Let’s look at three patients who presented with very similar histories and physical examinations. Each child could make a compelling case for acute appendicitis. Yet, only one of the three actually had appendicitis.

 

Jeff

 

Jeff was a six-year-old boy who woke up not feeling well. He was nauseated and didn’t want to eat breakfast. He said his stomach hurt just below the breastbone. By noon he had a low-grade fever, and the pain had migrated to the lower right side. He was uncomfortable and didn’t want to move around. When mom got him ready to go to the emergency room he walked hunched over and moved very slowly. In the ER they did some blood work and found that his white blood cell count was high at 16,300 (the norm is 5000-to-10,000) and his temperature was 100.9 degrees. Upon examination his abdomen was tense and tender, especially in the right lower quadrant. He even exhibited “rebound tenderness,” meaning when one pressed gently on the abdomen and then let go quickly the pain was intensified. The ER doctors suspected acute appendicitis and ordered an ultrasound. That revealed a dilated tubular structure in the right lower quadrant which confirmed the diagnosis of appendicitis. He was taken to the operating room and had an uncomplicated appendectomy.

 

Max

 

Max was a seven-year-old boy who had not been feeling well the past two days. There were no specific complaints and he had not missed school because of it. He just wasn’t his normal self. He complained of vague abdominal pain when he woke up. With a temperature of 99.0 degrees he had no appetite for food. He was neither constipated nor was there any vomiting.
 

When mom asked where the pain was located he pointed to the right lower quadrant. As the day progressed the pain worsened. Mom took him to the ER where they suspected acute appendicitis based on his examination. His abdomen was soft and not distended, but he was point tender in the right lower quadrant. He even had rebound tenderness. Labs showed a white blood count of 8,100 which was very normal. They did an ultrasound and it did not visualize the appendix. Instead, it showed three large lymph nodes in the right lower quadrant.. Everything else was normal. Mom was assured that he did NOT have appendicitis and would not need surgery,. He was sent home with instructions to follow up with his doctor the next day.
 

AMY

 

Amy was a seven-year-old who had an upper respiratory tract infection for a few days. She felt achy, had a runny nose and was congested. It seemed that each day progressively got worse and she began developing a fever. On the fourth day of illness she woke with a high fever of 103.6 degrees. Complaining that her stomach hurt, she pointed to the right lower quadrant. It was difficult to move without discomfort and she walked hunched over, guarding the right side. Fearing that she might have appendicitis mom took her to the ER. The temperature had gone up to 104.0 degrees and her examination was classic for appendicitis. She was tender in the right lower quadrant and had rebound tenderness. Her white blood cell count was 24,800. The ER doctor was phoning the surgeon to evaluate her for surgery when the results of the ultrasound came back, completely normal. This caught the ER doctor by surprise. He ordered a CT of the abdomen. This too was normal. He then ordered a chest x-ray. Low and behold, it showed a right lower lobe pneumonia. After cancelling the call for the surgeon, he assured Amy’s mother that she did not have appendicitis, nor did she need surgery.
 

Three different cases with very similar presentations that would make one highly suspect appendicitis.

 

Jeff clearly did have appendicitis and was taken to the operating room. Max had a condition called mesenteric adenitis which is a self-resolving infection, often times viral in nature, that causes swelling and inflammation of the lymph nodes within the abdomen. It can present just like an acute appendicitis. It does not require any specific treatment and will resolve on it’s own within a couple of days. Amy, on the other hand, had a pneumonia caused by pnuemococcus, which is a specific type of bacteria. She never did develop a cough, but had a high fever, high white blood cell count, and findings on examination that looked just like appendicitis. This scenario is not uncommon for pneumococcal pneumonia.
 

Not all right lower quadrant pain is appendicitis. While physicians must always have this diagnosis high on their list, they must be alert and open-minded to other possibilities. Quite often it boils down to doing detective work to finally arrive at the correct diagnosis.