Although many patients with acute appendicitis first present to the emergency room, primary care providers also frequently encounter patients with abdominal pain in their outpatient clinics. Some of these patients may be presenting with early appendicitis.
Case Study: You arrive in the clinic this morning and are looking through your patient list when your nurse tells you that you have an add-on patient who needs to be seen sooner rather than later. The patient was already waiting at the front door before the clinic opened, and she has a chief complaint of severe abdominal pain. Your nurse has already triaged the patient into an examination room. As you enter the room, you see a young woman with a grimace on her face, sitting very still in a chair. The patient introduces herself as Jennifer, and she is obviously in pain. She tells you,
“The pain just keeps getting worse and worse.”
You ask her what is going on, and Jennifer tells you that she has had right lower quadrant pain that has been getting worse since this morning. It is associated with lack of appetite, nausea and vomiting. When you ask her directly, she notes that she initially suffered from mild pain around her umbilicus last night. At that time, she also had loss of appetite. However, this morning, she began having nausea and vomiting and the pain has migrated to her right lower quadrant.
What do you want to do now?
You take Jennifer’s temperature and see that she is febrile with a temperature of 39 degrees Celsius, tachycardia with a heart rate of 125 beats per minute, and has normal blood pressure. On physical exam, Jennifer is quite tender to mild palpation in the right lower quadrant. She has guarding but no signs of peritonitis.
What do you do next?
You strongly suspect that Jennifer has acute appendicitis. After ruling out a past surgical history of appendectomy, you send her to the emergency room with a note relaying your suspicions to the attending ER doctor. The ER doctor decides to obtain labs while waiting for a surgical consult. She orders a complete blood count, basic metabolic panel, and urinalysis. Jennifer has an elevated WBC count and evidence of dehydration. However, her clinical symptoms appear consistent with a diagnosis of acute appendicitis, and she is taken to the operating room for a laparoscopic appendectomy. Thankfully, she has non-perforated appendicitis, and her hospital course after her surgery is straightforward.
What sorts of complications might you have encountered?
The differential diagnosis for appendicitis is vast. Early appendicitis, in particular, often mimics other causes of periumbilical abdominal pain, including gastroenteritis, gastritis, gastric ulcer, diverticulitis, urinary tract infection and cholecystitis. In addition, very young children are difficult to diagnose because of communication barriers. Pregnant women often have symptoms of pregnancy that appear similar to appendicitis, and the gravid uterus frequently displaces the appendix after the fourth or fifth month of pregnancy. Lastly, older adults have the highest mortality rates associated with appendicitis because of a combination of decreased, atypical, or absent signs and symptoms and co-morbid conditions.
Summary: Although acute appendicitis can be easily treated, delayed diagnosis may lead to perforation, sepsis and elevated risk of morbidity and mortality. Providers should frequently review how to diagnose acute appendicitis and keep appendicitis high on their differential diagnosis for abdominal pain.
Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999;60(7):2027-34.
Dr. V. Silverstein
Published on 12/28/17