|An Unusual Presentation of Ruptured Appendicitis|
An Unusual Presentation of Ruptured Appendicitis
Baldeep Singh, M.D.
Acute appendicitis is an uncommon primary care diagnosis, but one critical not to miss. Though appendicitis can manifest in a variety of ways, abdominal pain is the most common presenting symptom. However, the classic history of periumbilical pain migrating to the right lower quadrant with associated anorexia, nausea, and vomiting occurs in only 50% of patients.1 On physical examination, abdominal tenderness is found in 95% of patients, with the greatest area of tenderness in the right lower quadrant, usually over McBurney\'s point. The patient may have other \"classic\" exam findings as well. Rovsing\'s sign is pain in the right lower quadrant during percussion or palpation in the left lower quadrant. Psoas sign is pain in the right lower quadrant with extension of the right hip, and the obdurator sign is pain in the right lower quadrant with flexion and internal rotation of the right hip. However, these \"signs\" only occur in fewer than 10% of patients, and their absence should not prevent the examiner from making an accurate diagnosis.2
Ruptured appendicitis usually occurs when there is a delay in presentation or diagnosis. Although the clinical presentation may be difficult to distinguish, patients often have more impressive physical findings, with higher fever and leukocytosis. Appendiceal rupture also carries a mortality rate ten times greater than appendicitis alone. Therefore, making a prompt and accurate diagnosis is imperative.
Following is a case presentation and review of an atypical presentation of appendicitis and appendiceal rupture.
A 39-year-old female presented with a one-month history of right lower quadrant abdominal pain. She described the pain initially as diffuse, intermittent, colicky and unaffected by food or bowel movement. She saw another physician three weeks previous who prescribed ranitidine. One week prior to presentation, the pain became more intense and constant with no vomiting, change in bowel habits, rectal bleeding or melena. She stated that she had similar pain approximately one year ago, which lasted for a week before resolving spontaneously. On the day she presented for evaluation, she had experienced the onset of nausea, vomiting and diarrhea. She had fevers at home up to 102?F. She denied dysuria, vaginal discharge or back pain. She was sexually active only with her husband, denied any history of STDs or PID, had a history of a fibroid uterus, and a past surgical history limited to three cesearean sections. Other than that, her past medical history was unremarkable.
Her physical examination was remarkable for temperature of 98.6?F and mild distention of the abdomen with a large mass in the right lower quadrant, some voluntary guarding, no involuntary guarding, no rebound and no Rovsing. Her rectal examination was unremarkable and she was guaiac negative. The pelvic examination revealed some mild cervical motion tenderness; the uterus and adnexa were difficult to palpate secondary to patient\'s guarding, however, no discrete masses were felt. Laboratory data included a white count of 14,000/mm3, potassium of 3.3 and creatinine of 0.7, an RUA showing 6 white cells. Her chest x-ray was clear.
An abdominal CT scan revealed a cystic, loculated, complex mass measuring 11 cm x 11 cm in the right lower quadrant and right pelvis. There was also a 3 cm cyst in the right ovary, although this was not contiguous with the mass. There was a small amount of free fluid in the pelvis.
The patient was admitted for IV antibiotics and observation and made n.p.o. Her right adnexa could not be evaluated clinically, so an ultrasound was performed as stated above. Her white blood cell count decreased to 11,000/mm3 on IV antibiotics. She was seen by obstetrics and gynecology, who believed that the mass was likely suprapelvic in origin and was not involving the adnexa. The patient then agreed to proceed with an exploratory laparotomy.
The patient underwent exploratory laparotomy, where she was noted to have a perforated appendix. A right extended hemicolectomy, retroperitoneal dissection and repair of umbilical hernia was performed. She also had a dermoid cyst removed from her right ovary. She tolerated the procedure well, without complication, and was discharged home on post-op day seven.
Atypical presentations of appendicitis, the \"great masquerader,\" are important to review. Certain presenting groups are particularly significant to identify, as they are often misdiagnosed or appear later in the course of the illness. These include patients who have atypical anatomy, elderly patients, patients with acquired immunodeficiency syndrome (AIDS), and the uninsured. Importantly, delays in the diagnosis will increase the risk of rupture and increase morbidity and mortality.
Immediate appendectomy has long been recommended for acute appendicitis because of known progression to rupture. Studies on the natural history of appendicitis demonstrate that among patients taken to the operating room for suspected appendicitis, 14% have a normal appendix, 70% have an inflamed appendix, and 16% have a ruptured appendix.3 Delays in presentation are responsible for the majority of perforations. Appendiceal rupture occurs most frequently distal to the point of luminal obstruction along the mesenteric border of the appendix. Rupture should be suspected in patients with clinical symptoms in the presence of fever greater than 102?F and a white blood count greater than 18,000/mm3. In the majority of cases, the rupture is contained and the patient will display localized rebound guarding. Generalized peritonitis will be present if the walling off process is ineffective in containing the rupture.
Diagnosis may be delayed in patients with atypical anatomy. Two common examples are patients with a retrocecal appendix and those who present late in pregnancy. Both categories often present with right flank or costovertebral angle pain. In fact, appendicitis is the most common extrauterine surgical emergency during pregnancy, with an incidence of 1 in 1200. Since fetal mortality rates are as high as 35% in patients with perforation, the diagnosis is imperative.4
Older patients are also a high risk group, often because of the vagueness of their symptoms and their tendency to treat themselves with analgesic medication prior to presentation. One study revealed that for patients over the age of 55 years, appendectomy rates were performed an average of 2 days later than for those younger than 55. In older patients, delays in diagnosis commonly exceeds 50%, with perforation rates as high as 40 - 70%.5
Patients with AIDS comprise another high risk group for delays in diagnosis. They commonly present initially with abdominal pain with concurrent gastrointestinal symptoms, similar to symptoms seen with common opportunistic intestinal infections like cryptosporidiosis, cytomegalovirus colitis, or Mycobacterium avium complex infection. Consequently, acute appendicitis is difficult to diagnose in such patients. In fact, some studies have described perforation rates as high as 40% among AIDS patients due to delays in making an accurate diagnosis.4
In this era of cost containment, insurance coverage seems to make a difference in rates of perforation. Braverman and his colleagues reported a significant association between ruptured appendix and insurance coverage, after adjusting for socioeconomic differ-ences.6 There was a significantly higher rupture rate among the uninsured. Though mortality is rare in appendicitis, the rate of death is higher in patients with perforation than in patients with appendicitis alone (2 deaths in 1000, vs. 2 deaths in 10,000). Of particular interest, the patient described above was uninsured until one week before presenting to my office.
The ability to distinguish between uncomplicated appendicitis from perforation on the basis of clinical findings is often difficult. A CT scan may be helpful in guiding therapy. Small abscesses can be treated conservatively with IV antibiotics and with possible percutaneous drainage, but large complex abscesses should be considered for surgical drainage. In 2 - 6% of appendiceal rupture cases, an ill-defined mass will be present on physical exam, as noted in the patient presented above. Such patients will experience a longer duration of symptoms, usually at least 5 to 7 days. For this patient, the course may have been weeks.
In conclusion, the primary care practitioner should be wary of the possibility of appendicitis whenever a patient presents with abdominal pain, and should maintain greater caution with patients who are pregnant, elderly, have AIDS or are uninsured. As in this patient\'s case, appendiceal rupture may have an indolent course, however, the patient should receive a prompt surgical evaluation if it is suspected