Appendicitis is the most common acute abdominal surgical condition in medicine, yet there is probably not a single physician in practice today who hasn’t missed the diagnosis at least once. Often that results in “simple” appendicitis becoming a “ruptured” or “perforated” appendix. I have reviewed several such cases which have prompted this review.
The appendix is a tubular extension of the cecum, in the right lower quadrant of the abdomen at the beginning of the colon or large bowel. Because of its structure, it acts as a “catch basin” or blind pouch where a variety of bacteria and mechanical obstructions can cause problems. One can think of appendicitis as a boil or abscess. Germs get in, propagate, and cause an infection. If the infected appendix is not removed, it can swell to the point where pressure causes rupture, spilling the infection into the abdominal cavity.
Diagnosing appendicitis is easy – when it presents in classical, textbook fashion, which occurs in only about 50% of patients. The typical symptoms are:
- A sense of being ill
- Generalized abdominal discomfort
- Loss of appetite
- Pain in the right lower quadrant of the abdomen
Classically these symptoms appear over a period of about 24 hours in the order listed. Combined with tenderness in the right lower quadrant of the abdomen on examination, further testing rarely changes the diagnosis or alters the treatment, especially in children.
But when 50% of patients with appendicitis “don’t follow the rules,” the diagnosis remains one of the most commonly missed in medicine. Nationally, about 30% of appendicitis cases progress to perforation before the diagnosis is made. Sometimes that is because of delay on the part of patients in seeking medical care, and other times it is because the patient’s symptoms do not suggest to the physician a “surgical abdomen.” If the problem has not progressed to the point where surgery is considered a reasonable option at the time of first evaluation, regardless of the diagnosis, “watchful waiting” is often the best option. The reason for that is that there is still no “gold standard” for the diagnosis. CT scans, nowadays considered our most accurate study, still fail us, leading to both missed diagnoses and unnecessary operations in 5% and 10% of cases. The scans themselves are known to increase the risk, though marginally, of abdominal cancer in later life.
Clearly, once the diagnosis is made, surgical removal of the appendix is the treatment of choice. That said, there are numerous reported cases where non-operative management has been successful, or where a “healed appendix” was diagnosed at a subsequent surgical procedure. This shows that it’s not just that the diagnosis that can be obscure, but that the treatment is not as well-defined as we might think.
Below is an algorithm by Santacroce and Ochoa from their chapter on appendicitis in Sabiston Textbook of Surgery.
The key question any physician faced with a patient with abdominal pain must first ask is, “Does this patient have a potentially surgical abdomen?” If so, a full court press to define the cause – whether that is appendicitis or something else – is urgent. If at the time of examination a “surgical abdomen” is not present – in other words, regardless of the diagnosis, surgery is not immediately indicated – a physician may reasonably elect to postpone further studies.
However, choosing that pathway comes with added responsibility on the part of both patient and physician. The physician must inform the patient of the possible causes of the problem, almost always including appendicitis in the list, and warn the patient of the symptoms that would warrant re-evaluation, and within what time frame. Since the classic symptoms of appendicitis develop over a period of about 24-48 hours before rupture, time is a key component of the physician’s advice.
When some 30% of appendices are ruptured at the time of surgery, and 50% of patients present with atypical symptoms, missing the diagnosis of appendicitis is not uncommon. However, if the medical record reveals classical findings and the diagnosis was missed, care is likely to be found to be substandard. The reality, though, is that any time the diagnosis is missed, the medical record is likely to include few if any classic findings. The fact that a physician has even thought of appendicitis, yet classifies the patient as low risk, can be a valid defense, and the chart will usually support the physician’s impression. A good follow-up plan remains mandatory for all such abdominal complaints.
Although morbidity can triple (from 1% to 3%) when the appendix ruptures, fortunately for the patient the impact is rarely more than a few extra days in the hospital, a slightly higher cost, and a scar that might have been avoided if diagnosis had been made earlier and a laparoscopic appendectomy could have been done. Because of these factors, demonstrating that a physician’s care has been below acceptable standards can be an uphill climb with relatively little return for an unhappy patient and his/her attorney.
As summarized by Dr. Benson Yeh in an article on “evidence based medicine,” “Appendicitis will continue to be a diagnosis that calls for a composite approach that integrates all available factors and uses clinical judgment to determine the need for further imaging.” (Annals of Emergency Medicine. 52:301-303, Sep 2008.)
About Chuck Pilcher
Chuck provides expert witness review and testimony in medical malpractice cases related to the fields of emergency medicine, urgent care, EMS and general inpatient and outpatient hospital practice.
He has 35 years or experience as an emergency physician, most of those years as Medical Director of a now 50,000 visit per year suburban Emergency Department. Board certified in both Emergency Medicine and Family Medicine, he has has helped both plaintiff and defense attorneys with malpractice litigation for over 25 years. He is proud that attorneys on both sides have found his assistance valuable, and is especially honored when he has been retained by opposing counsel in a subsequent case following a deposition or trial. His CV can be found here.
Charles A. Pilcher MD FACEP