Case Acute Appendicitis
Acute appendicitis is one of the more common diseases encountered in the U.S. population. Although the population at highest risk (adolescent and young adults) rarely die as a result of appendicitis, there is significant morbidity attendant to the disease process. In older and younger age groups, where the diagnosis is more often delayed, the morbidity is even more significant and mortality is not rare.
ACUTE APPENDICITIS
A 17-year-old white female presented to the emergency room with a 36-hour history of abdominal pain, originating in the periumbilical region and now localized to the right lower quadrant. She also reported anorexia with one episode of minimal nonbilius emesis. She reported feeling febrile, but had not measured her temperature. She denied any previous episodes and reported that she was sexually active with one steady partner. She also denied any history of sexually transmitted diseases and had never been pregnant. Her menstrual history was noncontributory and her last menstrual period was 10 days earlier. On physical examination, she was noted to have a mildly distended abdomen with normal to slightly hypoactive bowel sounds. No scars were noted and she was tender to moderate palpation in both lower quandrants, right slightly greater than left. There was no rebound tenderness, egative psoas sign, and negative Rovsing’s sign. Pelvic examination showed mild to moderate cervical motion tenderness and rectal examination was normal except for moderate tenderness on the right side in the supralevator region. Her WBC count was 11,000/mm3 with a left shift, normal Hb and Hct, and a urinalysis with small amount of ketones and otherwise normal. An abdominal x-ray showed a nonspecific bowel gas pattern. She was admitted for observation, was resuscitated with intravenous fluids, and 6 hours later, upon re-examination, was noted to be persistently tender and was taken to the operating room where laparoscopy confirmed acute nonperforated appendicitis. A laparoscopic appendectomy was performed. The patient was discharged home 48 hours later.
A 17-year-old white female presented to the emergency room with a 36-hour history of abdominal pain, originating in the periumbilical region and now localized to the right lower quadrant. She also reported anorexia with one episode of minimal nonbilius emesis. She reported feeling febrile, but had not measured her temperature. She denied any previous episodes and reported that she was sexually active with one steady partner. She also denied any history of sexually transmitted diseases and had never been pregnant. Her menstrual history was noncontributory and her last menstrual period was 10 days earlier. On physical examination, she was noted to have a mildly distended abdomen with normal to slightly hypoactive bowel sounds. No scars were noted and she was tender to moderate palpation in both lower quandrants, right slightly greater than left. There was no rebound tenderness, egative psoas sign, and negative Rovsing’s sign. Pelvic examination showed mild to moderate cervical motion tenderness and rectal examination was normal except for moderate tenderness on the right side in the supralevator region. Her WBC count was 11,000/mm3 with a left shift, normal Hb and Hct, and a urinalysis with small amount of ketones and otherwise normal. An abdominal x-ray showed a nonspecific bowel gas pattern. She was admitted for observation, was resuscitated with intravenous fluids, and 6 hours later, upon re-examination, was noted to be persistently tender and was taken to the operating room where laparoscopy confirmed acute nonperforated appendicitis. A laparoscopic appendectomy was performed. The patient was discharged home 48 hours later.
Acute appendicitis remains a clinical diagnosis. Numerous tests have been advocated and are often useful in evaluating a patient with suspected appendicitis. The singular fact remains that the best reported results of the currently available tests show a diagnostic sensitivity of approximately 90% and will therefore miss at least 10% of cases of acute appendicitis if relied on. The obvious conclusion, therefore, is that a heightened clinical acumen is essential and no test should be used to rule out appendicitis. The diagnosis starts with a thorough history. The typical patient will be in the second or third decade of life. The onset of pain will be gradual and in the periumbilical region. Over the ensuing 24–36 hours, the pain will typically radiate to the right lower quadrant and be associated with anorexia. Nausea and vomiting are also common and low grade fever may be noted. In the pediatric population, a prior upper respiratory infection is a helpful clue to the diagnosis, as this may incite the local lymphatic response leading to obstruction of the appendiceal lumen and appendicitis. In the adult population, the lymphatic tissue is diminished and the lumen large. A history of a prior upper respiratory infection is generally not helpful. Although cases of recurrent appendicitis undoubtedly occur, they are rare and a prior history of similar pain should raise the suspicion of an alternative diagnosis. Similarly, urinary symptoms, at least early in the course of acute appendicitis, are uncommon and should lead to suspicion of urinary tract pathology as an alternative diagnosis.
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