Ok, appendicitis IS annoying

[DrQuinn]

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So, when I was a wee M3, back in... 2002, the general surgeon I did my rotation with told me "Quinn, Appendicits is the greatest pain in the ass." I said to him (and i really did) "No way, its so obvious! Fever, RLQ pain, boom, done!" He said "You'll see."

Fast forward 5 years.

Yesterday.

20 year old female. RLQ pain. 24 hours. anorexia. fevers. no urinary symptoms. no vag discharge. healthy. nausea. ride over hurt. RLQ pain. + Rovsings. + Psoas. + obturator. hit the bed with your knee, boom, hurts her RLQ right at McB's. negative pelvic exam. +WBC. +tachycardia. smidge of a dirty urine. BOOM, slam dunk, eh?

Negative CT with PO contrast.

same shift. 48 year old female. RLQ pain for a week. no f/c. no n/v. appetite great "can I eat?" no wbc. no tachycardia. no pain at McB's. negative rest of exam. no urinary symptoms. labs ALL completely normal. maybe a smidge of pain at right inguinal area/3 cm below McB's. pelvic normal. CT scan: classic appy.

WTF! How annoying. Seriously. Beer #5 right now.
Q

 

[JkGrocerz]

So, when I was a wee M3, back in... 2002, the general surgeon I did my rotation with told me "Quinn, Appendicits is the greatest pain in the ass." I said to him (and i really did) "No way, its so obvious! Fever, RLQ pain, boom, done!" He said "You'll see."

Fast forward 5 years.

Yesterday.

20 year old female. RLQ pain. 24 hours. anorexia. fevers. no urinary symptoms. no vag discharge. healthy. nausea. ride over hurt. RLQ pain. + Rovsings. + Psoas. + obturator. hit the bed with your knee, boom, hurts her RLQ right at McB's. negative pelvic exam. +WBC. +tachycardia. smidge of a dirty urine. BOOM, slam dunk, eh?

Negative CT with PO contrast.

same shift. 48 year old female. RLQ pain for a week. no f/c. no n/v. appetite great "can I eat?" no wbc. no tachycardia. no pain at McB's. negative rest of exam. no urinary symptoms. labs ALL completely normal. maybe a smidge of pain at right inguinal area/3 cm below McB's. pelvic normal. CT scan: classic appy.

WTF! How annoying. Seriously. Beer #5 right now.
Q

I just had a 10 year old with intermittent LUQ abd. pain X 2 MONTHS sent in by pmd for evaluation of colitis. no anorexia fever chills. would occasionaly vomit if he ate too much when having the pain. vitals stable, afebrile, exam was benign. elevated white count 13 CT showed early appy. 😱

 

[Dr.Evil1]

So, when I was a wee M3, back in... 2002, the general surgeon I did my rotation with told me "Quinn, Appendicits is the greatest pain in the ass." I said to him (and i really did) "No way, its so obvious! Fever, RLQ pain, boom, done!" He said "You'll see."

Fast forward 5 years.

Yesterday.

20 year old female. RLQ pain. 24 hours. anorexia. fevers. no urinary symptoms. no vag discharge. healthy. nausea. ride over hurt. RLQ pain. + Rovsings. + Psoas. + obturator. hit the bed with your knee, boom, hurts her RLQ right at McB's. negative pelvic exam. +WBC. +tachycardia. smidge of a dirty urine. BOOM, slam dunk, eh?

Negative CT with PO contrast.

same shift. 48 year old female. RLQ pain for a week. no f/c. no n/v. appetite great "can I eat?" no wbc. no tachycardia. no pain at McB's. negative rest of exam. no urinary symptoms. labs ALL completely normal. maybe a smidge of pain at right inguinal area/3 cm below McB's. pelvic normal. CT scan: classic appy.

WTF! How annoying. Seriously. Beer #5 right now.
Q

Why did you get the CT on the 48 yo female? Just curious.

I am a PGY2 EM resident. In all my medical school and residency I have NEVER seen or diagnosed appendicitis. That INCLUDES 8 weeks of general surg as a medical student and 6 weeks as an intern. I don't know what is wrong with me.

 

[DrQuinn]

Why did you get the CT on the 48 yo female? Just curious.

I am a PGY2 EM resident. In all my medical school and residency I have NEVER seen or diagnosed appendicitis. That INCLUDES 8 weeks of general surg as a medical student and 6 weeks as an intern. I don't know what is wrong with me.

Well, she did have a little bit of pain deep down in her RLQ near her pelvic brim. I observed her in the ED over a couple of hours, and her pain never got better (even though constitutionally she felt good). I could easily convince myself it was nothing, but she did wince.

When teh radiologist called, I literally did a "WTF" over the phone. Funny thing is, I told him this "wow, I mean, her pain was really really low in her pelvic brim, almost along the inside of her iliac."
Radiologist: "Yup, she's got a very low lying appy!"

Man I love our radiologists.

Weird case.
Q

 

[JkGrocerz]

Well, she did have a little bit of pain deep down in her RLQ near her pelvic brim. I observed her in the ED over a couple of hours, and her pain never got better (even though constitutionally she felt good). I could easily convince myself it was nothing, but she did wince.

When teh radiologist called, I literally did a "WTF" over the phone. Funny thing is, I told him this "wow, I mean, her pain was really really low in her pelvic brim, almost along the inside of her iliac."
Radiologist: "Yup, she's got a very low lying appy!"

Man I love our radiologists.

Weird case.
Q

another appy case i had a few months ago was in an 82 year old guy, had periumb/rlq pain. my attd and I were not thinking an appy on this old dude so we ordered a non contrast ct and this guy had a perforated appendix.... we were both like "wtf?!"

 

[dlung]

Why did you get the CT on the 48 yo female? Just curious.

I am a PGY2 EM resident. In all my medical school and residency I have NEVER seen or diagnosed appendicitis. That INCLUDES 8 weeks of general surg as a medical student and 6 weeks as an intern. I don't know what is wrong with me.

well... detroit is kind of a rough town...

 

[RayF]

I was just being schooled on the 75/25 rule of "when in doubt, cut it out" provided u have a clean urine.. even w/o clear CT! but then, the same day, there was talk of the 99/1 rule by another doc.
confusing.

 

[edinOH]

So, when I was a wee M3, back in... 2002, the general surgeon I did my rotation with told me "Quinn, Appendicits is the greatest pain in the ass." I said to him (and i really did) "No way, its so obvious! Fever, RLQ pain, boom, done!" He said "You'll see."

Fast forward 5 years.

Yesterday.

20 year old female. RLQ pain. 24 hours. anorexia. fevers. no urinary symptoms. no vag discharge. healthy. nausea. ride over hurt. RLQ pain. + Rovsings. + Psoas. + obturator. hit the bed with your knee, boom, hurts her RLQ right at McB's. negative pelvic exam. +WBC. +tachycardia. smidge of a dirty urine. BOOM, slam dunk, eh?

Negative CT with PO contrast.

same shift. 48 year old female. RLQ pain for a week. no f/c. no n/v. appetite great "can I eat?" no wbc. no tachycardia. no pain at McB's. negative rest of exam. no urinary symptoms. labs ALL completely normal. maybe a smidge of pain at right inguinal area/3 cm below McB's. pelvic normal. CT scan: classic appy.

WTF! How annoying. Seriously. Beer #5 right now.
Q

I would still argue the first patient may have an appy.

Was a surgeon consulted? What was your dispo?

 

[DrQuinn]

I would still argue the first patient may have an appy.

Was a surgeon consulted? What was your dispo?

Yeah, I called surgery right when I saw her. They said "We don't take girls to the OR with an appy unless they have a CT." Whatever. Fair enough, I suppose, keeps the OB GYN residents from coming down for BS consults.

Anyways, I signed her out with the presumptive Dx of appy, and told the other doc to call Surgery when the CT was done. They did, they consulted, and radiologist read it as a completely normal appendix. She did have a dirty urine, so the Dx was cystitis.

Q

 

[kungfufishing]

what about a torsion?
I had a similar scenario recently in a younger patient who had ended up having an ovarian torsion. However, she also had a big ol' cyst down there helping things go awry.

 

[GeneralVeers]

Seems like every patient with abdominal pain is getting a scan now. I also know of very few surgeons who will take patients to the OR without a scan, regardless of clinical symptoms.

When in doubt, irradiate.

 

[southerndoc]

Torsion without underlying pathology (i.e., cyst) is uncommon, although not rare. If the CT is negative and they have continued pain, I would probably pursue a TV U/S to rule out torsion. However, if there are risks (i.e., a mass on pelvic exam, sudden intense onset as opposed to gradual worsening, etc.), then a TV U/S should be the first diagnostic study.

As GeneralVeers points out, an increasing number of surgeons will not take a patient to the OR without a CT scan. Many of our surgeons feel the same way (even in male patients). If a female presents, they are guaranteed to get a scan. If a male presents, maybe 20% will go to the OR without a scan. One of the surgeons at a community hospital where we rotate frequently takes patients (even females) to the OR without scans.

 

[GeneralVeers]

Torsion without underlying pathology (i.e., cyst) is uncommon, although not rare. If the CT is negative and they have continued pain, I would probably pursue a TV U/S to rule out torsion. However, if there are risks (i.e., a mass on pelvic exam, sudden intense onset as opposed to gradual worsening, etc.), then a TV U/S should be the first diagnostic study.

As GeneralVeers points out, an increasing number of surgeons will not take a patient to the OR without a CT scan. Many of our surgeons feel the same way (even in male patients). If a female presents, they are guaranteed to get a scan. If a male presents, maybe 20% will go to the OR without a scan. One of the surgeons at a community hospital where we rotate frequently takes patients (even females) to the OR without scans.

With female patients, I tend to prefer U/S first and then a scan if their clinical history is equivocal (i.e. no fever, normal WBC count). The U/S can help r/o "female problems" which is ammunition you can use when you call the surgeon if the CT is negative.

 

[deleted6669]

how about this- 2 friends with diffuse belly pain x 4 hrs lower> upper with diarrhea that they attribute to eating fast food. both have minimally elevated white counts like 12 or so. both had a bit of rebound so I scanned both of them with iv + 2 hr oral prep. they both had appendicitis.....surgeon didn't believe me...reviewed ct's....both to o.r......

 

[deleted6669]

With female patients, I tend to prefer U/S first and then a scan if their clinical history is equivocal (i.e. no fever, normal WBC count). The U/S can help r/o "female problems" which is ammunition you can use when you call the surgeon if the CT is negative.

our typical u/s read for appy is "appendix not visualized, recommend ct scan". although I agree if they have the big ovarian cyst you're in good shape.

 

[deleted6669]

I work per diem at 1 place that uses iv + rectal contrast for appy. turn around time is much faster than oral prep studies....a lot of radiologists whine about rectal contrast but when our nighthawk/after hrs rads group is happy to do appy evals with iv contrast only it gets a little old listening to the day rads complaints

 

[GeneralVeers]

I work per diem at 1 place that uses iv + rectal contrast for appy. turn around time is much faster than oral prep studies....

When I did a rotation at Children's Hospital in LA, they don't even use PO contrast. They used IV only, so a scan could be done in about 10 minutes. I remember seeing several studies where the wall of the appendix vividly lit up with only IV contrast.

Honestly, I think that PO contrast is a delaying tactic by surgeons, and not necessary for an accurate diagnosis.

 

[southerndoc]

There are studies that suggest diagnosis of appendicitis is better without PO contrast than with. However, most radiologists who insist on PO contrast do so not because they can't see the appendix, but to try to diagnose other things if the appendix is normal.

 

[DropkickMurphy]

Weird case.

Like "writing it up" weird or just plain "that's odd" weird?

 

[DropkickMurphy]

well... detroit is kind of a rough town...

And it is where Houdini died of appendicitis. 😉

 

[DropkickMurphy]

how about this- 2 friends with diffuse belly pain x 4 hrs lower> upper with diarrhea that they attribute to eating fast food. both have minimally elevated white counts like 12 or so. both had a bit of rebound so I scanned both of them with iv + 2 hr oral prep. they both had appendicitis.....surgeon didn't believe me...reviewed ct's....both to o.r......

That's bizarre. *shakes head*

 

[ERMudPhud]

I had one last night 20's male WBC=15k, perfect story and exam for appendicitis. CT showed peri-cecal edema without clear visualization of appendix but thought by rads to be most consistent with appendicitis with phlegmon. PA called the surgeon who asked for patient to be admitted for repeat CBC and ultrasound in AM. I called him back and said, "You do realize the patient has appendicitis." He mumbled something about the appy not being seen and wanting to rule out adenitis. I think the time, 1:00 AM, had a lot to do with it. At my old institution you could still get appy's to the OR without a scan at my new one even with a scan you can't get them to the OR. The rad called back with the U/S result, " Why the hell di you get an U/S you already had a diagnosis last night"