June 15, 2012

So, Is it Appendicitis? An Experience From Three Cases of Non Classical Presentation of Appendicitis

Sir William Osler, A Canadian Physician once said ; “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.

From my understanding, seeing a patient without prior knowledge is indeed a BIG NO. While anything could happen, you will not be able to formulate a diagnosis by just relying on symptoms that has being described in the textbook. Patient will never always come with 100% classical description from the textbook. However, the magic word “COMMON IS COMMON” will sometime be very useful. Only by seing more and more patient and do a lot of observation than you can be more accurate in making diagnosis. In another context , having a prior knowledge without seeing a patient will  bring you nowhere in the room of improvement.

I have experienced three cases of appendicitis with different presentation and spectrum of severity. Even though appendicitis is a very straight forward case. But in certain case, the classical symptoms may not appear at all. The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases (eMedicine article 773895)

Alvarado score using in the aid of making diagnosis in district hospital or clinic setting may also yield a low score but patient did actually have appendicitis.

First patient is a late 20 year old man presented with sudden onset left flank pain that radiates to the groin that awaken him from sleep. The pain score is 7/10 and does not relief with any measures. The history that i obtain more suggestive of pyelonephritis. Recent history of sexual intercourse with urinary tract infection symptoms and positive renal punch kind of deviate me from the real diagnosis. Furthermore, the classical Rovsing, Psoas and Obturator signs are all negative. The only thing is that patient having a generalized peritonitis and slightly involuntary guarding over the right lower quadrant region. Total white blood cells are just mildly elevated and other blood investigations are normal. Urine FEME did not suggest a urinary tract infection. In view of the sudden onset of pain and the physical examination, my specialist decided that it is a perforated appendicitis and intra operatively, it is a valid diagnosis.

A Second patient who is a 30 year old gentleman presented with history of poorly localized lower abdominal pain but more on the right side. It is associated with 15 episodes of vomiting and constipation. Abdomen is distended and the patient was treated as sub acute Intestinal obstruction in the emergency department. There was no fever, migratory pain, rebound tenderness, and clinical tests for appendicitis are negative. After a suppositories enema and pain management, patient was discharged home. A month later he come in with a similar presentation except without vomiting and was managed the same. However, the pain subsided for one day only. Later, he develop sudden onset severe right iliac fossa pain while walking from the toilet. The pain score is about 7-8/10. There was  nausea but no vomiting, loss of appetite, migratory pain, fever. Examination shows right hypochondriac pain on deep palpation. Rovsing, Psoas and Obturator signs are negative. In ward, fever was documented, total white blood cells was elevated. Patient was posted for appendicectomy. Intraoperatively, there was a perforated appendix with localized pus and lot of adhesion. Therefore, a diagnosis of acute on chronic appendicitis was made.

Third patient is an 11 year old boy who presented with 10 days history of nausea and vomiting with diarrhea and was treated as Acute Gastroenteritis. Upon presentation to us, the child was very ill with septic looking. There was a generalized peritonitis and tender left inguinal mass which was non reducible, well defined margin and does not increase in size with cough reflex. Both testis are palpable and associated with hydrocele of the right testis. A diagnosis of strangulated hernia was made and patient was posted for emergency herniotomy, KIV laparotomy. However, intraoperatively, it was noted that the swelling was actually a pus collection that extend to the scrotum. There was no obstructed bowel or real hernia sac and therefore midline incision was done. The abdomen was filled with 1 Litre of pus and the appendix was  noted perforated. Therefore a diagnosis of intraabdominal sepsis secondary to perforated appendix was made. He made a good recovery except developing wound breakdown at the incision site which was later resolve with daily dressing.

From the three cases, I learn that a previously low score abdominal pain that suddenly become worsen should alert a physician that organ perforation may be occurs and should consider appendicitis as an aetiology since it is a common condition. Secondly, in children, acute appendicitis may present with acute gastroenteritis symptoms and if it is non resolving, therefore it should be investigate more. Failure to diagnose acute appendicitis or perforated appendicitis will increase the morbidity and mortality of a patient.


  1. Assalamu Alaikum
    Being following for a while but my first comment:)

    Currently rotating thru surgery and hv also come to realise that making a dx of appendicitis is not simply clear cut. Yes while many patients present like 'textbook' cases, some have totally non-specific signs and symptoms. In our institution WCC is regarded as highly indicative but we've had cases with relatively normal WCC's!
    In my opinion female patients are also more challenging coz of all d gynae cozes to exclude.

  2. Sorry doc. Nak betulkan sikit grammar. If a noun used as an adjective, it must be singular. Therefore, it has to be A 20-YEAR-OLD patient and AN 11-YEAR-OLD patient. No 's' after year is required.

    Good day. And thanks for all the knowledge and information!! ^^

  3. @Sabeehah: Wsalam wbt... indeed in women, the diagnosis are very difficult to exclude... the most common cause for RIF pain in female would be ovarian torsion, PID, Appendix, diverticulitis and also UTI.. we usually did UPT, UFEME and USG first before diagnose it as appendicitis.. previously, i once see a patient who was refered to us by O&G team to rule out appendicitis, after the diagnostic laparoscopy, we found out that it was actually a hemorrhagic ovarian cyst... so now, i will consider it as one of the differential diagnosis as well

    @Anna Mohamed Amin: Thank you very much sis.. really appreciate it. i admit that my english is not really good and i'm still struggling to produce a high quality article... thanks for the help

  4. You're welcome. My English aren't always perfect either, but I hope you don't mind me correcting you.

    Been following you for a while now, I love your blog. Very informative. Thank you for having the time to teach us. Keep on writing!


    1. No problem..we learn from each other

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  6. When my husband had his appendix removed on wednesday night just gone, they opened him to be greeted by puss. This was present in stomach and pelvis also. What does that mean though? We where told nothing. Also his white blood cell count was 26.5?

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