The image shows acute appendicitis. Because of the location of the appendix, it may cause atypical symptoms and signs, as seen in this patient who had both CVA and abdominal tenderness. Management includes administering intravenous antibiotics, maintaining a nothing-by-mouth status, and obtaining a surgical consultation.

Discussion

Acute appendicitis classically presents with <2 days of gradually worsening abdominal pain that either starts in or migrates to the right lower quadrant of the abdomen from the umbilicus. It is often associated with nausea, loss of appetite, and/or 1 to 2 episodes of vomiting. Classic examination findings include focal pain in the right lower quadrant with guarding and potentially a positive Rovsing sign.

Approximately 30% of cases of acute appendicitis present atypically with 1 or more features of the history and/or physical examination that may lead the clinician astray. These atypical features may include symptoms that have been present for >3 days, abdominal pain associated with diarrhea, or respiratory or urinary symptoms; atypical locations of pain may occur when the appendix is located outside of the right lower quadrant. 

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Diagnostic testing for appendicitis has limitations. The sensitivity of an elevated white blood cell count is approximately 85%, although it is 90% to 95% sensitive if a differential shows >70% PMNs. CT scan is approximately 95% sensitive; however, it may be more likely to miss early cases of acute appendicitis or cases with an ectopic location.

It is important to keep atypical presentations of appendicitis in mind in any patient with abdominal pain and no other clear diagnosis. Consider obtaining a CT scan early on to avoid delay in diagnosis and treatment. Provide clear parameters for returning to the hospital if discharging a patient with undiagnosed abdominal pain.

Conclusion

The patient in this case underwent a successful appendectomy of an unruptured appendix.

Table. Appendicitis

Symptoms • Usually persistent, progressive right lower quadrant pain and tenderness
• Migration of pain: 80% of cases
• Anorexia: 84% of cases
• Pain before vomiting: 97% of cases
Atypical Symptoms Approximately 30% of cases
• Symptoms last >3 days
• Upper respiratory tract infection
• Dysuria/frequency
• Diarrhea
• Pleuritic pain
• Ectopic: retrocecal; often nontender but usually positive psoas sign and/or limping
• Pelvic: surpapubic pain
• Perirenal: flank pain
• Parileal: diarrhea
• Retroileal: testicular pain
• Subhepatic: right upper quadrant pain
Symptoms During Pregnancy • Ultrasound first
• If no diagnosis, consider: surgical consultation, admit for serial exams, laparoscopy, MRI, CT imaging
Pediatric Cases Use pediatric appendicitis score to decide between imaging, surgical consult, or discharge home with observation
Laboratory Findings • Urinalysis: up to 30 red blood cells/white blood cells/bacteria per high powered field; up to 100 white blood cells with negative urine culture is possible.
• White blood cells: sensitivity/specificity, 85%/50%; differential, 95%; if WBC >20,000 consider pyelonephritis or pneumonia
Diagnostic Imaging • None; can consider for classic case as it avoids delays and radiation
• Ultrasound: fast, no contrast, no radiation. Sensitivity/specificity: pediatrics, 88%/94%; thin adults, 83%/93%
• CT: Not as accurate in thin adults, less reliable if appendix not seen; sensitivity/specificity, 94%/95%
• MRI: Not as accurate in thin adults, less reliable if appendix not seen; sensitivity/specificity, 97%/97%
Treatment 75%-90% of individuals with uncomplicated appendicitis treated without surgery (antibiotics only) have no recurrence at 5 years
Complications Rupture: 2% at 36 hours; increases by 5% every 12 hours; mortality rate, 5%

Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. EMresource.org. 2017;5.