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Left-sided Acute Appendicitis: A Pitfall in the Emergency Department
The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 980–982, 2012 Copyright Ó 2012 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
doi:10.1016/j.jemermed.2010.11.056
Clinical Communications: Adults LEFT-SIDED ACUTE APPENDICITIS: A PITFALL IN THE EMERGENCY DEPARTMENT Chih-Ying Yang, MD,*1 Hsiao-Yen Liu, MD,*1 Hsing-Lin Lin, MD,† and Jiun-Nong Lin, MD* *Department of Emergency Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan, and †Departments of Emergency Medicine and Trauma, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Reprint Address: Jiun-Nong Lin, MD, 1 E-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County 824, Taiwan
, Abstract—Background: Acute appendicitis continues to be a condition at high risk for missed and delayed diagnosis. It characteristically presents with right lower quadrant pain after vague epigastric or periumbilical discomfort. Leftsided appendicitis is an atypical presentation and has been reported rarely. The majority of these cases have been described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix. We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon. Objectives: To alert emergency physicians to an anatomical anomaly that could delay the diagnosis of appendicitis. Case Report: A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant. Abdominal computed tomography scan revealed a redundant, floating, ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. Exploratory laparotomy was performed and perforated appendicitis with turbid ascites was found during the surgery. Appendectomy was performed and the patient recovered uneventfully. Conclusion: This case is presented to increase awareness among emergency physicians of this anatomical variant and atypical presentation of appendicitis. Ó 2012 Elsevier Inc.
INTRODUCTION Abdominal pain is a common reason for emergent visits to the emergency department (ED) and may be caused by protean conditions including acute appendicitis. Typically, patients with acute appendicitis present with unresolved abdominal pain over the right lower quadrant after vague epigastric or periumbilical abdominal pain. Although it is the most frequent abdominal disease requiring surgical intervention in EDs, appendicitis continues to be a condition at risk for missed or delayed diagnosis due to certain pitfalls (1). Thorough history-taking, comprehensive physical examination, laboratory investigations, and physician experience play important roles in the accurate diagnosis of appendicitis (2). Left-sided appendicitis is rarely encountered in the ED and this condition is difficult to diagnose unless there is an acknowledged history of situs inversus or intestinal malrotation (3–7). Early suspicion and a proper use of imaging tools can prevent delayed diagnosis of this disease and avoid complications such as perforation and peritonitis (6,8,9). We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon.
, Keywords—left-sided acute appendicitis; computed tomography; floating colon; emergency pitfall
CASE REPORT
1
A 50-year-old hypertensive man presented to our ED with persistent abdominal pain over the left lower quadrant of his abdomen for 7 h duration. Except for poor appetite,
C.-Y. Yang and H.-Y. Liu contributed equally to this work.
RECEIVED: 2 February 2010; FINAL SUBMISSION RECEIVED: 18 June 2010; ACCEPTED: 21 November 2010 980
Left-sided Acute Appendicitis
there were no other associated gastrointestinal symptoms or signs such as vomiting, diarrhea, constipation, melena, or hematochezia. On admission, he was febrile (38.9 C) and his vital signs were as follows: blood pressure 156/ 100 mm Hg, pulse rate 81 beats/min, and respiratory rate 20 breaths/min. Physical examination revealed tenderness over the left lower abdomen with localized rebound tenderness and guarding. No costovertebral tenderness, testicular tenderness, or inguinal masses were observed. Complete blood count revealed a hemoglobin of 15.2 g/dL, a white blood cell count (WBC) of 17,900/mm3 with neutrophils of 83%, and a platelet count of 327,000/mm3. The blood biochemistry analyses, including blood sugar, kidney function, liver function, and electrolytes, were within normal limits. Urinalysis showed microscopic hematuria with a red blood cell count of 3–5 per high power field. Left decubitus abdominal plain film X-ray study showed no intra-abdominal free air. Abdominal computed tomography scan was performed 1½ h later due to persistent left lower quadrant pain. A redundant floating ascending colon was discovered and the appendix was adherent to the left abdomen. Left-sided acute appendicitis was considered due to infiltration of peritoneal fat surrounding the dilated appendix, which contained fluid and two radiopaque appendicoliths (Figures 1, 2). Exploratory laparotomy was recommended, but the patient refused. Cefazolin, gentamicin, and metronidazole were administered and the patient was discharged 5 days later when his symptoms improved. Unfortunately, he presented to the ED again, 2½ months later, due to similar abdominal pain. Physical examination still revealed localized tenderness over
981
Figure 2. Coronal view of abdominal computed tomography scan demonstrates acute appendicitis with an appendicolith (arrow) at the tip of the dilatated appendix, which adheres to the descending colon over the left side of the abdomen.
the left lower abdomen. Abdominal computed tomography scan was performed again and the findings were comparable to the previous scan. A laparotomy was performed and a redundant, floating, ascending colon and cecum were found to adhere to the descending colon over the left lower abdomen. Perforated appendicitis with turbid ascites was discovered during the surgery. An appendectomy was performed, and the patient recovered uneventfully. DISCUSSION
Figure 1. Transverse section of abdominal computed tomography scan shows a sausage-shaped dilatated appendix with an appendicolith (arrow) in the lumen accompanied by inflammation of the surrounding peritoneal fat.
Acute appendicitis is an inflammation of the appendix. It is one of the most common causes of acute abdominal pain requiring surgical intervention as an emergency (2,10). In its typical presentation, acute appendicitis begins with a vague abdominal discomfort around the epigastric or periumbilical region, which is accompanied by nausea and, occasionally, vomiting. Several hours later, the pain might shift to the right lower part of the abdomen, near McBurney’s point (2). Fever and loss of appetite also may be noted. However, the typical presentation occurs in only about 60% of patients (11). Despite its prevalence and the advancement of imaging tools, appendicitis continues to be a condition at high risk for missed and delayed diagnosis (1).
982
C.-Y. Yang et al.
There is no test specific for the diagnosis of acute appendicitis. Although a high WBC count is frequently found in this setting, it is not a reliable predictor of appendicitis (12). C-reactive protein (CRP) value alone also reveals poor specificity. Although a high WBC count and high CRP value do not effectively establish the diagnosis of appendicitis, some studies have found a high negative predictive value when the WBC count, neutrophil count, and CRP value were all within normal limits (13,14). Urinalysis is usually obtained in patients with right lower quadrant pain to exclude the possibility of urolithiasis or urinary tract infection. Pyuria or microscopic hematuria caused by the proximate location of the inflamed appendix to the ureter and bladder may confound the diagnosis of acute appendicitis. Left lower abdominal pain may be caused by many conditions, including left acute pyelonephritis, left renal stone, left ureteral stone, diverticulitis, irritable bowel syndrome, Crohn disease, ulcerative colitis, vascular disease, muscle origin, ectopic pregnancy, left ovarian disease, and infection of the left fallopian tubes (10,11). Acute appendicitis is rarely considered in the differential diagnosis of left lower abdominal pain. The majority of cases with left lower abdominal pain are described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix (3–7,9,11). To the best of our knowledge, left-sided appendicitis occurring in a patient with a redundant, hypermobile, and floating ascending colon has not been previously reported. In this case, the redundant ascending colon and cecum were poorly fixed to the posterior peritoneum, which made them become hypermobile, moving to adhere to the left side of the abdomen. CONCLUSION This atypical presentation of acute appendicitis in the left abdomen presents a diagnostic challenge and is fraught
with potential pitfalls. The accurate diagnosis of leftsided acute appendicitis relies on comprehensive history-taking, physical examination, laboratory testing, and rational imaging studies. It is important for the physician to be aware of the unique clinical manifestations of left-sided acute appendicitis so that appropriate surgical intervention may be offered early to avoid the complications of acute appendicitis.
REFERENCES 1. Old JL, Dusing RW, Yap W, Dirks J. Imaging for suspected appendicitis. Am Fam Physician 2005;71:71–7. 2. Vissers RJ, Lennarz WB. Pitfalls in appendicitis. Emerg Med Clin North Am 2010;28:103–18. 3. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653–71. 4. Hollander SC, Springer SA. The diagnosis of acute left-sided appendicitis with computed tomography. Pediatr Radiol 2003;33: 70–1. 5. Hou S, Chern C, How C, et al. Diagnosis of appendicitis with left lower quadrant pain. J Chin Med Assoc 2005;68:599–603. 6. Pillay SP. Perforated appendix in situs inversus viscerum. A case report. S Afr Med J 1976;50:141–3. 7. Israelit S, Brook OR, Nira B, Guralnik L, Hershko D. Left-sided perforated acute appendicitis in an adult with midgut malrotation: the role of computed tomography. Emerg Radiol 2009;16:217–8. 8. Welte FJ, Grosso M. Left-sided appendicitis in a patient with congenital gastrointestinal malrotation: a case report. J Med Case Reports 2007;1:92. 9. Ratani RS, Haller JO, Wang WY, Yang DC. Role of CT in left-sided acute appendicitis: case report. Abdom Imaging 2002;27:18–9. 10. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician 2008;77:971–8. 11. Nelson MJ, Pesola GR. Left lower quadrant pain of unusual cause. J Emerg Med 2001;20:241–5. 12. Cardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med 2004;11:1021–7. 13. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28–37. 14. Dueholm S, Bagi P, Bud M. Laboratory aid in the diagnosis of acute appendicitis. Dis Colon Rectum 1989;32:855–9.
doi:10.1016/j.jemermed.2010.11.056
Clinical Communications: Adults LEFT-SIDED ACUTE APPENDICITIS: A PITFALL IN THE EMERGENCY DEPARTMENT Chih-Ying Yang, MD,*1 Hsiao-Yen Liu, MD,*1 Hsing-Lin Lin, MD,† and Jiun-Nong Lin, MD* *Department of Emergency Medicine, E-Da Hospital/I-Shou University, Kaohsiung County, Taiwan, and †Departments of Emergency Medicine and Trauma, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Reprint Address: Jiun-Nong Lin, MD, 1 E-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County 824, Taiwan
, Abstract—Background: Acute appendicitis continues to be a condition at high risk for missed and delayed diagnosis. It characteristically presents with right lower quadrant pain after vague epigastric or periumbilical discomfort. Leftsided appendicitis is an atypical presentation and has been reported rarely. The majority of these cases have been described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix. We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon. Objectives: To alert emergency physicians to an anatomical anomaly that could delay the diagnosis of appendicitis. Case Report: A 50-year-old man presented with fever and left lower abdominal pain. Physical examination revealed local tenderness over the left lower quadrant. Abdominal computed tomography scan revealed a redundant, floating, ascending colon and inflammatory appendix adhering to the descending colon over the left lower abdomen. Exploratory laparotomy was performed and perforated appendicitis with turbid ascites was found during the surgery. Appendectomy was performed and the patient recovered uneventfully. Conclusion: This case is presented to increase awareness among emergency physicians of this anatomical variant and atypical presentation of appendicitis. Ó 2012 Elsevier Inc.
INTRODUCTION Abdominal pain is a common reason for emergent visits to the emergency department (ED) and may be caused by protean conditions including acute appendicitis. Typically, patients with acute appendicitis present with unresolved abdominal pain over the right lower quadrant after vague epigastric or periumbilical abdominal pain. Although it is the most frequent abdominal disease requiring surgical intervention in EDs, appendicitis continues to be a condition at risk for missed or delayed diagnosis due to certain pitfalls (1). Thorough history-taking, comprehensive physical examination, laboratory investigations, and physician experience play important roles in the accurate diagnosis of appendicitis (2). Left-sided appendicitis is rarely encountered in the ED and this condition is difficult to diagnose unless there is an acknowledged history of situs inversus or intestinal malrotation (3–7). Early suspicion and a proper use of imaging tools can prevent delayed diagnosis of this disease and avoid complications such as perforation and peritonitis (6,8,9). We report a case of left-sided acute appendicitis occurring in a patient with a redundant and hypermobile ascending colon.
, Keywords—left-sided acute appendicitis; computed tomography; floating colon; emergency pitfall
CASE REPORT
1
A 50-year-old hypertensive man presented to our ED with persistent abdominal pain over the left lower quadrant of his abdomen for 7 h duration. Except for poor appetite,
C.-Y. Yang and H.-Y. Liu contributed equally to this work.
RECEIVED: 2 February 2010; FINAL SUBMISSION RECEIVED: 18 June 2010; ACCEPTED: 21 November 2010 980
Left-sided Acute Appendicitis
there were no other associated gastrointestinal symptoms or signs such as vomiting, diarrhea, constipation, melena, or hematochezia. On admission, he was febrile (38.9 C) and his vital signs were as follows: blood pressure 156/ 100 mm Hg, pulse rate 81 beats/min, and respiratory rate 20 breaths/min. Physical examination revealed tenderness over the left lower abdomen with localized rebound tenderness and guarding. No costovertebral tenderness, testicular tenderness, or inguinal masses were observed. Complete blood count revealed a hemoglobin of 15.2 g/dL, a white blood cell count (WBC) of 17,900/mm3 with neutrophils of 83%, and a platelet count of 327,000/mm3. The blood biochemistry analyses, including blood sugar, kidney function, liver function, and electrolytes, were within normal limits. Urinalysis showed microscopic hematuria with a red blood cell count of 3–5 per high power field. Left decubitus abdominal plain film X-ray study showed no intra-abdominal free air. Abdominal computed tomography scan was performed 1½ h later due to persistent left lower quadrant pain. A redundant floating ascending colon was discovered and the appendix was adherent to the left abdomen. Left-sided acute appendicitis was considered due to infiltration of peritoneal fat surrounding the dilated appendix, which contained fluid and two radiopaque appendicoliths (Figures 1, 2). Exploratory laparotomy was recommended, but the patient refused. Cefazolin, gentamicin, and metronidazole were administered and the patient was discharged 5 days later when his symptoms improved. Unfortunately, he presented to the ED again, 2½ months later, due to similar abdominal pain. Physical examination still revealed localized tenderness over
981
Figure 2. Coronal view of abdominal computed tomography scan demonstrates acute appendicitis with an appendicolith (arrow) at the tip of the dilatated appendix, which adheres to the descending colon over the left side of the abdomen.
the left lower abdomen. Abdominal computed tomography scan was performed again and the findings were comparable to the previous scan. A laparotomy was performed and a redundant, floating, ascending colon and cecum were found to adhere to the descending colon over the left lower abdomen. Perforated appendicitis with turbid ascites was discovered during the surgery. An appendectomy was performed, and the patient recovered uneventfully. DISCUSSION
Figure 1. Transverse section of abdominal computed tomography scan shows a sausage-shaped dilatated appendix with an appendicolith (arrow) in the lumen accompanied by inflammation of the surrounding peritoneal fat.
Acute appendicitis is an inflammation of the appendix. It is one of the most common causes of acute abdominal pain requiring surgical intervention as an emergency (2,10). In its typical presentation, acute appendicitis begins with a vague abdominal discomfort around the epigastric or periumbilical region, which is accompanied by nausea and, occasionally, vomiting. Several hours later, the pain might shift to the right lower part of the abdomen, near McBurney’s point (2). Fever and loss of appetite also may be noted. However, the typical presentation occurs in only about 60% of patients (11). Despite its prevalence and the advancement of imaging tools, appendicitis continues to be a condition at high risk for missed and delayed diagnosis (1).
982
C.-Y. Yang et al.
There is no test specific for the diagnosis of acute appendicitis. Although a high WBC count is frequently found in this setting, it is not a reliable predictor of appendicitis (12). C-reactive protein (CRP) value alone also reveals poor specificity. Although a high WBC count and high CRP value do not effectively establish the diagnosis of appendicitis, some studies have found a high negative predictive value when the WBC count, neutrophil count, and CRP value were all within normal limits (13,14). Urinalysis is usually obtained in patients with right lower quadrant pain to exclude the possibility of urolithiasis or urinary tract infection. Pyuria or microscopic hematuria caused by the proximate location of the inflamed appendix to the ureter and bladder may confound the diagnosis of acute appendicitis. Left lower abdominal pain may be caused by many conditions, including left acute pyelonephritis, left renal stone, left ureteral stone, diverticulitis, irritable bowel syndrome, Crohn disease, ulcerative colitis, vascular disease, muscle origin, ectopic pregnancy, left ovarian disease, and infection of the left fallopian tubes (10,11). Acute appendicitis is rarely considered in the differential diagnosis of left lower abdominal pain. The majority of cases with left lower abdominal pain are described to be associated with congenital midgut malrotation, situs inversus, or an extremely long appendix (3–7,9,11). To the best of our knowledge, left-sided appendicitis occurring in a patient with a redundant, hypermobile, and floating ascending colon has not been previously reported. In this case, the redundant ascending colon and cecum were poorly fixed to the posterior peritoneum, which made them become hypermobile, moving to adhere to the left side of the abdomen. CONCLUSION This atypical presentation of acute appendicitis in the left abdomen presents a diagnostic challenge and is fraught
with potential pitfalls. The accurate diagnosis of leftsided acute appendicitis relies on comprehensive history-taking, physical examination, laboratory testing, and rational imaging studies. It is important for the physician to be aware of the unique clinical manifestations of left-sided acute appendicitis so that appropriate surgical intervention may be offered early to avoid the complications of acute appendicitis.
REFERENCES 1. Old JL, Dusing RW, Yap W, Dirks J. Imaging for suspected appendicitis. Am Fam Physician 2005;71:71–7. 2. Vissers RJ, Lennarz WB. Pitfalls in appendicitis. Emerg Med Clin North Am 2010;28:103–18. 3. Graffeo CS, Counselman FL. Appendicitis. Emerg Med Clin North Am 1996;14:653–71. 4. Hollander SC, Springer SA. The diagnosis of acute left-sided appendicitis with computed tomography. Pediatr Radiol 2003;33: 70–1. 5. Hou S, Chern C, How C, et al. Diagnosis of appendicitis with left lower quadrant pain. J Chin Med Assoc 2005;68:599–603. 6. Pillay SP. Perforated appendix in situs inversus viscerum. A case report. S Afr Med J 1976;50:141–3. 7. Israelit S, Brook OR, Nira B, Guralnik L, Hershko D. Left-sided perforated acute appendicitis in an adult with midgut malrotation: the role of computed tomography. Emerg Radiol 2009;16:217–8. 8. Welte FJ, Grosso M. Left-sided appendicitis in a patient with congenital gastrointestinal malrotation: a case report. J Med Case Reports 2007;1:92. 9. Ratani RS, Haller JO, Wang WY, Yang DC. Role of CT in left-sided acute appendicitis: case report. Abdom Imaging 2002;27:18–9. 10. Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician 2008;77:971–8. 11. Nelson MJ, Pesola GR. Left lower quadrant pain of unusual cause. J Emerg Med 2001;20:241–5. 12. Cardall T, Glasser J, Guss DA. Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis. Acad Emerg Med 2004;11:1021–7. 13. Andersson RE. Meta-analysis of the clinical and laboratory diagnosis of appendicitis. Br J Surg 2004;91:28–37. 14. Dueholm S, Bagi P, Bud M. Laboratory aid in the diagnosis of acute appendicitis. Dis Colon Rectum 1989;32:855–9.