ACUTE ABDOMINAL PAIN
History
Sarah is a 13-year-old girl who is brought to the A&E department by her mother, with a 2-day history of abdominal pain and vomiting. She got back from a family holiday in Devon yesterday evening and has been feeling unwell since. Initially she had central abdominal pain which was coming and going, but now she has more constant pain on the right side of her abdomen. She has vomited three times, but her stool has been normal. She has no significant medical history, was well during the 2 weeks in Devon and her last period was about 2 weeks ago. Her family are all well and report that they all ate the same food over the last few weeks.
Examination
She is flushed and has a temperature of 37.9C. Her heart rate is 95 beats/min, respiratory rate is 18 breaths/min, capillary refill time is less than 2 s, and blood pressure is 105/67 mmHg. She appears obese (weight 68 kg, 98th centile; height 151 cm, 25th centile). Her abdomen is tender in the right lower quadrant but there is no guarding or rebound tenderness. Pressing in the left lower quadrant elicits pain on the right.
INVESTIGATIONS
Normal
Haemoglobin 12.3 g/dL 12.1–15.1 g/dL
White cell count 16.3 109/L 4.5–13 109/L
Neutrophil count 10 109/L 1.5–6 109/L
Platelets 210 109/L 180–430 109/L
Sodium 133 mmol/L 135–145 mmol/L
Potassium 3.4 mmol/L 3.5–5.6 mmol/L
Urea 4.3 mmol/L 2.5–6.6 mmol/L
Creatinine 76 µmol/L 20–80 µmol/L
Bilirubin 5 mmol/L 1.7–26 mmol/L
Alkaline phosphatase 264 IU/dL 25–800 IU/dL
Aspartate aminotransferase 20 IU/dL 10–45 IU/dL
Albumin 35 g/L 37–50 g/L
C-reactive protein 16 mg/L 5 mg/L
Urine
Leucocytes + Negative
Nitrites Negative Negative
Blood Negative Negative
Ultrasound abdomen – liver, spleen and kidneys appear normal. There are a few slightly enlarged mesenteric lymph nodes. The appendix is not seen.
Questions
• What is the most likely diagnosis?
• What other diagnoses should be considered?
• How should she be managed?
Medicine
The most likely diagnosis is appendicitis. This is consistent with the history, the signs on examination, the low-grade fever, raised white cell count and neutrophilia. Vomiting, and even diarrhoea can be features of appendicitis and do not always indicate gastroenteritis. Sterile pyuria (leucocytes in the urine, without organisms) can be caused by the inflamed appendix irritating the ureter or bladder. Plain radiographs are usually normal unless there has been perforation of the appendix. Ultrasound can confirm the diagnosis of appendicitis but can miss an inflamed appendix, particularly if the subject is obese or the appendix is retrocaecal. CT scanning has better sensitivity and specificity but involves a high radiation dose. There is no perfect test for appendicitis, and in practice it remains a clinical diagnosis. If there is diagnostic uncertainty, repeated clinical examination and ultrasound are often performed. When the diagnosis is clear clinically, substantially delaying surgery to allow imaging can result in perforation of the appendix.
Causes of right lower quadrant pain
• Appendicitis
• Mesenteric adenitis
• Urinary tract infection
• Gastroenteritis
• Crohn’s disease
• Ovulation pain: ‘mittelschmerz’
• Ovarian cyst/torsion
• Ectopic pregnancy
• Pelvic inflammatory disease
Sarah should be admitted to hospital for a surgical opinion. She should have nil by mouth until the decision is made on whether or not to operate. Unfortunately, her abdominal pain was unconvincing when she was seen by the surgical team and so she was admitted for observation with a plan to repeat the ultrasound the next day. She developed worsening abdominal pain and peritonism the next morning and was taken to theatre, where a perforated appendix was removed and she had a 10-day in-patient stay complicated by sepsis and ileus.
KEY POINTS
• The triad of abdominal pain, vomiting and a low-grade fever is suggestive of appendicitis.
• The diagnosis is primarily clinical as there is no perfect test to rule in or rule out appendicitis.
• A prompt diagnosis is important to avoid perforation and peritonitis.
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