Jeremy Santiago, Anthony Medak
77-year-old female with a past medical history of diabetes mellitus and rheumatoid arthritis presented to the emergency department with 2 days of abdominal pain. Pt reports that she began feeling abdominal pain diffusely that has now moved to RLQ. States pain was worsened with movement, and she tried taking Pepto Bismol and Tylenol at home with no relief. She feels like her appetite has decreased due to the pain. She denies urinary symptoms, changes in bowel movements, nausea/vomiting, cough, fever, chills, chest pain, or back pain. Patient endorses she is currently taking methotrexate for her RA. Surgical hx notable for prior salpingo-oophorectomy and hysterectomy.
Vitals: BP 132/58 | Pulse 79 | Temp 98.4 °F (36.9 °C) | Resp 16 | Wt 52.2 kg (115 lb) | SpO2 100% | BMI 19.14 kg/m²
Physical Exam:
On physical examination the patient was alert and nontoxic appearing without any evidence of acute distress. The abdomen was soft, flat, and non-distended with tenderness to palpation in the RUQ and RLQ. There was no guarding, rebound tenderness, or evidence of peritoneal signs. There was positive McBurney point tenderness on exam, with a negative Murphy’s sign and Rovsing’s sign.
Labs: WBC 13.6, Lipase 9, U/A negative, CMP unremarkable.
Based on the history, physical examination, and labs, the Modified Alvarado score was 7, indicating probable/likely appendicitis. A focused bedside ultrasound examination of the RUQ and RLQ were conducted utilizing the curvilinear transducer.
Figure 1. Two separate dilated segments of the appendix were appreciated with periappendiceal fluid. A hyperechoic structure is noted within the lumen without shadowing concerning for possible appendicolith.
Figure 2. A longitudinal dilated segment of the appendix is visible with periappendiceal fluid.
Figure 3. CT abdomen and pelvis with contrast in axial and coronal views demonstrate acute appendicitis with a measured diameter of 9mm and associated fat stranding/periappendiceal fluid.
Discussion
Acute appendicitis is one of the most prevalent abdominal surgical emergencies worldwide with over 300,000 hospital visits reported annually within the U.S. alone [4,5]. Appendicitis is often a delayed or missed diagnosis, and one of the most common malpractice cases that Emergency Physicians face [2]. For many providers, the diagnostic accuracy of CT imaging, ability to detect other acute causes, and the fear of missing appendicitis are the reasons many providers opt for CT imaging in the workup of acute abdominal pain. Appendicitis can be characterized as uncomplicated or complicated based on presence of perforation, abscess, or necrosis in addition to histological findings. Management of acute appendicitis generally consists of medical, surgical, or combined modalities [4,5]. Although many institutions and societies have recommendations and guidelines for managing acute appendicitis with antibiotics alone, an appendectomy is the only definitive management, and patients often warrant prompt surgical evaluation.
The diagnosis of appendicitis is typically made utilizing clinical examination, laboratory markers, and imaging. Common symptoms include initial vague abdominal pain that localizes to the RLQ, anorexia, nausea with or without vomiting, diarrhea, and fever. Given the location of pain and non-specific symptoms associated with acute appendicitis, a broad differential diagnosis and additional workup should be considered [4,5,7]. CT imaging is considered the gold standard by The American College of Radiology and the most often preferred imaging modality by surgeons with an accuracy > 95%, (Sensitivity 91-96%, Specificity 90-95%) when compared to abdominal ultrasound (Sensitivity 78%, Specificity 83%) [5]. Ultrasound findings of acute appendicitis include appendiceal diameter >6mm, presence of appendicolith, increased periappendiceal fat stranding, and lack of appendix compressibility [4]. Risk stratifying tools such as the Modified Alvarado Score (MAS) can also be used to determine the likelihood of acute appendicitis without further imaging, with reported sensitivity and specificity up to 95% and 90% respectively, utilizing a cut off score of 7 [3,6,7].
Several studies have looked at the combination of MAS with abdominal ultrasound and demonstrated an increased sensitivity and diagnostic accuracy of acute appendicitis when utilized together. The combination of these two clinical tools to rule in appendicitis may save time, avoid unnecessary radiation, and subsequently reduce complication rates or negative appendectomies [1,3,6,7]. In the case of this patient, her clinical presentation and exam were consistent with acute appendicitis (MAS of 7). Bedside POCUS was notable for a dilated appendix with periappendiceal fluid and a possible appendicolith concerning for acute appendicitis. The positive POCUS findings in addition to MAS ≥ 7 made acute appendicitis very likely and her diagnosis was later verified on abdominal CT imaging. Her negative urinalysis and prior history of total hysterectomy made genitourinary sources of symptoms less likely, thus blunting the alternative diagnostic benefits of CT imaging. She underwent an appendectomy and had confirmed acute appendicitis and periappendicitis with abscess formation on pathology. No appendicolith was identified on imaging or pathology however, despite our POCUS findings.
As POCUS availability and experience becomes more common amongst Emergency Medicine providers, the use of abdominal ultrasound in conjunction with risk stratifying tools such as the Modified Alvarado Score may be beneficial to rule-in acute appendicitis in uncomplicated patients for whom you have a high clinical suspicion. These tools may be especially useful in resource- limited settings or when obtaining CT imaging may significantly delay patient care.
References
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