An eighteen-year-old college student suffers a four hour episode of mild abdominal pain and nausea that localizes in the periumbilical (near the belly button) region. She initially attributes this to “an upset stomach.” As the pain continues to increase, the patient suffers severe nausea, cramping, and feels feverish. Her roommates take her to student health services. Because of the symptoms presented, the student is immediately transferred to the emergency room (ER) of a nearby hospital. In the ER the pain continues to increase and localizes to the right lower quadrant (RLQ) of the abdominal region. On physical examination, the following is noted:
● A moderately elevated oral temperature (38.7 °C).
● An elevated number of white cells in the blood (23,000 per microliter; normal is about 8,000). Most of these cells are granulocytes.
● An area of local tenderness located on a line between the umbilicus and iliac crest, closer to the iliac crest.
● Right sided rectal tenderness.
Appendicitis is strongly suspected, and the patient is prepared for a CT scan of her abdomen. An axial CT scan through the upper pelvic region shows a dilated appendix containing a appendicolith, a calcified stone visible in the several sequential images (FIGURE 1-15). The patient is prepared for laparoscopic surgery. An edematous (fluid-filled) red appendix is removed at surgery (FIGURE 1-16), which when opened contained several appendicoliths. The patient recovered uneventfully.
FIGURE 1-15
FIGURE 1-16
Discussion
The combination of patient symptoms and signs are sensitive indicators of appendicitis in young adults but lack specificity. The elevated temperature and increased numbers of white cells (particularly granulocytes) are strong indicators of a response to tissue injury, which is most likely the result of a bacterial infection. The localization of the pain to the specific region of the abdomen (sometimes called McBurney’s point) and the right sided rectal tenderness suggest the infectious process may involve the appendix based on pelvic anatomy. However, a number of infectious diseases involving the intestine (as well as other illnesses) can present with similar signs and symptoms. The CT scan is a highly accurate test for appendicitis with a specificity approaching 95 percent. In young children; ultrasound is often used instead of CT to lower radiation exposure.
Etiology and Pathogenesis
Appendicitis is an inflammation of the appendix. The disease is most commonly related to blockage of the outlet of the appendix to the bowel (by stones representing calcified fecal material or sometimes by intestinal parasites). This results in bacterial overgrowth by gut microorganisms within the appendix and an inflammatory response. As you will learn in the presentation of inflammation, this response can lead to tissue injury and ultimately to rupture of the appendix (described more fully in the presentation on the gastrointestinal tract).
Questions
1. An elevated number of white cells is a sensitive indicator of systemic inflammation present in the above case. Why was a radiological study ordered prior to surgery?
2. Another patient comes to the ER complaining of pain on the center to left lower quadrant of her abdominal region. Is acute appendicitis ruled out? What are several additional potential diagnoses?
3. What are some of the potential advantages of the use of laparoscopic surgery (as opposed to “open” surgery) in this case? Consider the possibility that the diagnosis might have been uncertain.