The abdominal pain presented just like appendicitis. One needs to cover all the


It was a typical busy day at the office. I saw on the schedule that my next patient was a teenage male coming in for abdominal pain. I watched him walk down the hall as the nurse put him and his mom in the examining room. He walked very gingerly and was hunched over holding his right side. This was classic for what is known as the “appy shuffle” for patients who have appendicitis.


As I grabbed his chart I noticed that his temperature was a normal 98.5 degrees. When I entered the room he was slouched forward and was clearly uncomfortable. He was not very communicative so mom gave me the history. He had slept well all night. But when he got up for school he complained that his stomach didn’t feel right. After trying to eat breakfast he only managed a few bites. He went to school, but mom was called mid-morning by the nurse’s office to come and pick him up. The pain had intensified and seemed to be more in the right lower abdomen.


He denied any fever, nausea or vomiting. There was no pain with voiding and he did not have diarrhea. In fact, he had not had a bowel movement in two days. The urine sample he provided was completely normal. When getting up on the examining table he did so with much effort as he tried not to move too much. This is sure looking like appendicitis, I thought.


His exam was completely normal except for the abdominal pain. He did have bowel sounds present but his abdomen was tender. It seemed more tender in the right lower quadrant where the appendix is located. He grimaced when I pressed deeply. And when I quickly took my hand away he moaned and said it hurt.This is what is called rebound tenderness. I had him get off the table and try to squat down in a catcher’s stance. He tried, but halfway down he stopped saying it hurt more. Next I asked him to jump up and down which he did once but would not do it again because of the pain. Another version of rebound tenderness.


Herpetic Whitlow is a localized infection of the fingers caused by the virus herpes-simplex. It is the virus that causes gingiva-stomatitis or cold sores, first described in 1909. Over 60% of Herpetic Whitlow is caused by herpes-simplex virus type I. The rest are caused by herpes-simplex type II (genital herpes). Most children with Herpetic Whitlow are infected with type I herpes for obvious reasons. They will have cold sores in their mouth, and inadvertently have their fingers in their mouth (thumb sucking, finger sucking or nail biting). If there is a break in the skin such as a torn cuticle, they auto-inoculate the finger with the virus.


With all of this information I told them that I was concerned about an appendicitis. But before I did labs or called the surgeon I had to do one more test—a rectal exam. He was not thrilled with this news, but gave mom a knowing glance. She perceptively said, “Why don’t I just wait outside”.

Laying on his left side as I did the exam I was struck with how much hard stool there was in his rectal vault. It was rock hard and great in mass. No tenderness was elicited on the right side which would be expected if he did have appendicitis. I told him to get dressed while the stool sample was tested for blood. The test came back negative. Admittedly when I first saw him I would have sworn that he had appendicitis. But now it was less clear. Just then he sat up abruptly and asked, “Doc, is it OK if I go to the bathroom?” He quickly exited the room.

I was telling mom that I was not as convinced about appendicitis, but we may need to do an ultrasound and some lab work to be sure. She assured me that she would agree to whatever needed to be done. Our conversation came to an end and we were looking at each other as if to say, where is he? She even looked at her watch. Many more minutes went by before we heard the flush of the toilet. We politely smiled at each other but he didn’t return to the room. FinallyI said I’d better go check on him. He was still in the bathroom, and after knocking on the door he said, “Sorry doc, I’ll be right out”. There was another flush.


I was explaining to mom where she would need to go for the ultrasound when he bounded into the room and flashed a big grin. “Gee, thanks doc. I feel GREAT!!” Sure enough, he had been terribly constipated and that was the cause of the pain. After a re-examination he had a normal abdomen and was able to squat and jump up and down with ease. In fact, he asked mom if they could stop at In N Out on the way home, as he was starved.


This vignette is a common one. Constipation must always be considered when one is evaluating abdominal pain, especially appendicitis. But I have a tremendous respect for appendicitis as it can present itself in many non-typical ways.


I told mom that I thought he would be fine. She was to make an appointment for later that day in case there was any recurrence. She could cancel if all was fine but she had to call with an update to do so. If he seemed fine I wanted her to call me the next day with another update.