Wednesday, August 11, 2010

Appendicitis: Diagnosis, CT Scans and Reality

UPDATED 4/11/2013
ADDENDUM: Dear Readers, 
I am grateful that this post has been read by so many people and that several of you have written for advice about your abdominal pain.  While I would sincerely like to help you, it occurs to me that answering your questions has taken on a predictable scenario. You ask a complex question. I respond that not having examined or spoken to you nor having seen your CT/ultrasound reports or images, I cannot give you medical advice. 
From now on, I will not be able to answer specific questions via this blog or by email. Please read through the numerous questions and answers and you are very likely to find a situation like yours that has been asked and answered.
Best wishes to all,
Skeptical Scalpel
Yesterday, medical writer and pediatrician Perri Klass wrote in the New York Times about evolving issues regarding the diagnosis of appendicitis in children, which are also applicable to adults. There is well-documented concern regarding the excessive radiation exposure associated with CT scans. For example, a recent paper reported that a single abdominal CT scan with contrast delivers a radiation dose equal to undergoing more than 200 regular chest x-rays. The implications of this large dose of radiation are that an increase in cancer rates may arise in the future, especially if the CT scan is performed in a child.
The problem is how does one curtail the use of CT scans for the diagnosis of appendicitis when the test has become extremely accurate? Although Klass states that a normal appendix can be expected in 10-20% of appendectomies, those numbers are no longer valid. Even in a non-teaching community hospital, the rate of removal of a normal appendix during emergency surgery for the diagnosis of appendicitis should be well below 10%. She also repeats a commonly held misconception that a high rate of removal of normal appendices results in a lower rate of perforated appendicitis, which is not true. Some authors even believe that perforated appendicitis is a different disease than simple acute appendicitis.
I do not see the rate of CT scans for appendicitis decreasing because of three major factors.
1. Patients [or their parents] have come to expect accuracy in diagnosis. On more than one occasion, I have had the experience of seeing a teenage boy with classical symptoms and signs of appendicitis where the emergency physician has called me and said he did not think a CT scan was necessary. I examined the child and agreed. After I explained everything to the mother, she said, “What about the CT scan?” It then becomes hard to go ahead without the scan because in the unlikely event the boy did not have appendicitis, the mother would have accused me of performing unnecessary surgery. In fact, of my last 80 appendectomies, I have operated without a CT scan only four times. My rate of removal of a normal appendix is 6%. This is in a non-teaching community hospital with out-sourced CT scan readings at night.
2. Klass mentions the use of ultrasound as a substitute for CT scan. Although ultrasound does not involve radiation and is accurate according to some studies, the reality is that it is not always readily available at night [when most people with abdominal pain show up] in many community hospitals. The test is useless when the appendix is not identified, a situation that occurs frequently outside of academia. And unlike CT scan, ultrasound is far less likely to reveal an alternative diagnosis when the appendix is normal.
3. In a non-teaching hospital where there are no residents, it is very difficult to have every patient with a suspicion of appendicitis seen by a surgeon. When the emergency physician calls and says she has a patient with a positive CT scan for appendicitis, the diagnosis is correct more than 95% of the time. They rarely call when the CT scan is negative. Some scans are equivocal and the surgeon does have to see the patient and make a clinical decision. Regarding patients with positive CT scans for appendicitis, it pains me to say this but the history and physical exam are probably no longer relevant. This is particularly true now that all patients with abdominal pain receive narcotics within a few minutes of arrival to most EDs. It takes cojones to not go ahead with surgery when the CT scan is read as positive for appendicitis. I have done it once [successfully] in the last 19 months. Of course, I look at all the CT scans myself to usually confirm or rarely question the reading.
It comes down to this. Do you want an accurate diagnosis for yourself or your child with the possible increased risk of cancer years later or would you accept a higher rate of normal appendix removal? I believe that the general public would opt for the former.

143 comments:

Anonymous said...

my doctor told me that my appendix is not identified by CT scan...what does it mean?I had c section surgery...could they removed it without telling me? need advice,please...

Skeptical Scalpel said...

Do not construe this as medical advice because I have not examined you nor have I seen your CT scan.

It is very unlikely that your appendix was removed during your C section. You would have had to have been told about it. If you are in doubt about whether it was removed, you can obtain your records and read the operative note that describes the C section.

The appendix is occasionally not seen on a CT scan. That usually indicates that it is normal and has no signs of inflammation around it.

jrodi said...

Hi there. I'm in a pickle and would live some medical advice. I've been suffering excruciating pain in my lower right abdomen that radiates from my belly button to the point that it kills me to walk (right leg pain). I've been to the ER twice in two days after the pain increased dramatically after the first ER visit. On both occasions, the ER docs told me I had every single sign and symptom of acute appendicitis based on physical exam (bending my leg, rotating it, pressing and releasing both left and right sides of my belly - all which caused excruciating pain). All of this coupled with severe vomiting and not eating. However, labs showed no elevation in my white count and the CT scans have been normal. It's baffled both doctors as they felt that I definitively, based on all other tests, that I was a classic case of acute appendicitis. I'm a bit at a loss here. I'm doubled over in pain, the pain meds they've prescribed don't help whatsoever, and the pain worsens daily. I know that there seems to be differences in opinion as far as whether the CT showing a "normal appendix" can sometimes be wrong. Everyone, those I know who've had appendicitis, and ER docs all feel I have it, but due to the CT results, say I don't despite all other labs. I'm really not sure what to do. My pain level is through the roof and worsens daily, to the point that I can't walk and lay on a heating pad most of the time. Your advice would be greatly appreciated in what my options are or what my next steps should be.

Skeptical Scalpel said...

jrodi, I am sorry that you are in such pain and that the diagnosis is unclear. Unfortunately, I am unable to give you medical advice without taking a history and examining you in person.

I don't know where you live, but I suggest you obtain a second opinion. If there is a medical school hospital near you, go there. Before you go, get a CD-ROM of your CT scan or scans and a copy of your lab results to take with you.

Since it is a weekend, you may have a long wait and you may not see a senior MD, but I think it's your best bet.

Good luck.

jrodi said...

Thank you. If I may ask, how would going to a teaching hospital be in my benefit?

Skeptical Scalpel said...

At the very least, you probably would be seen by more than one MD at a teaching hospital. If there's not one near you, just go to a hospital other than the first one.

Anonymous said...

My 5 year old daughter had a CT scan done last night, within an hour the radiologist called the doctor and said the diagnosis was acute appendicitis. We were rushed to the ER where my daughter was given tylenol for fever and admitted to the hospital, iv with antibotics started. The ER called the surgeon and he said surgery in the morning. This morning the surgeon called the nurse on the peds floor and asked how my daughter was doing - complained of a little abdominal pain, but acted normal. 8 hours later we were discharged, never saw the surgeon but was told by the nurse that "there was no way my daughter had appendicitis, she is not doubled over or vomiting or anorexia, probably just a viral infection" and sent home. 6 hrs after being home, her fever has spiked to 102.1 and she is once again complaining of abdominal pain but not doubled over. Please suggest what to do. Thanks.

Skeptical Scalpel said...

Disclaimer. I have not examined the child. Medical advice on the Internet is worth what you paid for it. (nothing).

When a CT scan is read as appendicitis, it is almost never wrong. I've done over 200 appendectomies in the last 3 years and only once did I not operate on a patient whose CT was called appendicitis by radiology.

Most patients, especially children, are not doubled over with pain when they have appendicitis. Your daughter may have perforated (burst) her appendix. She needs to be seen by a surgeon, preferably a pediatric surgeon, immediately. Go to the hospital you were at last night a get a CD copy of the CT scan. Then go to a medical school hospital.

I am appalled that you child was not examined by the surgeon. Please let me know hat happened. I'm sorry I didn't see you comment last night.

CGH23 said...

Dear Skeptical Scalpel,

Five weeks ago: Occasional stabbing pain in my Right Lower Quadrant, early satiety, right-sided back pain, persisted until the situation became more acute.

Three weeks ago: Temp. 101.8, nausea, dry heaves, lost 8 pounds in the space of a few days, no bowel sounds, white cell count normal, urinalysis normal; right-sided low back pain; CT scan read: "mucosal thickening involving the cecum and proximal right colon with adjacent mesenteric stranding.... The appendix is not well identified.... possibly delayed CT scan of the abdomen could be helpful to further exclude appendicitis." (The radiology tech only waited approx. 15 min. after my finishing the oral contrast medium.) The next day, my family practice physician said it must have been viral since the appendix wasn't visualized and my fever and nausea had improved.

For the last three weeks: persistent slight elevation of temp.around 99.6; episodic sharp right lower quadrant pain. Four days ago the pain was persistent and increased with coughing and with every heel-strike when walking for about 6 hours, then went back to the usual "discomfort", including right-sided low back pain.

Today: 99.5 degree temp, generalized discomfort right lower quadrant, slight feeling of nausea (though I have not eaten today), right sided low back pain. I have regained 5 of the lost pounds, probably a good part of it being fluid since I was pretty dehydrated when I was more acute.

One other note: I had a colonoscopy about 1 1/2 years ago that was completely normal, except that the GI doctor could not visualize the appendix. He asked if I had had an appendectomy, but I never have. I had read that chronic inflammation in the region of the appendix could cause scarring. (I have had episodes in he past of similar discomfort, but I have never gone to the doctor about it in the past.) Could that be why it did not visualize on the CT scan, or is that more likely due to inadequate delay before conducting the scan?

Thank you for any consideration that you might give to my concerns.

Skeptical Scalpel said...

It is impossible to give you any medical advice without examining you. What I am about to say should not be construed as advice.

Temperatures of under 100 are within the normal range of variation of body temperature. Oral contrast is not necessary for visualization of the appendix. Many hospitals don't use it. Non-visualization of the appendix nearly always indicates is not inflamed. I'm not sure what you gastroenterologist meant when he said he couldn't see the appendix. All one can see from the inside is the opening of the appendix.

Please get another opinion from a respected surgeon or GI MD.

Anonymous said...

I have an 11 yr old and we have already been to the ER. They did an ultra sound and said that there is fluid around her appendix, they said that they can do a CT scan but it is risky due to her age. They sent us home told me told me to watch her for the next 12 hrs. Her pain is worse but I am so worried about the risk of a CT scan for her. What is the risk of taking out her appendix when they are okay?

Skeptical Scalpel said...

The risk of CT scan for an 11 year old is less than the risk of a ruptured appendix in my opinion.

There is very little risk involved in removing a normal appendix. If there is any doubt, I would opt for the surgery. Fluid around the appendix is not normal.

Please read the disclaimers in previous comments of mine.

STA Auction 2010 said...

I sit here now appendix free but with many questions as to my care. 3 weeks ago I awoke at 2 am with abdominal pains that I thought were related to eating out the day before. By morning, I realized it was not that but a reoccuring attack that I had had about 6 times over 2 years. Attacks lasted from anywhere from 6-12 hours and always went away completely after 1-2 days of tenderness. Same symptoms each time and each time I thought it was either a stomach virus or my appendix but they always went away. This time was the same but the pain was tolerable until 9 am when I thought I was going to vomit. In walking to the bathroom, I literally felt and explosion in my lower right side. The pain crippled me as I fell to the floor. 60 seconds later I threw up clear acid and lost control of my bladder. I couldn't move from the pain. My husband immediately took me to the ER. CT scan showed normal appendix but with surrounding inflammation and a fluid sac behind my uterus. Gyn consult/exam showed no signs of gyn issues - she said the fluid sac is common in the pelvis when an infection is somewhere in the abdomen - gravity pulls it downwards. She said it was my appendix. Admitted to hospital, IV antibiotics and opiates (which didn't work). 24 hours later surgeons request procedure to insert drainage tube (using another CT scan)through upper gluteas to evaluate fluid sac (even though GYN said it was nothing) - unsuccessful as not enough fluid in there and it tested negative. Hospitalist continues to say it's my appendix from physical exams and history. Surgeons continue to tell me it's not. For 48 hours I laid in bed in excruciating pain listening to internists tell me it's my appendix while surgeons say it's not. Finally convince surgeons by having a mental breakdown to go in laproscopically for exploratory surgery. As they wheel me in, they continue to say that it's not my appendix and they really think this is a waste of time. 2.5 hours later my husband receives the call that it was my appendix and it had ruptured. I felt it rupture and physically I showed all the signs of appendicits yet the surgeons were solely focusing on my normal CT scan. My recovery has been slower than expected and I am still experiencing discomfort. Thankfully, no signs of secondary infections so far and it has been 2 weeks and 4 days since the rupture. I have done some research, and most studies conclude that CT scans are reliable for diagnosis. But what about the physical signs vs. technology? Shouldn't there be a better balance? I feel like my CT scans exposure were a waste. I feel as though there was a complete disconnect between the surgeons and the other doctors/specialists in the hospital. This was a teaching hospital and I am dumbfounded that more research or collaboration between doctors doesn't take place. Should doctors rely so heavily on technology or should they use their own knowledge to diagnose? Just curious what your opinion is...

Frustrated in Phx

Skeptical Scalpel said...

STA, that's really quite a story. I'm sorry you had to suffer. You ask some very good questions, particularly "Should doctors rely so heavily on technology or should they use their own knowledge to diagnose?" Sometimes technology is wrong as seems to be what happened in your situation.

It's hard for me to comment on your care without seeing the CT scan and looking at your chart. Sometimes we surgeons can be mighty stubborn. It is unusual for everyone but a surgeon to want a patient to have an operation.

I hope you feel better soon.

Annon said...

Interesting situation. My girlfriend woke up to excruciating stomach pain. So much so that she could not sit up in the car for me to drive her to the ER (10 min away) so a ambulance was called. Got to the ER where they stated to work her up. ER doc did a full work up (including cardiac due to a successful ablation 9 months prior) and called for a ultrasound and surgical diagnoses. Pain in lower abdomen and tender spot on the right side. No fever, no vomiting, no nausea, not diarrhea, no pain while moving/bending/lifting legs. WBC and UA normal. Ultra sound came back without a definitive answer and the surgeon was not ready to operate due to lack of "clinical" symptoms. They checked ovaries at the same time. Surgeon ordered a CT scan. CT scan back and showed a "potential" appendicitis. Still no symptoms. The doctors decide to admit her and observe over night. Check vitals every hour over night and zero pain meds. Still no fever, no nausea, no vomiting, etc, More blood work in the morning. Surgical team comes to do another consultation. Pain has lessened dramatically. Still 0 symptoms. They had restricted her diet to IV only for the whole day prior. After the improvement in the pain without meds, they decide to let her eat and drink to see how her body will tolerate it. Started with clear liquid. Fine. Light snack/jello. Fine. Full meal of solid food. Fine. Appetite, normal. They have now discharged her and told to monitor her for the next 24-48 hours and if symptoms develop, they will operate. I was wondering if there is anything else that could present like appendicitis and not be appendicitis. I have read your other posts and thought I should mention that this all took place at a very notable teaching hospital with several sets of Doctors reviewing the case. She also had the flu last week. All symptoms from that had been cleared up for 5 days plus before the incident happened.

Sorry for the broken thoughts, it is a lot to remember and try to explain in a cohesive manor.

Thank you

Skeptical Scalpel said...

It could have been many things other than appendicitis.

I have treated many patients the same way your girlfriend was treated.

When a CT scan does not show a surgically treatable lesion, it is almost always correct. No one would explore the abdomen when the CT was negative or only showed a "potential" appendicitis. BTW, I have never heard potential used to describe an appendix. Maybe "possible" but not potential.

I hope she is Ok.

Anonymous said...

Need some help. I have a 7 year old daughter. She originally started out about 6 weeks ago with severe "tummy ache" as she described it followed by vomitting and diahrea for 2 days. We thought she had a bug so didn't think anything of it. The vomitting and diahrea resolved but the pain has never gone away. It is consistently in the lower right quadrant and is constant. Most of the time she rates it at as 4 on the pain scale 0 - 10 (at dr's office). Two to three times a day she has severe pain where she is crying. there is no consistent time of day when this happens.
She has been seen at urgent care(two weeks ago), they told us to give her fiber because she does not present with any clinical symptoms of appendicitis other than the pain, has been seen twice by her primary care, he told us the same thing although ordered an ultrasound. They couldn't visualize her appendix. That was yesterday. Today I took her to the ER because again, severe pain with slightly elevated temp of 99.9 and quite frankly my husband and I have had enough of the doctors scratching their heads. ER did a CT scan, again they couldn't see her appendix. She is not overweight and is consistently complaining of pain in the same region. They suggested giving her colase even though she goes #2 at least twice a day (due to the fiber we have been giving her).
Here's the rub, I had the same thing as did my Mom. suffered for two years and finally was able to get my gynecologist to do a laparoscopy where they found that my appendix were scarred over and leaking just enough infection on my ovaries to cause the pain. When I told the ER PA (no there was not a doctor to take the time to see her today), this she looked at me like I was insane. How do I help my daughter? We have done everything the docs have said. She's not lying about the pain and it's really beginning to affect her. Our insurance is an HMO so we are limited to what we can do and where we can go. How do I convince the doctors that this may be hereditary and to take a look at the dang appendix via surgery? I don't want her to have to undergo surgery if it's not needed, but, she is doing the same exact thing as me!

Skeptical Scalpel said...

Please read the many disclaimers above. I can't give you medical advice without having examined the child or seen her CT scan.

As I mentioned in another comment, non-visualization of the appendix almost always means it is normal. Fluid leaking from the appendix would usually show up on the CT. Of course, the history of your family's appendix problems should be taken into account.

Here's a secret. We often tell patients it's constipation when we don't know what is going on.

If the child is eating normally, having two BMs per day and sleeping through the night, her chances of having appendicitis are low. If the pain persists, you need to have her seen by a surgeon.

I wish I could help you more. Please give me some follow-up when this is resolved. Good luck.

Anonymous said...

Thanks for the feedback. Unfortunately it is keeping her awake at night and you did confirm my suspicions that we were just being blown off today at the ER. We have an appt. next week at Childrens Hospital with a Pediatric GI specialist. We decided it's worth paying $'s out of pocket if it gets her some relief. I hope they can figure this out. Thanks again.

Anonymous said...

I had some pains that I think started in one location and moved to my lower right side. Over the course of 4-5 days the pain got worse. The pain seemed to be better when lying flat and by the time I would awake it felt better, though by 4pm it would come back. It felt swollen and like there was something pushing on it. I had no fever, vomiting or diarrhea. By the time I went to the ER, the pain seemed to be going away. They took blood, urine, ct scan and an ultrasound and nothing showed as abnormal. Understanding that you can not diagnose me without seeing me:

1. Any suggestions for what this could have been? It felt like nothing I've experienced before, and I'm afraid of it coming back.
2. Is it possible that my appendix was swollen and by the time I went to the ER it had gone down?

Thank you.

Skeptical Scalpel said...

Thanks for reading my blog.

1. I can't say what it was. The fact that it was not preventing you from sleeping suggests it was probably not a serious condition.

2. It is highly unlikely that an inflamed appendix would get better that quickly. There are some cases of chronic, recurrent appendicitis reported, but CT eventually identifies an enlarged appendix.

Anonymous said...

Thank you for your response.

1. It did prevent me from sleeping one night because of pain/discomfort.
2. The whole thing lasted 4-5 days. If its unlikely a swollen appendix, are there any other organs in that area that could inflame and go down over 4-5 days?

Thanks again.

Skeptical Scalpel said...

The other common things it could have been are a ureteral stone, an inflamed appendix epiploica (Google it) or cecal diverticulitis. The latter two would have been seen on CT.

If you are a woman, it could have been any of the above or an ovarian cyst (also very likely to have been seen on CT) or endometriosis.

Worried Mother said...

I have an 11 almost 12 year old son. Sunday Jan 27, 2013 he complained of a stomach ache and nausea, slight fever of 99.1. Monday morning I go to wake him up from school and he is laying in bed crying that his stomach is hurting very bad. I asked him to show me where and he pointed to his right side. I made him an appointment with our dr. who ordered an ultrasound and prescribed him Prilosec. The radiologist said the ultrasound was normal. He remained in pain the rest of the day Monday with his temp remaining between 99.1 and 99.9. Tuesday he complained of the pain getting a little worse. Today Wednesday I woke him up for school, he didn't say nothing about the pain being very bad although I could tell he was uncomfortable. I dropped him off at school at 7:20 at 8:00 I got a phone call that my son was found in the boys bathroom crying of severe abdominal pain and experiencing diarrhea by a teacher. I went and picked him up and called the Dr. since this was a new symptom (diarrhea), I told her that he was experiencing rebound pain, when I had him lay down and lift up his right knee it hurt him to bad, if I press on the left side of his abdomen he says that it hurts on the right side. The Dr. ordered a CT scan, once again the radiologist says that the appendix looked normal, BUT my son does have swollen lymph-nodes in the lower right quadrant of his abdomen as well as an abnormal amount of free fluid. Our Dr. then said that it is probably a virus but she ordered a CBC to be on the safe side, we got the results and she says they are within normal range. So she took him out of school till Monday and prescribed him Phenergan for the nausea. I am at a loss, my son is in pain, and I can see that something isn't right, not to mention that mothers intuition telling me that we may be a ticking time bomb on our hands. I know that you can't actually provide medical advice and I understand that, I am just wanting some real guidance on what I should do in this situation. Anything at all..please help.

Skeptical Scalpel said...

I'm sorry to hear that your son is not well.

You are correct that I can't give your medical advice.

As I have mentioned to others above, there are several things suggesting that he does not have appendicitis or any other surgical problem. They is no fever (temps below 100.4 are not considered fever), no elevation of the WBC and ultrasound and CT scan which visualized the appendix are normal.

You did not mention whether he is eating normally or sleeping through the night. He is apparently not on pain medication.

If the pain persists, ask your doctor to refer you to a surgeon, preferably a good pediatric surgeon.

I hope he feels better. Let me know how it turns out.

Worried Mother said...

Thank you for the response. No he is not eating normally as his appetite and significantly decreased, as far as sleeping through the night no he has been up at least 2 times every night and has had a hard time falling back asleep. For pain we were told to give him Tylenol and Ibuprofen which I have been but he still complains about the pain. Earlier tonight when I checked his temp it was in the ear and it was 100.7. I see our Dr. in the morning and am going to talk to her some more to try and find out what is going on. I am just at a loss.

Skeptical Scalpel said...

It sounds like he is sick. The question is, is it a surgical problem? Could it be a variant of the flu?

I'll stick with my previous thought that a surgeon should evaluate him.

Worried Mother said...

We took him to the ER and he was diagnosed with Acute Mesenteric Lymphadenitis. The doctor said that this is and can be very painful since we have more lymph nodes in the right side of the abdomen than anywhere else. He said that this was more than likely caused from Gastroenteritis and that these two combined can cause very similar symptoms to appendicitis. I thought I would share this as it can be very useful to others who may have the same symptoms as my son.

Skeptical Scalpel said...

Thanks for the follow-up. My faith in the power of the CT scan is still justified.

I hope he is feeling better.

Anonymous said...

Hi,

I last posted on January 24, 2013 at 1:15 PM, my pain went away after about 4-5 days. Nothing showed up during the ER tests, I spent some time googling different things including what you suggested, though I didn't have the nausea, vommitting, bleeding, diarrhea or fever of many of the conditions.

Two days ago the pain came back. I can not find any correlation between the pain and anything specific happening, though I did become sick with a cold after the pain went away last time and I have been a bit congested over the past couple days. My appetite has decreased significantly since this first happened a couple weeks ago and I am Jewish, though I do not know about anyone else in my family with similar issues.

I just searched "Acute Mesenteric Lymphadenitis" based on Worried Mother's post (thanks for posting that!), and that description, as well as Crohn's disease and Ulcerative colitis seem like other possibilities.

I'm going to try and see my doctor over the next week, though in the meantime, just wondering if you have any other suggestions for me to look into or things that can be ruled out based on my info provided?

Thanks!

Skeptical Scalpel said...

Mesenteric adenitis would be accomapnied by large nodes on the CT scan. You said you had one, but there was no mention of enlarged nodes.

I don't have any other thoughts for you except to say it continues to sound like it is not a surgical problem.

Anonymous said...

I went into the ER on Sunday morning after having pain that started as mild discomfort in the stomach area on Friday night then progressed to terrible pain on Saturday and by Sunday morning I was doubled over if I moved around. We went to the ER Sunday morning they did blood work which was apparently negative but given the location of my pain they sent me for an Ultrasound where they said it was non-compressible and showed some fluid but it was normal at 5mm. They said they couldn't exclude early appendicitis.I was then discharged and asked to come back the following morning. I went back for an Ultrasound again at 12:45pm on Monday morning by this time I was vomiting I couldn't keep the water down to prepare for the test. That Ultrasound was inconclusive as well they couldn't see anything. I did not have a fever but felt very sick with cold sweats and nausea and had vomited a few times. My bloodwork came back with an elevated Neutrophilis count only slightly this time. They then decided to send me for a CT scan, I saw the report which said it was not identifiable on the CT but everything appeared normal. I saw my family doctor today who said it is likely that the appendix was irritated but not full blown appendicitis that perhaps any infection was fought off. Is that possible? Should I be concerned if I don't start to feel better soon? My doctor said the reason that they couldn't see it is because sometimes it is hidden behind the colon. I have to mention the pain is less severe today.

Skeptical Scalpel said...

See all disclaimers above. This is not medic la advice. Sorry for the delay in answering.

As I have said before, failure to see the appendix on CT scan almost always means it is not inflamed. CT scan can easily see behind the colon. Your case also demonstrates what I have said in other blogs about the lack of utility of ultrasound in the diagnosis of right-sided abdominal pain.

Missing information about you includes your sex, your age, whether you are eating and sleeping, are you taking pain medication, past surgical history.

If the pain persists, you should be examined by a general surgeon.

Anonymous said...

I have been scheduled for a non contrast ct scan (though I am told I am to drink "crystal light" to show contrast?) this coming Monday (2/11).
The reason is for a suspected appendicitis. I have already had an ultra sound that was inconclusive. Though during the ultra sound I asked if they saw a problem and they told me they did not. Except for a small amount of fluid in the area.
My symptoms started about 9 months ago. With a tender lower abdomen. It's progressed to having episodes of sharp pain that feels like trapped air and diarhea. With nausea. These episodes last a matter of hours and then go away. Except for some lingering tenderness.
I was suprised when the doctor suggested appendix was the problem. I thought that came on suddenly and was quick to come to rupture. I am a 41 year old woman, with one kidney and scared of the CT scan dye. My doctor assures me it will be a low dose and taken orally so it will not damage my one kidney. But I am still concerned. Is there any other way to make a diagnosis? Can I have a CT scan without any contrast dye? Also, is it possible to have a long lingering appendicitis?

Skeptical Scalpel said...

See disclaimers above.

Oral contrast will not damage your kidneys. Many radiologists feel that they get a better look at the appendix when there is contrast in the colon. Some feel it isn't necessary.

There is an entity called chronic appendicitis. It's not common, but it happens. It sounds like a CT is worth doing. It will visualize your uters and ovaries too.

Good luck. Let me know how it goes.

Anonymous said...

My 11 year old daughter has had abdominal pain for a little over a month. She has not had a fever, nausea, or diarrhea. Her pediatrician put her on laxatives and ordered a blood test which came back negative. Since she still had the pain, which is worse when she is on a school bus or a really bumpy car ride, he referred us to a GI. The GI also put her on stronger laxatives and probiotics. My daughter's pain lessened a little bit, but it's still bothering her. Still no fever or nausea. Her appetite hasn't changed, meaning she is still eating normally. She seems normal other than the persistent pain. The GI ordered blood tests and has also scheduled my daughter for an endoscopy and colonoscopy as well as a lactose intolerance test. I am worried about the possible complications of a colonoscopy as she is small for her age. Would a CT scan be better, even with the radiation?

Skeptical Scalpel said...

Please see the numerous disclaimers above. This is not medical advice. I have not examined the child.

When you say your daughter seems normal, does that mean she is sleeping well and doing OK in school? Is she going to the school nurse and complaining about the pain? Have you had to pick her up from school because of the pain? Is she having bowel movements every day or two?

Have you ever heard the expression, "When all you have is a hammer, the whole world looks like a nail"? It is common for GI docs to want to scope everyone. It is what they do.

I would think about the idea of scoping her. They have pediatric scopes so size is not a problem. But she would have to have light general anesthesia for the two procedures.

A doubt that a CT scan would be very revealing and you are right to worry a little about the radiation. You don't say where the pain is located in the abdomen.

Has puberty begun? Could this be a gynecologic problem? If the pain is in the lower abdomen, you may want to investigate the gyn area.

A second opinion from a surgeon or another GI doc might help too.

Let me know what happens.

Anonymous said...

Thanks for your blog and your prompt answers tp questions! Very interesting information. Have you ever had a "not visualized" appendix be abnormal? My daughter (11) has had an ultrasound, ct and MRI in the last month in which the appendix was not seen. She is being passed around to different specialties, none of whom have an answer for her pain. The GYN recommends we see a ped. surgeon to "look for" the appendix. She does have minimal free fluid in the abdomen. Thanks!

Skeptical Scalpel said...

I have had a non-visualized appendix turn out to be inflamed, but it eventually showed up on imaging studies. Since anything is possible, I suppose an appendix could not be seen on the 3 studies your daughter had and still be appendicitis, but it's unlikely.

Other than pain, does she have any other signs or symptoms (fever, loss of appetite, bowel movement problems, inability to sleep because of pain, etc)? Lab tests?

Minimal free fluid may be normal.

A peds surgeon sounds like a great idea.

Let me know how this turns out please.

Anonymous said...

She lost about 6 ls after the first attack in December, was hospitalized for 8 days with an NG tube to get her weight up. Pain with bowel movements, full bladder, and when food moves down past the right lower quadrant area. Had MRI and does not have IBD. Labs are normal but she is on Enbrel for JIA. My Mom had "chronic appendicitis" as a young adult. Not sure that matters, but I thought I would throw it in! Thanks!!

Skeptical Scalpel said...

I doubt that your mother's chronic appendicitis is related.

I suppose this may have occurred to your doctors, but one of the side effects of Enbrel is "severe abominal pain." You can read about it here http://is.gd/cjddlA.

I am sorry she's ill. I wish her the best.

Anonymous said...

Rheumatologist says it is not connected to Enbrel. They did see a small dermoid cyst on her right ovary. What is your opinion on dermoid cysts? Do they cause pain or need to come out? Thanks so much for answering questions...

Skeptical Scalpel said...

I am not an expert in the management of pediatric ovarian dermoids. I suggest you consult a competent gynecologist for advice about that.

Anonymous said...

I have a 4 year old and for over a month now she has had right abdominal pain. We have been in and out of the doctors for weeks. First she was constipated and with medication it took two weeks to clear out, but the pain hasn't gone away. We went yesterday for an ultrasound and they said she has free fluid in her pelvis and her appendix looked abnormal. So we went for a CT scan and they said that came back normal. There is fluid in her pelvis but they said it's minimal and the CT scan deemed it not important. I'm worried and curious as to how one shows bad and the other comes back normal.

Skeptical Scalpel said...

"I'm worried and curious as to how one shows bad and the other comes back normal."

That's an excellent question. But it's not that uncommon to have tests give conflicting results.

With the disclaimer that I have not seen the images or the child, I would believe the CT over the ultrasound. Many papers have shown that CT is more accurate.

Anonymous said...

I've been having bright red mucousy blood in my stool for over the last year. I seen a gastroenterologist and recently just had a colonoscopy and gastroscopy done (gastroscopy for a check up on my GERD). Two biopsies were taken during the colonscopy and as soon as it was over the gastroenterologist quickly asked me if I had had my appendix removed, which I hadn't. He then also asked if I have history of frequent cramping in my lower abdomen. Are these standard questions? I was thinking maybe he seen scarring and thought it was from an appendectomy. I can't really think of any other reasons.

Skeptical Scalpel said...

I have no idea why he would have asked that question. You really can't see appendectomy scarring from the inside of the colon. You can occasionally see a bulge if the stump of the appendix had been inverted, which is not done much any more. One would think that he might have taken a history and asked what prior surgery you had.

Anonymous said...

I'm a 16 year old female. I woke up yesterday at 5am vomiting, went back to sleep. Woke up around 9am again and vomited 3 times before going to an urgent care around 11pm. The doctor at the urgent care palpated my stomach: no pain except for severe pain when the lower right abdomen was palpated. The doctor told my mom and I that I was having an acute appendicitis and to go to the ER immediately. I went to the ER, as he instructed, where they did blood-work, urine tests, ultrasound, and a CT scan with oral and IV contrast. Blood work showed normal white count, urine was normal (besides a little blood, which is normal for me), ultrasound did not show the appendix due to bowel gas being in the way, and the CT scan was normal. I was sent home and told to follow up with my pediatrician (who is useless for the most part), and to come back if I experience pain without palpating if the area or other symptoms. I haven't thrown up since last night, but I have developed horrid almost uncontrollable liquid diarrhea and have been experiencing slight pain in the lower right abdomen without palpating it as of today. I am suspecting it is just a virus, but I'm worried in the back of my mind since the doctor at the urgent care seemed so immediately sure of appendicitis. Are my worries valid?

Skeptical Scalpel said...

Dear Anonymous,

I am sorry you aren't feeling well. Let me begin by repeating the standard disclaimer that I have not examined you and am unable to provide you with medical advice.

It is impossible for me to comment on a CT scan that I have not seen.

All I can say is the CT is very accurate when negative for appendicitis. Whether it is accurate for your specific case is impossible for me to say.

I am sorry I can't be more helpful.

Anonymous said...

I have a 9 year old son. He has been hospitalized over the past two weekends for abdominal pain. After first CTScan, I was told he had terminal ileitis and mesenteric adenitis. We saw a GI Dr two days later and he disagreed with terminal ileitis. He prescribed Prilosec and wanted to see how he did with that. 2 days later, he was in excruciating pain. I called the pediatrician back and she suggested taking him back to hospital that we did ctscan. When we arrived the attending ER Dr said they should never have sent him home after the ctscan. The attending pediatrician refused to admit him and brought him up to her floor for observation. She claimed he was constipated and ordered an enema and Miralax with torredol for pain. While he was cleaned out, he was still in pain. She sent him home claiming constipation as diagnosis with mesenteric adenitis. A week later, he began having pain again. I went to pediatricians office and she sent us to a local children's hospital for a second opinion. Though some bloodwork showed some elevations, none were alarming. They repeated the CTScan and found a stone in his appendix. He was given pain meds for 24 hours and sent home. It is only 10 days later. My son woke at about 5 this morning with abdominal pain. Unlike before, he points directly to his appendix each time when asked about pain. It is painful to walk. He cannot lift his legs because if the pain. He is not moving because when he does the pain is worse. The radiologist came in to assist with the ultrasound today. He saw that the tip of the appendix looked swollen. The remainder of it looked normal. Labs are relatively normal. He is very tender upon examination. The fellow surgeon said he has an appendicitis and should have it removed. The chief disagrees even though he has not examined my son. I know you have no lab work, and cannot examine my son, but I could use some help. I am typing away here knowing that they will probably end up sending him home again. Why wait to remove the appendix? Doesn't the mesenteric adenitis tell us something is happening there? Do his symptoms account for anything?

Skeptical Scalpel said...

With the disclaimer that I too have not examined the child, it seems to me that since so many people think he has appendicitis, why not remove it?

A stone in an appendix with a swollen tip sounds like appendicitis.

The risks of the surgery are not great. He's 9 and has had 2 CT scans already. Some would argue that the radiation risk outweighs the the risk of surgery and anesthesia.

Perhaps another surgeon should see the child.

Please let me know how this turns out. Good luck.

Anonymous said...

I had lower right abdominal pain 3 weeks ago and went to ER twice with CT scan and blood test. All the results are normal. My pain was much better one week ago when I visited a general surgeon as ER doctor suggests. The surgeon confirmed that the Ct scan I took 2 weeks ago is normal. However, my pain got worse 2 days ago, serve pain in the same location. I also feel nausea and have a low fever this time, which did not have before. Feel painful when pressing in the spot. Is this still possible appendicitis? Should I go to ER again or can I wait one more day to see regular doctor or GI specaist? Thanks.

Skeptical Scalpel said...

Of course it is possible that you can have appendicitis.

Please refer to the addendum at the beginning of this post.

I am sorry that I cannot give you medical advice. Read through the previous comments above and you can get a sense of what options you have.

Danielle said...

My son was taken to the ER a few weeks ago with severe abdominal pain. He has been sick several hours before (vomiting, not eating)Slight fever. WBC was elevated, CT came back normal. given pain meds and Sent home. Less than 24 hours later he was doubled over crying in pain. Took him to a different hospital where they did another CT scan which came back as a ruptured appendix. Emergency surgery performed.

The first hospital called to talk to me today. They had pulled his charts and reviewed his CT scan. Still was showing normal. so I just wanted to say that yes it is possible, although unlikely I'm sure but it happened to us, to have a CT scan show normal but still have appendicitis. Also since he went an extra 24 hours instead of getting it taken care of right way it had ruptured and extra days in hospital because of it.

Skeptical Scalpel said...

Danielle, thanks for commenting. I hope your son is feeling better.

It is possible for CT scans to be wrong both false positive (calling it appendicitis when the appendix is not inflamed) and false negative (saying the appendix is normal when it isn't).

Without seeing the original CT myself, I can't comment of what it showed.

Vomiting, slight fever, severe pain and an elevated white count? Other options would have been to admit him for observation or ignore the CT findings and operate anyway. I might have chosen to admit him. It is very uncommon to find pathology at surgery when the CT is normal.

Danielle said...

Thanks for the reply Skeptical Scalpel. According to what they told me the appendix was not even shown on the CT scan...so I'm assuming they thought since they don't see it, it must be okay. Showed up right away on his 2nd CT at the next hospital.

The first ER doctor had suspected appendicitis but since he saw "normal" CT, he dismissed his symptoms as something else.

I guess there needs to be a balance between diagnosing symptoms and what technology tells you.

He's doing great now, no problems. I guess his case was just an odd one!

Skeptical Scalpel said...

Non-visualization of the appendix on CT almost always means it is normal.

Yes, there must be a balance between what the clinician finds on history and physical exam and what the studies show.

Glad he is feeling well.

Anonymous said...

First off, thank you for this blog. I am a 28 year old female located in a major city. I would never generally consult the internet, but I am at my wits end. Additionally, as I work in the medical-legal field, I understand completely that you cannot give medical advice. Mostly, I am looking for peace of mind from a seasoned professional.

Two weeks ago, I was hit in the abdomen during a soccer game. I did not pass out, feel extreme pain, or have any symptoms that night.

The next morning, I was urinating every 15 minutes with a feeling of a brick being laid on my abdomen. I went to urgent care (thinking possible UTI). Once there they ran my urine (normal) and told me I probably had a bruised bladder and was fine.

The next day I attempted to work but began to experience extreme LRQ abdominal pain. I went home and attempted to lay down. When trying to walk to the bathroom I collapsed from the pain and a roommate rushed me to the ER. For the next two weeks, I was in the ER 3x (CBC done - normal. WBC done - normal. CT done - normal) with no relief. They pushed a ton of pain meds during these visits and gave me antibiotics for a possible UTI. With the pain still extreme after finishing my pills, I followed up with my PCP who has done a transvaginal ultrasound, an ultrasound of my gallbladder, and of my right leg (she thought there may be a clot from being hit.) When none of this was the cause, she decided to refer me to a surgeon for a consult (they are thinking possible hernia??). I find this to be a little scary as they have not yet done an ultrasound of the painful area (I know they are relaying on the CT done 3 weeks ago for that.)

In the course of all of this, I am unable to eat without a bloating pain and have lost a great deal of weight. The pain is constant and does not let up, but is more extreme and "attacks" at certain times.

My question is - do you believe in chronic appendicitis? I want to believe this doesn't exist but my recent luck has me feeling otherwise.

Additionally, while I have had a CT of my abdomen, I am wondering if an ultrasound of the exact area I hurt would be more helpful?

Mostly, this has taken over my life and I am very scared I am never going to feel normal again. Seeing doctor after doctor and being told "you'll heal, you're fine" has me feeling extremely frustrated and crazy.

Best,
L

Skeptical Scalpel said...

I believe in chronic appendicitis. I've seen several cases, but I've not seen it present like yours. It is highly unlikely that an injury during soccer would cause appendicitis. Also, CT is very good at identifying appendicitis. The CT you had 3 weeks ago would have seen it. CT is also very good for picking up a hernia, which could have resulted from an injury.

I am not sure what an another ultrasound would accomplish. Most gallbladder ultrasounds include the entire abdomen. However, US is non-invasive and certainly is not a problem to repeat.

I never heard of a "bruised bladder" and doubt that such a thing exists.

I am a little confused as to exactly where your pain is located. Does it radiate to any other area? Is it worse with eating? Does it occur right after you eat or an hour or two later? Nausea or vomiting? Diarrhea or constipation? Have you been taking a lot of narcotic pain medicine?

In what large city are you located?

Anonymous said...

Hi.
I am a 29 year old female living in a regional town.
I had strong pain in my right side a couple of days ago, pain walking, driving, breathing out. I attended my local ER early in the morning & they have no facilities to test blood, ultrasound etc at that time of night so gave me pain killers and sent me home.
I went back for ultrasound the next day, with much less pain. Results were fluid around my appendix and inflamed. Radiologist & Dr booked me straight in & called the surgeon. Surgeon sent me home as my pain was reduced.
Another day has passed. I haven't eaten much & the pain is reduced but I get infrequent sharp pains & a constant tight feeling in my side. Should I be worried about the ultrasound?? I have no other symptoms other than initial constipation (2 days) and now diarrhoea.

Thank you

Skeptical Scalpel said...

See the numerous disclaimers included with my previous answers.

Your case highlights two reasons why ultrasound probably will not replace CT scan for diagnosing the cause of abdominal pain. It's not available at night in many hospitals, and the surgeon did not believe the reading.

You did not mention whether you have a fever of any nausea/vomiting. Those signs and symptoms are not always present with appendicitis. Diarrhea can be associated with appendicitis.

At the very least, you need to be examined by another competent doctor, preferably a surgeon. A CT scan and/or a gynecologic examination might help clarify things.

Please let me know how this turns out.

in pain said...

I'm a 30 y/o female, with pain that started as generalized then seemed to settle into my RLQ, vitals normal, temp 98.3 in triage. I went to the ER within 6 hours or so of this starting. Bear in mind I have worked in healthcare and emergency services for 11 years, and I don't take an ER visit lightly. Upon evaluation by the ER attending physician he swore it was classic appendicitis. They did a CT and bloodwork, all of which were normal except for 'multiple fluid-filled loops of non-distended bowel. consider enteritis' as on the CT report. I was quickly discharged with a diagnosis of 'viral enteritis' even though I did not have any GI symptoms besides nausea and 2 bouts of vomiting that morning. I was d/c with a Rx for zofran and protonix. It is now 2 days later, no diarrhea or other GI symptoms, except mild nausea, and still continue to have stabbing RLQ pain and a temp of 99.9.

Skeptical Scalpel said...

In pain, sorry you are not feeling better.

See above disclaimers and notice in red at the beginning of this post.

I don't really have enough information to comment on your situation. One of the more important missing pieces is a personal history and physical examination.

It is not clear whether your appendix was seen as normal or not seen at all, which almost always indicates that it was normal. Non-distended bowel is usually normal too.

Your options include waiting and seeing what happens or getting a second opinion.

Viral enteritis and acute gastroenteritis are what we tell people when we don't know what is wrong with them. Patients just don't seem to be satisfied with "I don't know."

Anonymous said...

i want my appendix to be removed....because my lower right abdomen pains a lot but when i go for a scan the reports suggests that everything is normal and when i walk for some distance the right side of the abdomen starts paining.... can u plzzz suggest me something

Skeptical Scalpel said...

Sorry it has taken so long to respond, but I am on a brief vacation.

As you know, I cannot give you medical advice.

Your story is a bit brief. You don't mention any other symptoms, such as whether you've had nausea, vomiting, diarrhea, constipation, weight loss, if the pain wakes you from sleep, etc. You also did not mention your age or sex.

A CT scan showing a normal appendix is usually accurate.

An orthopedist friend suggests your pain may be musculoskeletal. It might be worthwhile to see an orthopedist or a primary care doctor.

Good luck.

Anonymous said...

Last year I ended up in the ER thinking I had appendicitis. Turned out to be a ruptured cyst. They told me I had fluid in my abdomin and it would reabsorb. Today while I was grocery shopping I suddenly got really bad pain in my lower right side. When i would lay down i felt fine but whenever I would move it would hurt. I ended up in the er. They did a ct scan which the dr said it showed some free fluid in my abdomen but everything else looked fine and it was probably another ruptured cyst. My paperwork said cause for my pain is unknown. Wouldnt a ct show a ruptured cyst? I frequently have bad right side pain. I was told in 2002 i had reoccuring appendicitis. Today my symptoms were sudden pain. Gas. Horrible stomach pain. Low grade fever. Help?

Skeptical Scalpel said...

A ruptured cyst might not be seen on a CT scan because when it ruptures, it gets very small. You don't mention if your appendix was actually seen on any CT. If it was seen and is not enlarged, it is highly unlikely to have been inflamed. Hernias are also usually very easy to see on CT.

I'm not sure what you mean by low grade fever. We don't consider it a fever if the temperature is below 100.4 degrees.

You have had 3 abdominal CT scans in the last 11 years. Some experts would consider that 3 is a lot for a young woman. Ultrasounds are not as accurate as CT's, but there is no radiation involved. Ultrasound might be a better choice of test next time.

Of course, I don't know what the pain is being caused by, but a ruptured ovarian cyst is at least plausible.

I suggest that you follow-up with a gynecologist.

plshelppp said...

Recently I have been experiencing nausea in my upper left stomach, below my rib and my lower right abdomen. I am slightly over weight, I have had an Ultrasound, a CT scan, and X-Rays done. Everything came back normal. But It continues to progress over the days. I am experiencing back pain with it now, and a lot of diarrhea, but the highest temperature I've had so far is 99.4, and me and my mother didn't strike it as a problem. My lower abdomen does feel a bit firmer than it was before, and it hurts when I hit any bump, or if I am to jump, and sometimes walk. But everything came back normal, and I, my mother, and my doctors are so stuck. Please help!

Skeptical Scalpel said...

Dear pls, I wish I could give you an answer, but it is impossible for me to tell what might be going on. There is a lot of missing information that can only be obtained by a proper history and physical exam in person.

Positives--Your CT scan was normal. 99.4 is not a fever.

I suggest that you consult with a good gastroenterologist for futher workup of the diarrhea and pain.

Anonymous said...

Yesterday I had a colonoscopy and endoscopy. Among other findings, the doctor found my appendix to be inverted and when she tried to manipulate it, it oozed a milky fluid. She suggested a wait and see approach, possibly scanning it if I begin to have symptoms. I have had instances of quick stabbing pains in the LRQ from time to time, but they don't last long.

Skeptical Scalpel said...

I do not have an explanation for the milky fluid. An inverted appendix is a rare finding. You are unlikely to get appendicitis, but I suggest you follow you doctor's advice.

Anonymous said...

I have had pain in my lower right side for over a week now. It radiates as far up as my waist and across to my belly button. It is excruciating at times. While lying down it is only in the lower right side but when I get up and move around is when it radiates. I have no fever or vomiting,but I do have nausea. I saw a Dr yesterday and when she examined me she thought it was my appendix. I had a cat scan which showed a normal appendix,no hernia, no cyst. All it showed was diverticulosis which does not cause pain. Her only explanation was maybe I pulled a ligament and didn't know I had done it. She wants me to take toradol is for inflammation. I don't do good with this type meds because of stomach problems, but that is all she offered and told me to put hear on it. I really don't think I have a pulled ligament,but of I seek treatment elsewhere I don't want another CT scan. My question is could it still be my appendix or what do you suggest I do. I know you can't diagnose my problem as I have already read your disclaimer. I just know I am in a lot of pain. Any suggestions appreciated.

Skeptical Scalpel said...

Assuming the CT scan was read correctly and when it is seen and looks normal, it usually is, appendicitis is very unlikely. I'm not sure what ligament your doctor is referring to.

You don't mention your age, sex, previous history of abdominal surgery, whether you are able to sleep or work and a few other parts of your history that would be helpful.

You can always get a copy of your CT scan on a CD-ROM. Many places aren't even charging for making a copy these days. So if you wanted to get another opinion, you should take a copy of the CT with you. If you don't feel better in a few days, you should probably see a gastroenterologist or a general surgeon.

Doctor Which said...

No, not another patient looking for a disclaimer

I would be fascinated to hear your opinion on a case of ruptured retrocaecal appendicitis I have presented on http://clinicalarts.blogspot.mx/2013/11/arts-1-science-0.html

Skeptical Scalpel said...

Doctor Which, I read you post about that case. I agree that making diagnoses without technology is becoming a lost art, but I must say that it would be very unusual in my experience to have a CT scan miss a perforated appendix as extensive as what you described.

Anonymous said...

I had a ruptured appendix in 1997. Gastro doctor had treated me for IBS with Xanax for a year...miserable year!
Did the hospital do a biopsy on the appendix. Is that standard?
I was diagnosed with a female cancer stage IV in 2005 and had chemo and radiation. I am now having tests to determine carcenoid syndrome.
So, just wanted to know if they biopsied my appendix.

Skeptical Scalpel said...

Anon, yes, your appendix would have been examined by a pathologist. You should be able to obtain that report from the hospital. It would be worth doing.

Anonymous said...

I had typical appendicitis symptoms in the early 80's. the surgeon did an appendectomy, but found the appendix to be "thickened" other findings were enlarged retroperitoneal ( sp?) lymph nodes. Post op, I abscesed and was septic. The surgeon wanted additional diagnostic studies such as colonascopy, but the HMO did not want to pay for them. Appoximately 1 year later I was dagnosed with Crohns diease by a gastroenterologist. Have you ever done an appendectomy and found out later that the pt. had Crohns. I am now doing very well thanks to immune modifiers. Your blog is very informative.

Skeptical Scalpel said...

Good question. I personally have never done an appendectomy and later found that the patient had Crohn's disease, but I know of several such cases. It is a well-known occurrence. I'm glad to hear that you are doing well.

Anonymous said...

Not sure if I should ask or post, given the 11-Apr-13 update and appreciation regarding inability to fully respond with a clinical (or more) evaluation. That said, hoping to get any insight.

Had minor pain initially and directly above appendix (3/10), over 3 days linearly decreasing to 0/10. Second day had slight fever (not measured; felt chills, etc). Went to ER of large NYC teaching hospital 60 hours after first symptoms to r/o. Single Tylenol dose alleviated fever, initial physical exams cited low likelihood of appendicitis. 40 year old male, no previous symptoms, no other ongoing symptoms. Good appetite, bowels not unusual, no nausea, vomiting, etc. Only went to ER out of abundance of caution.

CT scan positive for appendicitis. Distended to 11mm, enhancement of wall and luminal fliud. Substantial soft tissue thickening at the cecal insertion. Minimal thickening of fasical planes, no extraluminal collection or gas. Attendings were surprised by scan, but moved towards surgery. I asked for 2 hours to go home, get organized - they were unhappy, but eventually allowed.

Returned to ER, now third shift of attendings (both ER and surgical). Preparing for surgery, senior surgeon was notified due to unusual lack of symptoms with positive scan, now 18 hours total ER observation time and almost 80 hours since first symptoms. Senior surgeon overruled everyone and sent me home; said I was healing. Gave me 10 days of Cipro and another ABX. Explanation from surgery resident (who was shocked) was that I'd been symptomatically healing over 3+ days, had no ABX nor pain meds, showed no current physical symptoms, etc.

Concern is now I sit, self-evaluating, 16 days later. Cannot get a f/u with the discharging surgeon for another 10 days. Been told to run to the ER if I'm concerned. No ongoing symptoms, other than "funny" feelings occasionally throughout my abdomen and beyond. 30% at appendix, 20% LRQ generally, 50% completely random in other spaces. Not painful, no apparent pattern, but noticeable. Decreased over 10 days of ABX, but has remained consistently since then. 1-3 seconds per time, about once every few hours.

So I'm concerned about whether I should be concerned, while I wait and watch. Naively figure that if I'm infected, I'd have an ongoing and/or new response - as thought it's impossible I'd have a burst, leaking, something appendix with no physical expression - beyond a tiny occasional strange feeling in my abdomen. Or possibly an abscess that's just forming in some relaxed way... Wish I'd had more symptoms previously which I could judge against. The 3-4 doctors I've spoken with (no exams) have also expressed somewhat significant concern...along the lines of all is probably fine, but that's uncertain and they'd all be worried and would NEVER send someone home with a confirmed CT scan...

Skeptical Scalpel said...

I see that you are now familiar with the new "shift" mentality of modern medicine.

Thanks for the detailed description of your situation.

Question: Did the senior surgeon who sent you home personally examine you or did he rely on what he was told by the resident?

You've read the disclaimer. This is not medical advice. You are not my patient. An 11 mm appendix with the characteristics you mentioned is not normal. It could be a benign or malignant tumor. In addition, you will be obsessing about this for the rest of your life if it is not removed.

I suggest you obtain a second opinion from another surgeon. A laparoscopic appendectomy is not usually a big deal.

Good luck. I would appreciate hearing from you about how things turned out.

Anonymous said...

I Am a 37 year old female and was sitting at work the other day and my stomach started hurting. It felt like I was going to have diarrhea, but when I went, nothing really happened. I stopped eating, became nauseas the next few days and noticed my lower right side of my abdomen was hurting. I started taking Ibuprofen and the pain would come and go. Finally, I started vomiting one night, so I took some Phenergan I have for migraines and during the day, I took Zofran that I have. My mom suggested I go to the ER, so I went and my WBC was elevated and they did CT. Not sure what CT showed except I know I have cyst on left side. Doc said he didn't think I had Appendicitis, but had virus. Then, he tells me I'm on Appendicitis watch? So confused. I don't have fever, but I do have chills still at times. Vomited again tonight and took Zofran this morning. Also, took ibuprofen throughout day because I felt feverish this morning. The pain was worse today and was hard to walk a few times, but then it goes away. I figure I don't need to do anything unless I get fever or am doubled over in pain for long period of time, correct? I am also having no bowel movements but I'm assuming it's because I'm not eating. And when doc pressed on stomach, it was tender in middle too.
Thanks!

Skeptical Scalpel said...

I am sorry that your pain is undiagnosed. I regret I cannot answer your specific question "I figure I don't need to do anything unless I get fever or am doubled over in pain for long period of time, correct?"

If the pain persists, I suggest you seek a second opinion. If you do so, have the first hospital give you a CD-ROM of your CT scan so you don't have to have it redone.

John Hornbeak said...

Whoa! "Regarding patients with positive CT scans for appendicitis, it pains me to say this but the history and physical exam are probably no longer relevant." I realize that some surgeons do an H&P only as a last resort (after complications have set in), but this is beyond the pale.

If the H&P are actually performed before the CT, the History is relevant if the patient reports that he/she has already had their appendix removed AND this is confirmed by Physical examination. JOHN

Skeptical Scalpel said...

John, of course you are correct. That is an important piece of history that should not be omitted. I'm sure you are aware though of the entity known as "stump appendicitis." This problem was rarely seen in the days before laparoscopic appendectomy, but is now appearing more often. It is caused by leaving a remnant of the appendix during an appendectomy. This is more common after laparoscopic appendectomies.

So maybe a history of having had an appendectomy is not necessarily a contraindication to a CT scan. Also, one cannot "confirm" that an appendectomy was done by physical examination. The present of a scar or scars does not rule out stump appendicitis.

Anonymous said...

hi,
i'm a 31 year old female and in a ton of pain. It started yesterday morning around 3:30 when a severe pain hit me in the right side of my abdomen. I have been overly nauseated, no vomiting and no diarrhea. I have had minimal gas and bms regularly. I went to the urgent care where they immediately gave me toradol(spelling), Zofran, IV fluids and morphine. they sent me for a CT with IV contrast. I had similar pain to this a few months ago, but my OB said it was endometriosis and put me on Danacrine. The pain was also much lower and resembled extreme menstruation cramps. This pain is much higher. When I tried to explain that to the doctor in urgent care, she was non responsive and rude. That's a story for another blog. She stated that all the blood tests and CT scan was normal. She stated that she was sending me home with nausea medicine and pain medicine and to see my doctor in a week if it doesn't get better. I have an HMO so my choices are slim. Well the "pain medicine" she sent me home with is Bentyl for IBS. She didn't give me any diagnosis while I was there. The pain has continued and is worse at times. I cannot sit for long periods or lay on my right side. I went through all of these same problems before they took my gall bladder out. All tests showed normal, it wasn't until they removed my gall bladder that they saw it was 3 times the normal size. (this was in 2005). I'm at a loss. I'm in so much pain and miserable. Still nauseated and hurts to do anything. I am trying to decide if I should go to the ER or not. I'm just skeptical b/c all tests keep saying normal. I know there is something wrong and can't stand to be told "we don't know".

Skeptical Scalpel said...

I'm sorry you are having so much pain. As stated above many times, I am unable to give you medical advice via the Internet. Did anyone mention "kidney stones" as a possible diagnosis?

If the pain is still present, I suggest you go to an ER. It would help if you could get a CD-ROM of your CT scan and the report from the urgent care center so that it doesn't have to be repeated.

Good luck.

Anonymous said...

Hoping I’m posting this correctly; apologies in advance if not. I was the 12-Dec-13 sent home with a positive CT scan from above. Wanted to share in case it’s useful for anyone...

Short repetitive summary is that I arrived at the ER with limited to no symptoms; had LRQ pain two days earlier which linearly abated over time – only visited ER out of abundance of caution. Zero pain, etc. upon arrival. CT scan showed 11mm distended and other details listed in an earlier post. While preparing for surgery in the ER, a senior surgeon (who did not personally review me, but had ongoing interaction with the ER attendings) overruled everyone and sent me home. Again – details from above 12-Dec-13 post.

It resolved spontaneously (well, maybe took longer than the word implies). Had “strange” feelings throughout my abdomen for about a month, similar to the details from my previous post. Met with the discharging surgeon after one month; spoke for 45 minutes, he felt if I’d gotten through the first few days (finally presenting in the ER without symptoms, etc.) that I was already on the path to – well, being okay. There was no initial blockage showing on CT scan, no other symptoms, etc. He basically told me, while it’s strange, it had already gotten to a point where the first response doesn’t have to be cutting someone open. I’m not meaning that in an aggressive way – it was literally what he said, and he also told a surgical resident that the night they discharged me.

Unusual feelings resolved in about one month, and nothing has been notable since then. I’m definitely not trying to market this, but with my unusual case of relatively quickly resolving pain and whatnot – it actually worked to sit and do nothing...for what that’s worth...

Skeptical Scalpel said...

Thank you very much for the follow-up information. It's good that you are feeling better.

My only concern is that you may still have an appendix which is 11 mm in diameter--clearly not normal. Did your surgeon suggest getting an ultrasound or a repeat CT in a few months? It would be something to consider doing.

Anonymous said...

I went to the ER after I was told my son (14) ultrasound showed acute appendicitis. The ER doc did a CT scan and informed me that his appendix is fine. My pediatrician still believes he as acute appendicitis. Who do I listen to??

Skeptical Scalpel said...

I can't answer the question for a number of reasons. I haven't examined your son, seen the images, reviewed the images with a radiologist I trust, and you left out some important information. That is, how does your son feel. Is he better, worse or the same?

There are many other questions.

This is not medical advice. The literature shows that CT scans are more accurate than ultrasounds.

Anonymous said...

My son spent the last 24 hours in the hospital with what we thought was appendicitis. He'd been complaining on and off for the past few days about pain around his belly button and tenderness towards lower right side of abdomen. He's 11, eating fine, no fever, no diarrhea. Not in excruciating pain but clearly tender in those spots.

ED did CT scan and said it measured around a 5, high side of normal. But no fluid, but did see lymph nodes in the area. CBC showed high count of 18 (I'm assuming that means 18,000). He was admitted to a nearby partner hospital, as this one was just an ED, for observation. In the morning they did an ultrasound and blood redraw. U/S showed no fluid or inflammation, CBC came back lower, unsure by how much. He was feeling better, was able to keep down food so he was discharged. The radiology dept at this hospital wouldn't have called it appendicitis (neither did) had they been the ones to review the CT scan. The size being 5 I think was just indicating something slightly abnormal and hence the observation.

I do understand you can't give medical advice and I understand the disclaimer. My question is, does being on the higher end of normal for appendix size + tenderness + elevated WBC = coincidence for just a bug he was fighting off? Or could this truly be appendicitis? We're keeping a close eye either way but should he present with pain again, they will operate. Thank you.

Skeptical Scalpel said...

Your questions are appropriate and difficult to answer. Of course, it could be appendicitis or mesenteric adenitis (medicalese for "swollen lymph nodes") which can cause pain that mimics appendicitis. A 5 mm appendix suggests that it is normal.

It sounds like you and your doctors are doing all the right things. If you have a minute, I would appreciate your letting me know how it turns out.

Good luck.

Anonymous said...

We have a follow up tomorrow and absolutely will. Thanks so much for taking the time to reply!

Anonymous said...

Apologies for the late response/follow-up. I’m Anonymous initially from 12-Dec-13, with additional info from 14-Jan-14. Had a symptomatically quickly (seemingly) resolving appendicitis situation, which was discharged and eventually/apparently resolved spontaneously.

Following is somewhat repetitive. Had minor pain for one day; linearly decreased to no symptoms after three days. Went to the ER out of abundance of caution (and literally cluelessness) only due to having a friend who is an ER attending. Physical exam indicated no problems; later CAT scan showed an 11mm distended appendix and with complimentary signs, certain appendicitis. Given symptom evolution and time, a senior surgeon at a teaching hospital surprisingly (versus 3 shifts of attendings and others) overruled everyone and discharged with no surgery.

Waited a month before follow up (not my choice). Strange feelings in abdomen over that period, but nothing painful. Eventually met with discharging surgeon (never examined me initially, but had many talks with ER attendings – always love how a surgeon won’t often take a walk to see someone...).

That’s the catch up. For Skeptical Scalpel, who has been very helpful to me and many others, this is the progression/evolution:

1. Surgeon was concerned yet confident. We sat and spoke for 45 full minutes about this during my follow up. Reacted with sensitivity when I questioned how comfortable he was with taking this course initially, but we opened up over time. He said this route/situation really never has happened in this hospital group, but it was his judgment given many things (in large part, or at least amusingly, that I did jumping jacks in front of an ER attending 12 hours after the CAT scan). I spoke to an ER attending at a removed/disassociated hospital group who said their protocol would not have allowed a discharge, but I digress and it was part of my research in progress.

2. He delayed my follow-up for so long (from my na├»ve patient perspective) because it was difficult to get a judgment/interpretation short of time passing. Was discharged with no symptoms, yet that 11mm distension. So resolution of symptoms wasn’t available. I’m in Manhattan, so within 3 miles of many teaching hospitals and obviously quick/easy responsiveness – this was another factor the surgeon cited. It was simply approached as a you are fine situation, and worst care it can be responded to quickly/easily.

3. He also said my appendix might continue to be 11mm or similar. We took a picture in time, after symptoms were done, and saw that. His suggestion (which I followed) was that we don’t get another CAT scan right now. Appearing fine, and now it’s been almost two months. So keep the CAT scan in my pocket for a later time when I need one. While you’d certainly take one whenever you feel it’s necessary, his soft suggestion was that we’re probably fine now, so no need. Strange abdomen feelings had also resolved, so we spoke of doing this, but he suggested no need...we were going to do it if there was anything out of the ordinary (feelings, otherwise – but nothing to date).

Finally – surgeon suggested something you mentioned. Said I might still have an 11mm diameter. His view – was that I might have had this for a long time. As though I could have had this for many years, but my body doesn’t have problems with “infections” and I have literally a secondary situation with a non-infected but unusual appendix. He did say this would be crazy. He was spit-balling a little bit, but off the cuff mentioned maybe I didn’t have significant pain because my appendix was already that size, so to speak... I do have somewhat strange optimistic responses to medical situations, which runs through my family. Although I appreciate this sounds/feels ridiculous. But it was interesting that he said you might have appendicitis via pictures, but if it’s “fine”, then what would we do anyways – if it’s always like that and we were avoiding surgery anyways? Weird question/situation – although all seems well now...

Skeptical Scalpel said...

Thanks you for the follow-up. I'm glad you're doing well.

traci said...

13 year old daughter came home from school yesterday complaining of pain and cramping in her abdomen. Seemed to be everywhere. She took a motrin and went to lay down with a heating pad. Around 6:30 pm she ate a small dinner, still complaining of pain and cramping. At this time it seemed to be focused more in the lower right area. Still no fever. No constipation or diahreaa. Took 2 more ibuprofen and went 2 bed. By around midnight she was in severe pain. Complaining of nausea, dizziness, and hurting to move. She looked flushed and felt warm. Cried as she tried to get dressed for drive to E R because it hurt to move. At small community Hospital she was set up with IV, morphine and anti nausea meds. They drew blood and took urine sample. Attending ordered Ct to confirm appendicitis that she suspected. WBC was up, but CT didn't clearly show appendix. At 5 am we were given option to stay and wait for the surgeon, or to go home, wait and watch. We came home, she slept from 5 until almost noon. Ate a small lunch (again, saying she wasn't really hungry), no fever, no diahreaa, still in pain and cramping, but less severe. Still hurts to walk. By around 2 she is holding still as much as possible, hurts to lift her legs, but pain is still less than that which sent us to ER last night. Temp up a bit (99.8). Right now I'm thinking we will probably be heading back to ER if this continues. We are within an hour of a large Children's Hospital in Iowa City. Any thoughts?

Skeptical Scalpel said...

Sorry, I was unable to get back to you sooner. This is not medical advice. It would have been nice to know exactly what the CT scan reading was. We don't consider 99.8 to be a fever.

If she still had pain, I would have taken her to the pediatric hospital with a CD-ROM of the CT scan so it would not have to be repeated.

Please let me know how this turned out.

Anonymous said...

My appendix was removed in emergency surgery a week ago. We went to a teaching hospital! I am a female, not pregnant, 41.
The pain I experienced was incredible and unlike any before including labor pain. That is what made me go to the hospital - couldn't straighten up!
I had atypical symptoms for appendicitis. Most of my pain was concentrated in the stomach area. Because I have a history of ulcers, and ovarian cysts (functional) I thought it was one of those. I really thought my stomach was being ripped apart.
I wasn't able to straighten up enough to have the CT scan till they gave me morphine. Even with that, the pain never went away completely. The medicine for nausea only worked for a little while. They kept pumping me with both till surgery.

We were all surprised when he came back with the news it was my appendix. I knew they had it right after surgery, when I awoke. The nausea was gone and so was the pain. I am sore from the surgery but that is nothing compared to the pain from the appendix. What took the longest was waiting for my white blood cell count to drop as it was slow in doing.

The surgeons were young and very well mannered. I liked them. Once upon a time it would have distressed me to see young people, surgeons, enter the room. I would have wanted an older, seasoned dr. They did a great job!

Skeptical Scalpel said...

Thanks for one, not asking me an impossible question to answer and two, telling your story. Appendicitis can present in myriad ways. You had an experience that most people with appendicitis have, which is that you had immediate relief when you awoke after the surgery. Also, it's nice to hear that you were happy with your doctors. It's rare for that sort of sentiment to be expressed on the Internet.

Anonymous said...

Your welcome. I know what you are talking about regarding the internet and the venting of all negative experiences. I hope to give credit where credit is due! And the negative experiences I hope to address in person because I know negative comments made me hesitate using this particular hospital. Now, after reading your recommending a teaching hospital, etc, I will use this one in the future. And I will address any problems personally.

I am developing a theory regarding pain and interpretation in my own body. I think due to 3 c-sections my feeling in the lower abdomen is compromised greatly. I was just thinking it was surface (running hand over lower abdomen, can tell difference in feeling vs upper part) but now I am wonder if it goes deeper - organs. I had tried to identify where the appendix was via pain I should have from the surgery and I felt just a tiny sore spot where the appendix should have been located. I would have interpreted that as minor gas pain. Also, the, what I consider funny, conversations I have with my OBGYN make sense now. He finds some things that do not bother me as hard to believe! I suppose if I had normal feeling, it would cause more pain than it does.
I do wonder if my body sent signals to one place I would not ignore; stomach! I just now have to take into consideration my diminished feeling in lower abdomen and run tests!

Skeptical Scalpel said...

That's an interesting theory and quite possibly correct. But it's not your organs. The pain from appendicitis is caused by irritation and inflammation of the peritoneum (the lining of the abdominal cavity), not the appendix itself.

The other possibility is that you have an increased tolerance to pain. People react differently to similar stimuli.

Anonymous said...

Hello I do hope you can help me on this matter.
I am a 46 year old male from the UK and in early December of last year started with slight backache one morning. I hadnt done anything to hurt my back but carried on until earl January when I just didnt feel myself.
Felt run down very lathargic this was proceeded by a dull ache in the lower right of my abdomen. I went to my doctor who thought it might be an appendicitis and I was admitted to hospital.
I had all test done including an x-ray and all came back normal.
I was discharged to be refered back to my doctor.
The weeks went by and although the pain was tolerable I just didnt feel right losing interest in everything.
Then one night I was woken by my pain my stomach distended around the appendix area I had to urinate and pass wind to ease the preassure. My partner took me to hospital where I had CT scan and more tests. The test again were normal but the CT scan showed mild calcium in appendix. The doctor said he didnt think it was appendicitis but there was a lot of tenderness but there was no inflammation although there was some signs of calcium?
He then said the pain might be because im constipated! He said there was fecal overload and blockage was in accending colon. I have never had constipation in my life and was still having regular bowel movements.
Doctor now decieded in February for a gastro consultant to do more tests.
I waited another 2 week in meantime more symptoms appereared gassy breath green tongue and pain under ribs like indegestion pain after eating. I didnt matter what it was I ate the feeling came on in minutes.
I just felt toxic if that makes sense like im being slowly poisoned.
Also started with changes in bowel habit loose stools and then pencil sized stools which worried me. All the time my throbbing pain in appendix never subsiding.
I saw the gastro consultant who decieded on a colonoscopy to rule out anything sinister. I had the colonoscopy and showed early diverticular disease in left side lower colon.
Although this is not want to hear it must be the problems to all I have.
But no I never had any left colon pain even now knowing I have the disease, there is no pain there, all my issue were in lower right abdomen.
Now the consultant want an MRI scan of the small bowel and to see me again in 4 week!
My friends and family say your in good hands now and it will get sorted but deep down I feel like a ticking time bomb, I know my body and sure my problem is my appendix I really do and think I really need a more current scan as im not getting any better after nearly 3 months.

Skeptical Scalpel said...

You must realize that this is not medical advice.

Calcium in the appendix could be referring to a fecalith (stone). Many surgeons in the US would consider that a reason to do an appendectomy. You didn't mention the size of the appendix which would be nice to know.

The fact that you have lost 14 lbs in the last 3.5 months (in a comment on Read This Before Commenting) is concerning.

I'm with you on this. Why wait a month? Get the MRI now. Maybe a second opinion from a competent surgeon would help.

Good luck and please let me know how this turns out.

Anonymous said...

Skep,

This might take a WHOLE different track, but when I ask a few comments from a doctor online I'm not looking for *medical advice*, I'm looking for an *educated opinion*. My doctors that actually I employ, pay for, see on a visit in the office basis, those and medical references like UpToDate, etc. (I'm starting on a whole new relationship with the Clinical Chemistry people), that's medical advice. Just asking a few questions thrown out on the internet is what I would consider the equivalent to 'give me some advice on whether you'd wear a short sleeve or long sleeve top to the park today'. Someone who has a degree, experience but just an off the top of your head thoughts type of thing.

Do you find that not true of most people?

Reason why I say that is it would seem to me that doctors learn by different experiences, more so than any other reference. That's what I hear. So that's why I figure throw it out, ask, and see what you get back, and use that as a reference point. Something to think about.

What is your experience, and that of other bloggers or the like?

Skeptical Scalpel said...

Anon, I have no idea what the motivation of people who ask me questions on this post is. If you read the questions, I think you will agree that they are asking for medical advice. I cannot give medical advice without seeing the patient, taking a complete history, doing a physical examination, and looking at ALL the lab work and imaging studies myself.

I'm not sure what the difference is between an educated opinion and medical advice. It seems to me the line is pretty blurred.

Anonymous said...

My 11 year old son has been complaining of abdominal pain for the last 3 days. Pain started in the mid abdomen and moved to the lower right. Today it was so painful he coudnt walk and I took him to the hospital. The pain came and went all day and was worse when standing or walking. No fever and blood tests normal. He has had no bowel movement in 2 days. An ultrasound indicated a maximum appendix diameter of about 6.5mm and wall thickness 1.8mm, a tiny clear fluid pocket was seen at the tip. The specialist radiologist noted 'features of early acute appendicitis'. He was sent home on the basis of the blood results. Does this mean the ultrasound was not correct? Can the appendix be 'inflammed' and not infected and heal itself? If he has similar pain over the next 24-48hrs should I request a CT scan?

Skeptical Scalpel said...

Anon, again I must preface my comments with the disclaimer that it is impossible to give you medical advice without seeing or examining your son.

Up to 10% of kids with appendicitis may have normal white blood cell counts, but it usually is abnormal if the appendix ihas been inflamed for 3 days. You did not mention whether he was prescribed antibiotics. I assume he was not. If the pain persists, a repeat ultrasound would probably be the next step since it involves no radiation. If that does not clarify things and he still has pain, most experts recommend a CT scan if the ultrasound is equivocal.

Appendicitis can resolve without treatment or with antibiotics. It also can recur.

Good luck and please let me know how it turns out.

Anonymous said...

Hello
About 2 weeks ago we visited Disney in Orlando. On night 1, my son got sick and threw up. The next day, he woke up with a fever. We took him to a walk in clinic as I thought he had an upper respiratory infection given that it had been going around in our house for two weeks. The doctor said his lungs were clear and he gave us Zithromax, and off we went. Christopher vomited again that afternoon, and night. His fevers were around 102 – 103 when acetaminophen & ibuprofen wore off. He had chills, and was looking very pale. The next morning he had a fever again and complained of having a belly ache and he said his left shoulder hurt. I brought him to the ER, where they did an XRay & Ultrasound. The XRay showed clear, but on the ultrasound they found that his appendix tip was 7cm, so they ordered a CT Scan and Lab Work.

The CT scan showed the following:
The appendix is noted to contain some air. The tip of the appendix is mildly enlarged at 7mm. No surrounding inflammation or fluid. No appendicolith. Rest of bowel is unremarkable.

The lab work came back with normal WBC. During the CT scan, they also found he had a right sided mesenteric lymph node measuring 1.7cm. They also found a patchy infiltrate or atelectasis in the right middle lobe, & minor atelectasis at the lung bases.
The doctor told me that given the results they didn’t think he had appendicitis. That they thought everything was due to the pneumonia they found in his lungs. They administered IV antibiotics and sent us back to the hotel that night with 10 days of Augmentin. By the following night, he was doing really well, and has been normal since.

Now that I am back home I am wondering if I should bring him to a specialist (GI? Surgeon?) to get a second opinion to ensure that his appendix is okay? What would your thoughts be? His pediatrician and pulmonary specialist said that they wouldn’t recommend it and that its not worth exposing him to more radiation. I’d like to see if someone can at least do a follow up ultrasound.
I appreciate your thoughts.
Regards,
Jennifer

Anonymous said...

Diagnosing appendicitis: If all else fail, examine the patient.

Skeptical Scalpel said...

First anon, This is not medical advice.

Most would say appendicitis is highly unlikely since there was air in the appendix, it wasn't very large, and your son is well a couple of weeks later. As the erudite commenter just after you said, examining the patient is always worth doing. You didn't mention what the doctors found on physical examination. Of course, it is possible that it was appendicitis all along and the Augmentin has "cured" him. It could recur at a future date.

I'm a little skeptical about a "pneumonia" that was diagnosed after a clear chest x-ray and a normal WBC. Atelectasis is not pneumonia. You didn't mention if he was coughing up any sputum either. That's a very common finding with pneumonia. A physical exam might have helped there too.

Regarding the snarky comment about all else failing, I would point out that numerous papers have shown that CT scanning is far more accurate than physical exam in making the correct diagnosis in both abdominal pain in general and appendicitis in particular. It used to be that a 10% or 15% rate of normal appendix was accepted. Now it should be less than 5%. If you search my blog for "appendicitis," you will find a number of posts on the subject.

Anonymous said...

Hello and thank you for responding. They did do a physical examination and mentioned his belly was soft / tender and this was another reason that they ruled appendicits out. The ER called it pneumonia, my son's pulmonary specialist said it was very little and that he had more stool in the CT Scan then he had pneumonia (he was joking). My son was coughing a little, but he wasn't wheezing. The ER as well as his regular pediatrician mentioned that if caught early, they can miss it on XRay, and that CT Scan finds it earlier? Thank you for all of your help. Jennifer

Skeptical Scalpel said...

Thanks for the follow-up. I'm not so sure about CT catching it earlier, but the boy recovered and that's good.

Carolyn Thomas said...

My own experience with appendicitis happened in the Dark Ages of 1966 when I was a teenager attending convent boarding school a couple hours from my home. I spent much of Easter exams week that year in our school infirmary, feeling increasingly worse day by day. Our nuns misdiagnosed me first with menstrual cramps, then with the flu, and even "malingering to get out of writing exams" etc etc. They refused to consult the local doctor on call (- a whole other story!) until finally my sister - attending the same school with me - finally phoned our mother who drove immediately to pick me up and bring me home (over the protests of the nuns, insisting even as I was being half-carried to the car that "...there is nothing wrong with her!"

My mother became so alarmed by my condition as we drove home that she stopped en route at our family physician's office to have me examined. He listened to her recital of my week's adventures as I lay on the exam room, took my temperature, palpated my abdomen, and then lifted my right ankle and pulled it sideways crossing over my left leg. I screamed in agony. "It's her appendix alright!" he pronounced.

I was taken immediately to hospital where I had my ruptured appendix removed, was diagnosed with peritonitis, and spent one month in hospital recovering.

No CT scans, no x-rays, no ultrasound - just a very experienced family physician.

Anonymous said...

I am a 28 year old male in very good shape. I woke up March 26 with extremely nausea, vomiting seven times within a day and not able to hold down water, and a fever that followed into the second day. I saw my Doctors PA the next morning. I was given nausea medicine then slowly got better. Last weekend when the vomiting ended I started having lower centralized abdominal pain. Pain that is like a burning, constant palpitating pain but centralized. The pain goes from moderate to severe at times and no problem passing stole. I went back to the PA this Friday morning because I was being woken up with the pain. They gave me an abdominal X ray order and then nothing else and a follow up next Friday. My pain is persistent when I sit down or bend over and is a constant moderate if not worst at times. No fever now and everything else is normal. I might ask to order a CT scan earlier than they had planned. I am curious should I go to the ER to get this done faster because I have been living with this pain over a week now and cannot take it anymore. Also my fears are appendicitis I also have tried getting an appointment with a Gastro doctor but the wait is ridiculous. My question is will they do a CBC and CT scan with contrast at a really good hospital ER? Also what are the possibilities this could be an inflamed appendix or appendicitis? Other history includes no medical problems or surgery ever. Thanks any advice is much appreciated.

Skeptical Scalpel said...

Carolyn, great story. Thanks for the comment. Appendicitis is still difficult to diagnose at times even with all the technology.

Anon, as I have explained countless times, I am unable to give you medical advice. Your history is not typical for appendicitis. Could it be appendicitis? Of course.

There is no guarantee that an ED MD will order a CT scan. If you really can't tolerate the pain any longer, you should go to an ED.

Good luck. Let me know how it turns out.

J D Patten said...

I'd have been in serious trouble (Do people still die from appendix complications?) were it not for my wife, my family doctor, the ER doc, and that pivotal CT.

Three years ago I had a tummy ache. Being in my late 60s, I'd had enough of those not to be too worried. I'm talking about slight discomfort around the belly-button. As I told my wife, it couldn't possibly be my appendix. As she told me, it'd been a few days so I should see the doc anyway. OK. He pokes and prods and can't elicit anything. He says "Well... just to be on the safe side...", and sends me off to the ER. It's evening now. Not too busy. The ER doc pokes and prods and does all sorts of additional manipulation with my legs and he, too, elicits nothing. He says "Well... just to be on the safe side...", and sends me off to CT. I lie there waiting for the results shaking my head thinking "This is a joke. I should be back home having dinner." The ER doc comes with the results, shaking his head and grinning, to tell me on-call surgeon was on her way.
"What??"

Turns out my appendix was bloated to four times the size it should have been, black, and dead. Necrotic. Five days of intravenous antibiotics later I was finally able to go home and have some dinner.


So, as you might imagine, I concur 100% with your notion that CTs are the way to go!

But I still wonder what would have happened to me had I not taken my wife's advice in the first place?

Skeptical Scalpel said...

Great story. Thanks. The moral? Always listen to your wife.

lagooner21 said...

Hi ive had a bit of bloating and constipation like a blockage is stopping me from getting everything out.
My Gp did my blood and that was normal. Then I had a ct scan and it said the appendix is thickened near the base measuring 7.4mm in calibre and there is a mild fat stranding about the appendix without adjacent mass or abcess. Impression was, the findings are consistent with appendicitis.
I went to hospital as advised and was fasting for the surgery but when the surgeons snd doctors csme around they examined me and said you have no pain and are not ill so go home.
Is this right?

Skeptical Scalpel said...

Lagooner21, see the numerous disclaimers included with my previous answers. I cannot give you medical advice.

Most surgeons will not operate on a CT scan. The appearance of the patient has to be factored in. Your history as you stated it and the lack of pain suggest that appendicitis is not the cause of your problem. Could it be? Yes, it's remotely possible. Is it likely? No.

lagooner21 said...

Thankyou so much.
So the surgeon was right in saying the inflammation was very minimal?
Im booked in for a colonoscapy consultation tomorrow which im sure will find the problem.

Skeptical Scalpel said...

I think he's right. Good luck. Let me know how it turns out.

Anonymous said...

My 7yr old child had a catscan to rule out appendicitis and it was negative but she has not moved all day due to pain around belly button and right side and started with a fever last night and now 101.9 could the catscan have been wrong? she is nauseous & has only eaten a few crackers in 2 days, no diarrhea or vomiting..It has now been 37hrs since the first onset of pain

Skeptical Scalpel said...

You understand that I cannot give you medical advice. It is impossible to diagnose appendicitis without examining the patient.

Yes, CT scans can be wrong. You should strongly consider returning to the ER. The child should probably be examined by a surgeon. If there is a children's hospital in your area, you might want to go there. If you do, you should get a copy of the CT scan the child had on a DVD so that it could be seen by the doctors at the other hospital.

Please let me know how it turns out. Good luck.

Anonymous said...

Thank you so much for replying! I took her to the doctor yesterday & they sent us to the pediatric e.r. While their she felt a little better and the doctor pressed on her tummy and she seemed to be ok so they said it was a virus, fever was 99.7 at e.r...At 8pm fever was 101.5,gave her tylenol and she slept til 8am with a fever of 101.9 gave tylenol she slept til 1pm..She is still complaining of tummy ache,laying around pm and (she also has a fractured foot) and her nose is all stuffy now, took temp at 8pm and it was 102.8!! I took it with 3 different thermometers and all were in a few pts of each other...So I will be calling doctor tomorrow morning if fever has not broke. Seems odd to have a stomach ache and now high fever for 4 days with no other symptoms...She has eaten a few crackers and a banana in 4 days, not to alarming but she is a huge eater even though she is tiny...I will let you know what happens , if you have any suggestions please let me know..TY

Skeptical Scalpel said...

You may want to discuss with your doctor the concept of not trying to suppress a fever. Fever is useful in helping the body fight infections, and Tylenol has been associated with side affects such as asthma and liver damage. Many authorities recommend treating a fever only if the patient is extremely uncomfortable.

Anonymous said...

yesterday morning I had a sudden but mild pain, mostly uncomfortable, and it's been having very brief feels of uncomfortable pain since, I haven't been naustious, etc of the other symptoms, but it felt REALLY tense down there, I rubbed it once and the pain stopped, the pain has stayed at that same spot and hasn't moved, and hasn't gotten worse, not even pressing down and letting up makes it hurt, but it just randomly and briefly hurts for about 5 seconds then stops, and it may be a while before it does it again, I've gone to a doctor, they did a urine test, nothing else, and it all tested negative, yet it still hurts like it did, same spot, etc, so....what's going on? I should mention that this only happens when I lay down or sit down, but when I stand up and move, it almost never happens, what's going on? it doesn't hurt to move, and it doesn't hurt when I do anything else but sit, and the pain is at most 4-5 seconds then it stops, then does it again after a while. whats going on please help

Skeptical Scalpel said...

I am rarely completely stumped, but I think this time you have me. I have no idea what this could be. If it persists, go to an emergency room.

Anonymous said...

My daughter was sick for a couple days so I didnt think much of it at the time. On a Monday at 2am she complaind of stomach pain that was so bad I took her to the ER to be looked at after some test they gave her a shot of morphone and we were sent home. about 12 hours later her stomach pain was so bad she could barely walk so i tooker her to an urgent care place and they told me to get her to the ER as they believed the appendix burst. Well, it did and she was in surgery for over an hour and stayed in the hospital for 7 days. She had a drain put in and was givin antibiotics as the test revieled an infection in the blood. After her stay she still had a temp and night sweats so i took her back and now she has to stay for 2-3 days again in the hospital.

My question is that should they have seen it the first time we were in the ER? I am not sure exactly what test were done or were not done and I know this is limited information. just really seeking an answer.

thank you for your time

Skeptical Scalpel said...

Despite all the technology, it is unfortunate that appendicitis is sometimes still a tricky illness to diagnose. Without knowing what test she had during the first visit, it's impossible to tell if the test missed the diagnosis. You would also need to know what the ED MD wrote in the chart about the history and physical exam.

You have a right to view the chart. If the hospital is willing, one of its employees, an MD, RN or someone from the risk management dept should go over the chart with you.

If they decline to do that, your only option would be to get a lawyer.

I hope your daughter feels better soon.

SkylarStarz said...

Never knew appendicitis could be spotted via a CT scan, pratice must have evolved since having mine removed in 07. That said I was a super emergency with a high temp anyway. I know you can not give medical opinions etc, but have you ever heard about people suffering with long term chronic constipation after an appendectomy? I've been to too many consultants pillar to post yet none seem to know much of what might be wrong, other than the obvious fact I'm blocked like rush hour traffic with anaemia and vit D/calcium defiency. :< I drink like a fish (a good 2l a day) and although I don't eat as much as peers my age do (also significantly healthier) I've tried pretty much every diet hi fibre, low, no wheat, lacto, fodmap etc and pretty much a collective of laxs (everything from fybogel, movicol, lactolose, senna etc) without much if any improvement, and I just wondered how atypical it was re-statistics to end up with this mystery constipation outcome lol!

Skeptical Scalpel said...

Skylar, CT scans have been used to diagnose appendicitis for more than 20 years. The accuracy improved about 10-12 years ago with the advent of faster and higher resolution scans.

I am not aware of any study that has reported chronic constipation after appendectomy nor have I ever seen a patient with that problem. I did a PubMed search and found only 2 case reports, but can't give you any details because one was in Japanese and the other in German (http://www.ncbi.nlm.nih.gov/pubmed/14299549 and http://www.ncbi.nlm.nih.gov/pubmed/1714191).

I'm sorry you have had so much trouble. I hope you have seen a competent gastroenterologist because I doubt the problem is related to your surgery.

Anonymous said...

How would a doctor go about finding out if it is chronic appendicitis if it is not always seen on a CT scan?

I have been suffering on and off from severe right sided lower abdominal pain. I first went to the ER in May when I couldn't stand the pain anymore. They did a CT scan, Ultrasound Trans vaginal and abdominal, blood and urine. All came back completely fine. I was sent home and the next day went to another ER because the pain persisted and I wanted another opinion. They also intially though appendicitis but also ruled out STDs just to be safe. Everything was clear.

I spent the next month trying to get better and slowly feeling a little bit more normal. I went to various doctor appointments where I was first told I had the flu, then possible cyst on my ovary (no actual cyst was seen) and started birth control incase this was the culprit. I have also stopped eating gluten, and cut out all fast food and fatty foods from my diet, incase that was causing it. I never got back up to 100% but tried my hardest.

Then yesterday it came back, full force. No sleep, but I didn't want to go back to the ER because I knew they would say I was fine. I finally broke down and went tonight and of course, clear CT scan (His initial reaction was appendicitis even when I truly believed it wasn't and told him so) Blood clear, urine clear, no cysts, no kidney stones, nothing.

I don't know where to look for answers anymore. Im exausted every day and I thought that this would be a one time deal, but apparantly not. Can you point me in any direction of what I should look at next?

I know you can't help much with no medical documentation, but any advice would be more than appreciated.

Skeptical Scalpel said...

The standard disclaimer applies. It's hard to believe that your appendix is causing all this with normal CT scans, ultrasounds, and blood tests. Over the years I've learned "never say never," but appendicitis seems unlikely.

You didn't mention nausea, vomiting, diarrhea constipation or weigh loss. I assume that those issues have not occurred.

An ovarian cyst should have shown up on a CT scan or ultrasound.

Have you been investigated for a herniated disk or pinched nerve?

Anonymous said...

I have had nausea, diarrhea I have fought with for years. Along with vitamin deficiency. No weight loss recently. I had x-rays about 6 months ago for an army injury where I pulled a muscle. They didn't find any bone issues, but only x-ray ed to mid spine. The only other thing I am considering is a femoral hernia that doesn't bulge like normal. I have researched the Web and not being a dr I have no idea what to look for. Oh I have also had pain in my right shoulder, comes and goes, went to the chiropractor for it right before my first episode in may and it never helped. It finally went away and came back with this episode. I noticed it last night when I was trying to fall asleep.

Skeptical Scalpel said...

CT scans should pick up a femoral hernia especially when you are symptomatic. I'm out of ideas. I will think about it.

Anonymous said...

I'm the same anon from august 2nd, so I reviewed my files online after I left and they did find something on the ct scan just not enough to tell me apparently.
"There is very slight inflammation within the fat adjacent to the upper ascending colon. Consider minimal colitis although significant wall thickening is not evident."

Can this cause pressure and pain the abdomen? I assume it should heal naturally if they sent me home.

My blood results also had low LIPASE at 20 and says the range is supposed to be at 22-51

It also showed high EOSINOPHIL at .44 and range is from .0 - .40

I have no idea if its even relevant, but I thought I would post all the abnormalities they found.

Are any of these reasons I should be in pain? I couldn't find really anything online describing what the CT scan found and what exactly it is or means.

Skeptical Scalpel said...

I doubt that the mild inflammation seen on the CT would cause the amount of pain you seem to be having. The report sounds like an over-read from the radiologist, which is a common problem. It's not clear to me if you had 1 or 2 CT scans. If you had 2, did they both show the inflammation?

A low lipase and eosinophils of 0.44 are not indicative of any disease and not responsible for your pain.

Anonymous said...

I understand the disclaimer you have posted. For the last month i have been having right side discomfort (at times mild pain). Went to doctor after the first week who did physical exam and found no issues, did not hurt when he pressed down on right side. After week 2 went and had CT scan done and results came back as normal. Discomfort has persisted for the last couple weeks, including a 6-7 hour period where i was having spasm like pains on my right side every few minutes, but then went away about 5 days ago. Other symnptoms includes limited appetite lately and some diarhea. No fever, and pain has never reached a level where i cannot move around. Just wondering can appendicitis symptoms last this long? or what else could be a possibility. Thanks for this blog very helpful.

Leisa Wimpee said...

Thank you for your blog and all of your comments. I really appreciate the time you take to answer so many questions.

I have stage 4 endometriosis and have had 4 surgeries to remove it which one time also included removing my appendix. I am quite used to severe pain for hours on end. This is my only health problem.

However Saturday Night at 8:00pm I was playing a card game with family and had quick excruciating pain come on. I left the game and went upstairs to take a bath. The pain went immediately to about an 8. After about 4 hours of pain a that level with no ups or downs or relief, my husband took me to the ER. The pain was everywhere in my abdomen and if I laid on my back the pain even moved into my back too.
CT, Ultrasound show nothing. Urine shows nothing. Bloodwork shows slightly elevated white blood cells. I have a very high pain tolerence and this pain is extreme. They give me morphine which makes my pain worse. Then they give me dilatin? I think that is what it is called ..which just barely takes the sharpness of the pain off. The Doctor never physically examines me. He just goes off the tests and sends me home in pain.

I go home in excruciating pain around 4am and try to rest. By 8pm my pain was steadily at 10 and I was throwing up non-stop and lost control of my bladder at the same time. I couldn't walk at this point and was passing out so my husband called an ambulance which took me back. A doctor looked at my file and saw that my scans and ultrasound was normal and sent me to the waiting room for 4 HOURS crying in extreme pain, begging several times the staff to help me somehow. Even if I could just lay down. When I finally got to a bed and laid down my pain began to lessen on it's own somehow. At that point I got a very thorough Doctor who said he wouldnt let me leave until my pain was manageable. He went over my tests and drew more blood and did a physical exam finding the source of my pain was on my right side. My pain on it's own without any more pain medicine went down to a 1 or 2 and they sent me home to go to my regular Doctor. Which I most definitely will...I never want to endure that ever again if I can help it. Im am not looking for diagnosis...just so curious on what things I should have looked at when all of those tests are clear? What could cause such severe pain. It wasn't gas..and they could not see any constipation in the CT. It was 17 hours straight of pain between 8 - 10 levels. Today Im extremely exhausted, the area is tender and Im having a bit of vision problems but other than that fine.

Thank you in advance.

Yunar Winardi said...

my first hospital failed identified my appendicitis and my second hospital see normal result from blood test result and normal from urine result test and just found appendicitis by USG test. Advice seek second opinion when you still found something wrong with your body.

Skeptical Scalpel said...

I am on vacation. I will respond to these latest comments in a few days. Thanks.

Skeptical Scalpel said...

As always, it is impossible to give medical advice without examining a patient and seeing the lab and imaging studies personally.

Anon, appendicitis can be intermittent and chronic. However, it is unlikely if your CT scan was truly negative. There are a number of other possibilities but something musculoskeletal or neurologic might be worth investigating. Many times the exact cause of pains like you describe cannot be found.

Leisa, I think what they gave you may have been Dilaudid. It's a very strong narcotic pain med. Again, a normal CT scan is reassuring, but it is possible that a small focus of endometriosis could have been missed. You did not mention whether your recent pain was similar to previous bouts of endometriosis. I don't know of any other tests that could have been done. I agree that you should see your regular doctor and if he/she is not an expert in endometriosis, you may want to consult one.

Yunar, I agree that a second opinion is worth obtaining if you feel your problem has not been solved.

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