One Saturday she awoke with ‘stomach cramps’ and vomited. She felt very weak.
The next day her temperature was 102oF, and she could drink fluids but was too weak to walk. On a phone conversation, her pediatrician suggested she has the “stomach flu going around” and suggested she go to the ER.
Is this gastroenteritis?
On day 3 she had copious diarrhea and felt weak. She was seen in an urgent care facility: A nurse recorded her abdominal pain as 6 on a 10-point scale. Her temperature was 98 oF, blood pressure 101/72, heart rate 137. The triage NP described her abdomen as soft and non-tender with no distension, but as mildly tender diffusely by the MD. Labs were ordered, but no imaging in view of the apparently benign abdomen. Her WBC was 20,000/mm3 with 91% neutrophils and no ‘bands’. She was given large amounts of IV fluids but her symptoms persisted and her blood pressure dropped to 85/39, prompting additional IV fluids. The parents relayed the suggestion from the outpatient pediatrician for an abdominal ultrasound to rule out appendicitis or a ruptured appendix, prescient advice that was never heeded.
She was transferred to an inpatient facility for further hydration due to persistently “soft” blood pressures. On admission, her blood pressure was 91/49, with a fever of 101.5 oF. Physical exam described the abdomen as “soft, non-distended, with diffuse tenderness to palpation. No McBurney's point tenderness. Murphy Sign negative. Rovsing sign negative. Negative Obturator sign. ….able to climb out of bed and jump twice.”
The clinical impression was gastroenteritis, or possibly food-borne illness or appendicitis. Appendicitis was thought less likely due to the non-focal physical examination findings and the lack of peritoneal signs. The plan was to continue fluids and serial examinations. The notes documented that an ultrasound of the abdomen would be considered if she developed right lower quadrant pain.
As day 5 progressed, her pain became extreme and was noted to have difficulty answering questions, with altered mental status. Alice pointed out to the medical team that her belly was getting swollen, a sign of ascites--infectious fluid accumulating in the abdomen--but no action was taken.
Her Father Intervenes
Frustrated by the refusal of the inpatient team to obtain abdominal imaging, the patient’s father contacted a hospital administrator to intervene. The clinical team obliged but informed the family: “She doesn’t need this.”
A plain film of the abdomen, however, showed multiple air fluid levels and subsequent CT imaging confirmed perforated appendix with small bowel obstruction, large amounts of intraperitoneal fluid, and large abscess pockets. She was transferred to a surgical team, but was now hypotensive (BP 77/44). She was given large amounts of IV fluid and was started on vasopressors. Unstable for surgery, the fluid collections were drained percutaneously over several days.
She was ultimately discharged on oral antibiotics despite a medium-size abscess still being present on ultrasound the day before. A week later, worsening symptoms prompted a repeat ultrasound which showed a now larger abscess. She was readmitted to the hospital for another week of stronger antibiotics and multiple drainage procedures. An appendectomy with lysis of adhesions was performed 3 months later.
Commentary: Alice ultimately recovered, but the delayed diagnosis of her ruptured appendix was nearly fatal, and has left lasting scars.
All medical trainees learn the classical findings of appendicitis, but remain largely unaware that appendicitis, especially after a 24 hours of symptoms, may cause diffuse abdominal pain, not just the localized “McBurney’s point tenderness” in the right lower abdomen that Alice’s doctors expected. Despite the ready availability of ultrasound and Xray imaging, the diagnosis is delayed or missed in 5-10% of cases. Alice would have likely died if her father, CNN news anchor Jake Tapper, had not successfully intervened with the hospital administrator.
The lesson for clinicians is quite clear – we need to be aware of atypical presentations of appendicitis, and take advantage of modern-day imaging to confirm or refute this possibility. The lesson for patients (and clinicians) is equally clear – when a diagnosis like “gastroenteritis and dehydration” is made yet the patient’s condition gets WORSE despite IV saline, this is the time to question the current thinking. Keep asking ‘what else could this be?’ and request that other clinicians take a fresh look.