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Appendicitis: A continuing diagnostic challenge
The Journal of Emergency
Pergamon
Medicine, Vol 13, No 1, pp 95-96, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. AU rights reserved 0736-4679/95 $9.50 + .OO
0736-4679( 94)00127-8
Editorial
APPENDICITIS:
A CONTINUING
DIAGNOSTIC
In the rhyming version of his classic monograph on the acute abdomen, Zachary Cope summarized the problem of atypically presenting appendicitis in the following way:
CHALLENGE
tion of computer-aided diagnosis. This method, however, has not been shown to be more effective in the diagnosis of appendicitis than traditional clinical techniques (5). The use of scoring systems to quantify diagnostic parameters has, likewise, not met with significant success (6). Such systems have been utilized more effectively to reduce the negative appendectomy rate than to improve diagnostic efficiency (6,7). Although ultrasonography can occasionally aid in the diagnosis of appendicitis, it has not been shown to be of benefit on a routine basis (8). The foundation for diagnosis of appendicitis continues to be predominantly the skills of the examining clinician. A decade ago, Buchman and Zuidema (9) studied the reasons for which delays in the diagnosis of acute appendicitis occurred. They found that the most important factor leading to diagnostic delay was a history of recurrent attacks of acute abdominal pain rather than an uninterrupted course of symptoms. This was thought to reflect temporary resolution of an acute attack due to relief of appendiceal obstruction. Misdiagnoses in this series tended toward age and sex specificity; namely, women of child-bearing age were diagnosed as having pelvic inflammatory disease, and older patients were frequently thought to have diverticulitis. Precedent viral illnesses such as gastroenteritis contributed to diagnostic delay. Symptoms were occasionally blunted by intercurrent chronic illness, such as diabetes mellitus, diabetics being known to have a poor perception of both visceral and somatic pain. It is understandable, to some extent, that diagnostic accuracy is low. We are, after all, attempting to make a diagnosis where there is neither a consistent clinical course nor definitive laboratory tests or imaging studies. Unfortunately, the expectations of patients and families regarding diagnosis do not reflect this difficulty. Every lay person knows that abdominal pain (and certainly right-sided pain) represents
“In a typical case You will soon find the place From where the acute pain arises But so often you’ll find Symptoms act as a blind And your life will be full of surprises.” ( 1) Rothrock and colleagues in this issue (2) present a report on appendicitis in women of child-bearing age. They determine that one-third of the patients they evaluated were initially misdiagnosed. Those who were misdiagnosed were more likely to have atypical physical findings and frequently exhibited more positive findings on pelvic examination than did women who were diagnosed correctly. The authors had previously examined clinical aspects of missed appendicitis in children (3). In that series, misdiagnosed cases were likely to display atypical symptoms, especially those of respiratory infection. These reports and others point out that acute appendicitis continues to represent a challenge to the emergency physician. Although a number of important diagnostic and surgical advances in the acute abdomen have occurred within the past decade, and although mortality related to appendicitis has declined, diagnostic accuracy has not improved. Delays in operative intervention occur in as many as 28% of cases (4). As the article by Rothrock et al. points out (and Cope implies in his verse), diagnosis of the obvious case is readily achieved, inasmuch as the clinical picture is typical. More subtle and atypical cases, however, are problematic. Efforts at improving diagnostic accuracy have included a number of approaches. One area of investigation has involved the applica95
96
The Journal of Emergency Medicine
appendicitis. Why, then, can the diagnosis be so difficult for the physician? Part of the difficulty lies in evaluating the patient only on one point on the temporal curve of the illness. Perhaps the most consistent aspect of the clinical history is the complaint of pain that started somewhere and subsequently moved to another location. Unfortunately, even this may not be reported in a significant number of cases. However, when the emergency physician attempts to apply all diagnostic efforts on a single history and physical examination, it is not difficult to see how the diagnosis can be missed. The typical clinical picture may evolve over time and subsequently make the final diagnosis easier to see. One recommendation is to observe the patient who is not easy to define. This can be done in one of three ways: keep the patient in the emergency department and reexamine; discharge the patient to return for reexamination by the same physician; admit the patient to a surgical service. Another recommendation is to not assume too much pride in one’s diagnostic acumen. Share the experience with a surgeon who will have to make the decision to operate. Paul Harper, Professor of Surgery at the University of Chicago, where one of us (P.R.) trained in surgery, once said: “Share responsibility. If you share it often enough, it will disappear.” Don’t be afraid to involve a consultant, even at odd hours. Yet another aspect lies in accepting that it will not be possible to provide a diagnosis for every abdominal pain. In Lewis and Dunphy’s series of 1,000 appendicitis cases from San Francisco General Hospi-
tal, of the patients who were operated upon with a preoperative diagnosis of appendicitis, roughly onethird never had a diagnosis made of the cause of their abdominal pain (10). These were patients who had laboratory findings consistent with appendicitis, as well as multiple examinations by the usual hierarchy of surgical house officers, with physical findings also consistent with the entity. There is a modern reluctance to operate upon a patient and find a normal appendix. Whereas diagnostic accuracy can be increased in the male patient, there is, at present, no way short of laparoscopy to substantially increase the accuracy in the female patient. The magnitude of this problem is one of the areas presented by Rothrock. A certain number of normal appendices will have to be removed to avoid an increase in the number of ruptured appendices with peritonitis. We require a better diagnostic mousetrap to apprehend the appendiceal rodent. Until such a definitive laboratory test, imaging study, or new technology appears, we must accept the reality that this is a disease that is mysterious in origin, uncertain in course, and difficult in its proof. Continuing investigation indicates that the diagnosis of appendicitis remains difficult in cases presenting in atypical fashion. The life of the clinician encountering such cases continues to include the risk of surprises. George Sternbach, MD Associate Editor Peter Rosen, MD, Editor-in-Chief
REFERENCES 1. Cope Z. The acute abdomen in rhyme, 5th ed. London: H. K. Lewis&Co., Ltd.; 1972. 2. Rothroclc SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in nonpregnant women of childbearing age. J Emerg Med. 1995;13:1-8. 3. Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med. 1991; 20:45-50. 4. Browder W, Smith JW, Vivoda LM, et al. Nonperforative appendicitis: a continuing surgical dilemma. J Infect Dis. 1989;159:1088-94. 5. Van Way CW III, Murphy JR, Dunn EL, et al. A feasibility study of computer aided diagnosis in appendicitis. Surg Gyneco1 Obstet. 1982;155:685-8.
6. Teicher I, Landa B, Cohen M, et al. Scoring system to aid in diagnosis of appendicitis. Ann Surg. 1983;198:753-8. 7. Christian F, Christian GP. A simple scoring system to reduce the negative appendectomy rate. Ann R Co11Surg Engl. 1992; 74:281-5. 8. Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study of ultrasonography in the diagnosis of appendicitis. N Engl J Med. 1987;317:666-9. 9. Buchman TG, Zuidema GD. Reasons for delay of the diagnosis of acuteappendicitis. Surg GynecolObstet. 1984,158:260-6, 10. Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis. A critical review of diagnosis and treatment in 1,000 cases. Arch Surg. 1975; 110:677-84.
Pergamon
Medicine, Vol 13, No 1, pp 95-96, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in the USA. AU rights reserved 0736-4679/95 $9.50 + .OO
0736-4679( 94)00127-8
Editorial
APPENDICITIS:
A CONTINUING
DIAGNOSTIC
In the rhyming version of his classic monograph on the acute abdomen, Zachary Cope summarized the problem of atypically presenting appendicitis in the following way:
CHALLENGE
tion of computer-aided diagnosis. This method, however, has not been shown to be more effective in the diagnosis of appendicitis than traditional clinical techniques (5). The use of scoring systems to quantify diagnostic parameters has, likewise, not met with significant success (6). Such systems have been utilized more effectively to reduce the negative appendectomy rate than to improve diagnostic efficiency (6,7). Although ultrasonography can occasionally aid in the diagnosis of appendicitis, it has not been shown to be of benefit on a routine basis (8). The foundation for diagnosis of appendicitis continues to be predominantly the skills of the examining clinician. A decade ago, Buchman and Zuidema (9) studied the reasons for which delays in the diagnosis of acute appendicitis occurred. They found that the most important factor leading to diagnostic delay was a history of recurrent attacks of acute abdominal pain rather than an uninterrupted course of symptoms. This was thought to reflect temporary resolution of an acute attack due to relief of appendiceal obstruction. Misdiagnoses in this series tended toward age and sex specificity; namely, women of child-bearing age were diagnosed as having pelvic inflammatory disease, and older patients were frequently thought to have diverticulitis. Precedent viral illnesses such as gastroenteritis contributed to diagnostic delay. Symptoms were occasionally blunted by intercurrent chronic illness, such as diabetes mellitus, diabetics being known to have a poor perception of both visceral and somatic pain. It is understandable, to some extent, that diagnostic accuracy is low. We are, after all, attempting to make a diagnosis where there is neither a consistent clinical course nor definitive laboratory tests or imaging studies. Unfortunately, the expectations of patients and families regarding diagnosis do not reflect this difficulty. Every lay person knows that abdominal pain (and certainly right-sided pain) represents
“In a typical case You will soon find the place From where the acute pain arises But so often you’ll find Symptoms act as a blind And your life will be full of surprises.” ( 1) Rothrock and colleagues in this issue (2) present a report on appendicitis in women of child-bearing age. They determine that one-third of the patients they evaluated were initially misdiagnosed. Those who were misdiagnosed were more likely to have atypical physical findings and frequently exhibited more positive findings on pelvic examination than did women who were diagnosed correctly. The authors had previously examined clinical aspects of missed appendicitis in children (3). In that series, misdiagnosed cases were likely to display atypical symptoms, especially those of respiratory infection. These reports and others point out that acute appendicitis continues to represent a challenge to the emergency physician. Although a number of important diagnostic and surgical advances in the acute abdomen have occurred within the past decade, and although mortality related to appendicitis has declined, diagnostic accuracy has not improved. Delays in operative intervention occur in as many as 28% of cases (4). As the article by Rothrock et al. points out (and Cope implies in his verse), diagnosis of the obvious case is readily achieved, inasmuch as the clinical picture is typical. More subtle and atypical cases, however, are problematic. Efforts at improving diagnostic accuracy have included a number of approaches. One area of investigation has involved the applica95
96
The Journal of Emergency Medicine
appendicitis. Why, then, can the diagnosis be so difficult for the physician? Part of the difficulty lies in evaluating the patient only on one point on the temporal curve of the illness. Perhaps the most consistent aspect of the clinical history is the complaint of pain that started somewhere and subsequently moved to another location. Unfortunately, even this may not be reported in a significant number of cases. However, when the emergency physician attempts to apply all diagnostic efforts on a single history and physical examination, it is not difficult to see how the diagnosis can be missed. The typical clinical picture may evolve over time and subsequently make the final diagnosis easier to see. One recommendation is to observe the patient who is not easy to define. This can be done in one of three ways: keep the patient in the emergency department and reexamine; discharge the patient to return for reexamination by the same physician; admit the patient to a surgical service. Another recommendation is to not assume too much pride in one’s diagnostic acumen. Share the experience with a surgeon who will have to make the decision to operate. Paul Harper, Professor of Surgery at the University of Chicago, where one of us (P.R.) trained in surgery, once said: “Share responsibility. If you share it often enough, it will disappear.” Don’t be afraid to involve a consultant, even at odd hours. Yet another aspect lies in accepting that it will not be possible to provide a diagnosis for every abdominal pain. In Lewis and Dunphy’s series of 1,000 appendicitis cases from San Francisco General Hospi-
tal, of the patients who were operated upon with a preoperative diagnosis of appendicitis, roughly onethird never had a diagnosis made of the cause of their abdominal pain (10). These were patients who had laboratory findings consistent with appendicitis, as well as multiple examinations by the usual hierarchy of surgical house officers, with physical findings also consistent with the entity. There is a modern reluctance to operate upon a patient and find a normal appendix. Whereas diagnostic accuracy can be increased in the male patient, there is, at present, no way short of laparoscopy to substantially increase the accuracy in the female patient. The magnitude of this problem is one of the areas presented by Rothrock. A certain number of normal appendices will have to be removed to avoid an increase in the number of ruptured appendices with peritonitis. We require a better diagnostic mousetrap to apprehend the appendiceal rodent. Until such a definitive laboratory test, imaging study, or new technology appears, we must accept the reality that this is a disease that is mysterious in origin, uncertain in course, and difficult in its proof. Continuing investigation indicates that the diagnosis of appendicitis remains difficult in cases presenting in atypical fashion. The life of the clinician encountering such cases continues to include the risk of surprises. George Sternbach, MD Associate Editor Peter Rosen, MD, Editor-in-Chief
REFERENCES 1. Cope Z. The acute abdomen in rhyme, 5th ed. London: H. K. Lewis&Co., Ltd.; 1972. 2. Rothroclc SG, Green SM, Dobson M, et al. Misdiagnosis of appendicitis in nonpregnant women of childbearing age. J Emerg Med. 1995;13:1-8. 3. Rothrock SG, Skeoch G, Rush JJ, et al. Clinical features of misdiagnosed appendicitis in children. Ann Emerg Med. 1991; 20:45-50. 4. Browder W, Smith JW, Vivoda LM, et al. Nonperforative appendicitis: a continuing surgical dilemma. J Infect Dis. 1989;159:1088-94. 5. Van Way CW III, Murphy JR, Dunn EL, et al. A feasibility study of computer aided diagnosis in appendicitis. Surg Gyneco1 Obstet. 1982;155:685-8.
6. Teicher I, Landa B, Cohen M, et al. Scoring system to aid in diagnosis of appendicitis. Ann Surg. 1983;198:753-8. 7. Christian F, Christian GP. A simple scoring system to reduce the negative appendectomy rate. Ann R Co11Surg Engl. 1992; 74:281-5. 8. Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study of ultrasonography in the diagnosis of appendicitis. N Engl J Med. 1987;317:666-9. 9. Buchman TG, Zuidema GD. Reasons for delay of the diagnosis of acuteappendicitis. Surg GynecolObstet. 1984,158:260-6, 10. Lewis FR, Holcroft JW, Boey J, Dunphy JE. Appendicitis. A critical review of diagnosis and treatment in 1,000 cases. Arch Surg. 1975; 110:677-84.