Acute Appendicitis: Two Cases

The diagnosis of acute appendicitis is usually straightforward. When the presenting symptoms are atypical, abdominal ultrasonography can be of diagnostic assistance if it shows the thickened walls of the appendix and a distended, noncompressible lumen. Drs Robert P. Blereau, MD and James T. Kountoupis of Morgan City, La, and Dr John C. King of Gheens, La, present two cases in which ultrasonograms provided evidence of acute appendicitis.

Case 1: A 17-year-old boy began to experience right lower quadrant abdominal pain at about 11 o'clock one evening. A famotidine tablet offered no relief, and he spent a restless night. Persistent vomiting and profuse diarrhea commenced at approximately 9 o'clock the next morning. When seen by a physician that afternoon, the patient appeared acutely ill and had localized abdominal tenderness just above McBurney's point. His oral temperature was 35.7°C (96.3°F), and his white blood cell (WBC) count was 16,000/µL with a shift to the left.

Abdominal ultrasonography was ordered, and a transverse section through the appendix revealed double “bull's eyes” (A), seen when the appendix is curled on itself. (Usually, only a single bull's eye is seen.) A longitudinal section showed distention of the appendix and its thickened walls (B). An appendectomy was done that afternoon, and the acute suppurative appendix is shown here (C). The patient was discharged on the second postoperative day and had an uncomplicated recovery.

Case 2: A 37-year-old man presented with right lower quadrant abdominal pain of 2 days' duration, referred rebound tenderness, and an oral temperature of 37.4°C (99.3°F). He had mild nausea, but no diarrhea or fever. His WBC count was 17,000/µL with a shift to the left.

Abdominal ultrasonography again showed double bull's eyes, but this time a fecalith was seen in the center (D). Appendectomy was performed without delay. It revealed, once again, acute suppurative appendicitis, and the patient had a good recovery.