Faces of appendicitis in children, men and women

About 15 years previously I did a consultation on a two yr old male child with vague abdominal pain and also vague & changing abdominal findings and to make a long story short I checked him numerous times over the next 3 days and finally operated and found appendicitis with perforation and abscess. The pediatrician, family, and myself were all upset with me. I can vividly remember the Mother saying, “How could you let this happen to my little boy?” I made an agreement with myself that I would never let this happen again and so far it hasn’t. I could feel the frustration and stress the posting on appendicitis in women. I developed and implemented a plan.

My surgical practice is almost 100% referral based and essentially all patients that I see with abdominal pain have been screened by one or more physicians prior to myself. Mostly the patients have already been admitted to the hospital but some are in the ER and the decision to admit or discharge is mine. On any patient that I see with abdominal pain that has not had a previous appendectomy, appendicitis is always a consideration and is included in my differential. I do not subscribe to “when in doubt take it out” and I don’t believe in the “art” of medicine. I approach it as a science and any decision has to be evidence based and I aggressively seek “evidence”.

The approach is a follows:

Every patient with abdominal pain gets a CBC, UA, Chem 7, KUB (abdomen), pregnancy test in women in appropriate age group. After above tests completed and history and physical if I think patient has an 80 % chance of appendicitis I do an appendectomy (open – not laparoscopic) and no other testing. If I think patient has less than 20 % chance of appendicitis I do no additional tests and suggest they go home and call me if pain becomes worse next 12 hours and regardless call me in 24 hours. After 24 hours patient is asymptomatic that ends it and if they still have pain I see and examine then again.

For the patient below 80% and greater than 20 % I continue the investigation:

Barium enema without preparation and with thin barium mixture with specific detail to demonstrating the appendix. If the appendix is not infected and the examination is done by an experienced radiologist the appendix will visualize 70 % of the time. If the appendix visualizes the patient does not have appendicitis – many times it is only on the post-evacuation film.

If the appendix does not visualize I become highly suspicious of appendicitis and I must be convinced that the patient does not have appendicitis.

I frequently order an ultrasound especially in women and if the appendix is infected it can be seen between 60-70 % of the time. The US is ordered specifically to visualize the appendix and is somewhat operator specific – there is one part time US technicial who is seldom capable of demonstrating the appendix and if that tech is on call I do not order US.

I sometimes order CT RLQ especially in women looking for an enlarged appendix and for fluid. We do not have Spiral CT @ the hospitals where I practice as yet but will have in less than 6 months. With Spiral CT and with very thin cuts in the RLQ with IV contrast (to pick up hyperemia) the “hit” or positive rate will be 80-90%. The test is called CTAP (CT appendix). I will shift to that when the hardware is available.

Now for some cases in the past 2-3 month which illustrate the multiple faces of appendicitis:

  1. A 40 yr old female was referred by an internist for right sided abdominal pain. An US of abdomen 6 weeks previously was reported as “small contracted GB with solitary calculus”. The pain subsided and patient did not keep the office appointment. About 2 weeks later she called one evening with severe abdominal pain and was seen in the ER. The WBC was 14,000 and the liver panel and amylase were normal. She had 3+ tenderness with guarding in the right mid abdomen (not RUQ).Patient was told that she had a “surgical problem” about 50 % chance acute cholecystitis and about 50% chance of appendicitis and laparoscopy was recommended. No additional tests were done. At laparoscopy the GB was small and contracted but not inflammed. There was cloudy fluid in the RUQ and furthur exploration revealed an inflammatory mass in the right mid abdomen which was acute appendicitis. The appendix was removed laparoscopically and she was discharged on PO day # 2. To my knowledge she has never had the GB removed.
  2. A 41 year old policeman had abdominal pain for 36 hours. He had not been seen a physician for 25 years except for mandatory physical examinations every two years for employment. The patient and his referring physician were both convinced this was “nothing” but the wife was very suspicious because she said her “husband never complains” and he has been complaining all day. Physical examination was not that impressive but there was diffuse tenderness in the RLQ with minimal guarding. I told the patient there was at least a 50% chance of appendicitis and suggested a BE, CBC and UA. The radiologist called about 45 minutes later and said “this patient has appendicitis – there is no visualization of the appendix and there is evidence of indentation of the caecum with possible abscess”. The WBC was 22,000 and the UA was normal. An appendectomy was performed and the appendix was gangrenous. On the 3rd PO day when he should have been ready to go home he was vomiting and the abdomen was distended. X-ray= ileus vs early obstruction and the WBC 19,000. Gastrografin UGI no contrast beyond the ileo-caecal valve in 24 hours. NG suction x 3 days no improvement and temp 100 and WBC 18,000. DX on KUB was small bowel obstruction and laporotomy thru midline incision performed and single adhesion in RLQ lysed along with drainage of abscess in the RLQ incision. Patient was now on TPN and NG suction continued for 3 more days when NG suction stopped and oral liquids started but temp returned and WBC was 14,000. The midline incision was indurated and probing produced 20 cc of thick purulent material. Patient was in hospital and additional 3 days and he was seen in the office today and “wants to return to work”. He is returning to “light work a week from today” and this will be for one month then regular duty.
  3. A 16 year old asian male student was seen in the ER 10 days previously for abdominal pain duration 24 hours. The temp was normal and he WBC was 12,000, KUB normal and UA normal. There was some tenderness in the right lower abdomen-more in the right suprapubic area than the RLQ. KUB was negative. Rectal examination was negative but I was suspicious of appendicitis. A BE was requested and the radiologist called about 30 minutes later and reported, “the appendix does not fill but caecum seems to be in the pelvis, I want to do an US to confirm”. An US was consistent with an enlarged appendix in the pelvis with a small amount of fluid. I now had the diagnosis but why the negative rectal examination with acute appendicitis in the pelvis? Laparotomy thru a RLQ incision revealed an acute appendicitis in a retrocecal appendix. 40 hours later the patient was discharged and he returned to school 7 days later. He was seen in the office today for the last time unless there are problems.
  4. An 8 year old male child was seen in the ER on Christmas day with a diagnosis of “small bowel obstruction”. His Mother gave a 4 day history of the “flu” but he just was not getting any better. This young man was obviously very ill – he was dehydrated and appeared toxic. The WBC was 23,000, BUN 50, CR-1.7. Abdominal Series consistent with small bowel obstruction. Physical findings diffuse tenderness with guarding and rebound throughout abdomen much more prominent in the entire lower abdomen with probable pelvic mass. US- large fluid collection in pelvis probable abscess. Diagnosis probable acute appendicitis with perforation and pelvic abscess. Consultation with Pediatrician – decision patient too ill for surgery at this time, started on triple antibiotics and aggressive hydration. On laparotomy thru a midline incision and drainage of pelvic abscess and removal of appendix with gangrene and perforation. On 5th PO day spiked temp and WBC 13,000. US of pelvis “4.0 cm collection in left pelvis” and was drained by radiologist with CT guidance (30cc of pus obtained) and patient was seen in office and drainage catheter removed and should return to school next week.
  5. A 14 year old male was seen in the ER with 36 hour history of pain in the right lower abdomen. The temp was normal, WBC 8,000, UA neg, KUB neg. Physical findings moderate tenderness in the RLQ poorly localized. Patient had no appetite past 24 hours. I did not feel comfortable sending the patient home because of physical findings. Following AM WBC, 7,000, Temp normal but still moderate tenderness in the RLQ. BE ordered and radiologist reported the “appendix is not seen”. CAT scan ordered with attention to the RLQ and report “possible enlarged appendix in the right lower quadrant”. Laparoscopy performed and at surgery the distal 1/2 of the appendix was rigid and enlarged. Laparoscopic appendectomy performed and final pathology report “acute appendicitis in distal portion of appendix”. Patient was discharged the day after laparoscopy.
  6. About 3 months previously I was asked to see a 29 year old female with a 1 month history of lower abdominal pain. Patient had been seen in ER and admitted to the surgical ward. There was a history of long standing “ovarian cyst problems” and after 2 weeks of lower abdominal pain she was seen by her family physician in Northern California and was told “it’s your ovaries again”. She accepted this but 2 weeks later when she was visiting her Mother in Southern California and had lost weight and was constantly complaining her Mother insisted she see a doctor. The entire lower abdomen was rigid and tense and bowel sounds were minimal. She was obviously seriously ill. The WBC was 19,000 and KUB was consistent with “ileus”. CAT scan ordered and reported as “two collections, one in the pelvis and one in the pouch of Douglas” Conversation with the radiologist, “Can you drain it”, “yes on the pelvic and no on the Pouch of Douglas -no window”. My clinical DX was acute appendicitis with perforation and abscess of the pelvis but tubo-ovarian abscess was a possibility. The radiologist drained the pelvic abscess and I drained the pouch of Douglas abscess posterior to the cervix via the vagina. 10 days later she was discharged. About one week later she was seen in the office and she said “I have another abscess” and on examination the lower abdomen was completely rigid. Repeat CAT scan – “large collection in the pelvis”. At this time I decided to perform laparotomy and findings were “large pelvic abscess, appendix not found, appendicial base found, free floating appendolith in abscess cavity. Patient in hospital 5 days later patient discharged with no pain. 5 days later patient seen in office and she says “I have a another abscess” and the temp was 99 and WBC was 12,000. Repeat CAT scan “5.0 cm fluid collection in pelvis probable abscess”. Conversation with Dr. Montin, the Radiologist, “Can you drain it”, the answer was “yes” and it was accomplished on OP basis. 5 days later I removed the drainage catheter in the office and the patient has now returned to Northern CA and has resumed her normal lifestyle.

Now for the outcomes, for the past five years I have had a “kill rate” of 89% (acute appendicitis), almost no appendectomies in males or children without acute appendicitis. I do not do primary GYN surgery and almost all of the appendectomies which have been normal have been in women in which I recommended laparoscopy (done by a GYN surgeon) with the knowledge in advance that this was probably not acute appendicitis but laparoscopy was indicated (many times recurrent symptoms). An appendectomy was done only when the appendix begged to be removed “two passes of the ENDO-GIA device”.

Can you improve upon this? Did you do, “BE, US, CAT scan? I am not requesting suggestions on the patients presented. This is past history.

Comments, do you have a better outcome? Comments both positive and negative.

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