Young Man With Acute Right Lower Quadrant Pain

A 21-year-old man presents to the emergency department with abdominal painof 6 hours' duration. When the pain began, it was diffuse and periumbilical; now,it is worse and localized to the right lower quadrant. It has been accompanied byanorexia but not by diarrhea or emesis. Lying down, consuming liquids, andshowering have not provided relief.HISTORY
The patient is healthy, has no history of serious illness or surgery, andtakes no medications. He has had one or two episodes in previous months thatresembled this one; however, they were less severe and resolved within hours.He recently married and has not traveled abroad.PHYSICAL EXAMINATION
This thin, afebrile man is in moderate distress from the pain. He favors thedecubitus position with legs flexed at the hip. Head, ears, eyes, nose, throat,chest, and heart are all normal. Bowel sounds are diminished, and the abdomenis tense. There is tenderness to deep palpation and significant guarding in theright lower quadrant. No signs of peritonitis are present. Rectal examination revealstenderness on the right with digital pressure; stool is heme-negative.LABORATORY AND IMAGING RESULTS
Platelet count, hemoglobin level, and chemistry panel results are normal.White blood cell (WBC) count is 19,800/μL with a left shift. Urinalysis resultsare normal, and microscopic examination reveals no red blood cells (RBCs) orWBCs. An ultrasound scan of the abdomen is normal; however, the appendixis not visualized.Which of the following is the most appropriate next step forthis patient?A. Obtain a urine culture, and initiate empiric treatment with ciprofloxacin.B. Arrange for a diagnostic laparoscopic examination.C. Admit the patient for observation for 6 to 10 hours.D. Have the patient taken directly to the operating room for appendectomy.E. Because the ultrasound scan did not reveal pathologic findings, allowthe patient to return home.CORRECT ANSWER: D
This is a straightforward presentation of acute appendicitis,and most clinicians--with significant support in the literature--would immediately proceed to surgery. Surgicalremoval of the appendix remains the most common emergencyabdominal procedure in the United States; an estimated250,000 emergent appendectomies are performedeach year.¹ Appropriate diagnosis and prompt surgical interventionare important because delay increases the likelihoodof perforation, which is the source of the morbidityand mortality of acute appendicitis.When appendicitis is suspected, clinical findings canbe very helpful in establishing the diagnosis. The 3 findingswith the greatest predictive value are:

• Pain in the right lower quadrant.
• Migration of that pain from the periumbilical region.
• Abdominal rigidity on examination.

An elevated WBC count is also common in acute appendicitis;however, this is seen in many other disorders in the differential diagnosis--such as urinary tract infection(UTI) and pelvic inflammatory disease in women--and is therefore less helpful.All 3 key findings are evident in this patient. A recentreview suggests that a presentation which includes acuteright lower quadrant pain that has migrated from a periumbilicallocation, together with abdominal rigidity, has a diagnosticaccuracy for acute appendicitis of 95%--a figure thatimaging studies are unlikely to improve on and that is sufficientjustification for proceeding to surgery.

¹

The predictivevalue of such a presentation is particularly strong in ayoung man.Most of the other management options are bestreserved for settings in which the diagnosis of appendicitison clinical grounds is more difficult, such as in premenopausalwomen, children, and elderly persons. Insuch patients, clinical observation for 6 to 10 hours(choice C) reduces the rate of unnecessary appendectomywithout resulting in an increase in perforations or other morbidity.

²

Because CT is highly accurate, it has replaced hospitalobservation for evaluation of most patients with anequivocal presentation of appendicitis.

¹

Although CT hasnot affected morbidity, it is more cost-effective.Ultrasonography has a sensitivity for appendicitis of70% to 90%.

³

However, an ultrasound scan is worthless ifthe appendix is not definitely visualized, as was the case inthis patient. Thus, choice E is not correct.Laparoscopy of the right lower quadrant has beenshown to reduce unnecessary appendectomy, particularlyin women.

⁴

A normal appendix is found during surgery innearly 40% of women with suspected appendicitis but inonly 20% of men.

⁴

In premenopausal women, various pathologicconditions can mimic appendicitis; these include ectopicpregnancy and pelvic inflammatory disease, whichare easily diagnosed by laparoscopy. This operative techniqueis not recommended in men, however, because laparoscopicappendectomy does not result in lower morbidity,lower cost, or a shorter length of hospitalization thanopen appendectomy--whether or not appendicitis isfound.

⁵

In men, reserve laparoscopy for patients with atypicalpain of uncertain origin and for those who are veryobese. This patient meets neither criterion; thus, choice Bis incorrect.UTI is one of the many entities in the differential ofacute abdominal pain in both men and women; others--in addition to appendicitis--include epididymitis and gastroenteritisin men and pelvic inflammatory disease andectopic pregnancy in women. However, UTIs usually produceadditional symptoms and significant urinary RBCand WBC counts, none of which are seen here. This essentiallyexcludes UTI as the cause of the symptoms andsigns in this patient. Thus, choice A is incorrect.

Outcome of this case.

The patient underwent traditionalappendectomy. Pathologic examination confirmedacute appendicitis. His postoperative course was uncomplicated,and he was discharged after 4 days.

References:

REFERENCES:

1.

Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis.

N Engl J Med.

2003;348:236-242.

2.

Jones PF. Suspected acute appendicitis: trends in management over 30 years.

Br J Surg.

2001;88:1570-1577.

3.

Puylaert JB, Rutgers PH, Lalisang RI, et al. A prospective study of ultrasonographyin the diagnosis of appendicitis.

N Engl J Med.

1987;317:666-669.

4.

Thorell A, Grondal S, Schedvins K, Wallin G. Value of diagnostic laparoscopyin fertile women with suspected appendicitis.

Eur J Surg.

1999;165:751-754.

5.

Mutter D, Vix M, Bui A, et al. Laparoscopy not recommended for routine appendectomyin men: results of a prospective randomized study.

Surgery.

1996;120:71-74.