28-year-old black male presented to the emergency room with a 24-hour history of right flank pain and fever to 38.8°C. The patient reported feeling fine the day prior and noted that the onset of the pain was gradual and was currently only moderate in severity. He also reported watery bowel movements for the past 48 hours, occurring five to six times a day. He denied any previous similar episodes, denied any recent travel outside of the United States, and also reported that no other family members or friends were currently ill. He otherwise felt well and had a normal appetite and denied nausea and vomiting. He did admit to increased frequency of urination in the past 3 days but denied nocturia or dysuria. On physical examination, the patient was noted to be a healthy appearing young black male in apparent mild distress. His temperature was 38.7°C, HR, 118 bpm; and respiratory rate, 14 breaths/min. His heart and lung examination were normal and he had only mild tenderness deep in the right lower abdominal quadrant and iliac fossa. He had moderate CVA tenderness on the right side, a strongly positive psoas sign on the right, and a negative obturator and Rovsing’s sign. Laboratory evaluation included a WBC count of 18,000/mm3 with a left shift and a normal Hb and Hct. A urinalysis showed two to five WBC per high power field, and no bacteria, and a KUB demonstrated a nonspecific bowel gas pattern with an absent psoas shadow on the right side. An ultrasound showed a complex periappendiceal mass consistent with perforated appendicitis. He was given intravenous fluids and broad spectrum antibiotics. At laparotomy, on exploration, a phlegmonous mass was noted. With some difficulty the appendix was located and removed and the base of the appendix oversewn. A small amount of purulent fluid was present and drains were placed in the area. The fascia was closed and the skin left open to heal by secondary intention. He was continued on intravenous antibiotics for 5 days. The drains were advanced and after a 7-day hospitalization the patient was discharged home with wound care instructions.
Two overriding factors contribute to a continued, steady incidence of 10–15% of clinically perforated appendicitis. The first is the lack of a noninvasive, sensitive, and specific means of making or confirming the diagnosis of acute appendicitis. The second is the considerable expense and definable morbidity associated with a negative appendectomy, which leads physicians to wait until the diagnosis is obvious because of the advanced disease. Acute appendicitis is most commonly seen in the second and third decades of life, but can occur at any age. Indeed, the extremes of age account for morbidity out of proportion to the percentage of the population who are treated for the disease. The reasons for this are clear and include (1) failure to consider the diagnosis due to the atypical patient population and presentation, (2) the difficulty in obtaining a history from many patients in the pediatric and geriatric populations, and (3) the comorbid conditions encountered in the geriatric population