominal pain due to several reasons including pelvic infectious disease, tubal pregnancy, endometriosis, tubo-ovarian pathology, fibroid etc. Because of these a very careful menstrual history has to be obtained in all these patients.

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Monte 

probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.

soroush 

it was better if you mentioned that his pain was acute onset or not

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