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 Although Klass states that a normal appendix can be expected in 10-20% of appendectomies, those numbers are no longer valid.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.


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Rebecca Lee said...

So here is a Situation for you, I am an 18 year old female.Well about 3 days ago I started having pain on my lower right abdomen above my hip bone, followed by severe heartburn. So i took some tums and went on with my day. Well the pain started to get worse followed by a loss of appetite. and nausea so i went to the urgent care and they said possible ovarian cyst WBC was fine and sent me home and told me to go to GYN. So i went there today and got a full exam and ultrasound and no sign of cyst and any female problems were ruled out. She referred me to General Surgeon who sent me for a CT scan with IV Iodine Contrast and the stuff you drink and they released me and said the doctor was going to call me. But so far I haven't heard anything. and this was at 6pm today and it's now 11pm so i am guessing it was normal? but if that's the case why am I starting to have diarrhea, Dry heaves earlier today worse Nausea, Cannot eat anything\ no appetite. Pain is a lot worse and VERY tender to the touch. I am starting to wonder if I should give up and just deal with it. The doctors don't seem to be finding a cause but I know the symptoms aren't just happening for no reason at all. So what now?

Skeptical Scalpel said...

Rebecca, just so you know, this is not medical advice. I would not make any assumptions about the CT scan results, especially since it was done at night. It may not even be read until the next day. I suggest you call your surgeon as soon as possible today. If you can't reach your surgeon, go to an emergency room right away. I hope you feel better. Please let me know how this turns out. Good luck.

Worried and confused said...

Hi I'm 36 year old female in the UK. I had right side pain for 2 months starting off bad then nearing the end of the 2 months it tapered off, then 2 moths later I got the Right side pain back, it started off at the navel and abit on the lower left side and settled in the right lilac fossa, I felt unwell in myself have incredible tummy cramps and although my temp was in the normal range I was flush and red faced sweaty/clamy I saw my gp he felt my stomach started at the gallbladder area all OK moved down to low right side and I yelped, he said I wasn't expecting that,so then pressed into the right side again which hurt so bad but not as bad as when he let go,I nearly jumped off the bed/couch, he sent me to see the surgeon's at our local hospital, and they took bloods gave me iv morphine but the pain still came through,I was nill by mouth, anyway the surgeon came to see me in the er and did her own prodding and poking asking questions she said I hurt in the right places for appendicitis and that she totally believes in chronic appendicitis and wanted to take it out that evening,I signed the consent forms for her to do it was put on a ward and prepped for surgery,at 2 am the nurse told me theatre had called cancelling till the next day and they gave me a cup of tea and some toast I ate some of the toast and half the tea,then nurses took away the water jug I had a mouthful was put on nil by mouth a second time had more morphine through iv, again didn't take the right side pain away but I wasn't in screaming agony I've a high pain threshold as have given birth naturally to 6 boys with little or no pain relief,
Next day abdominal specialist came to see me held off the op till I had a ultrasound. I had the scan external and internal they saw no problems with ovaries tubes womb endometrius was normal bowel pathway normal no masses or cysts and kidneys were unobstructed, that's the uss report my blood's showed nothing odd my inflammation markers were in normal range,I had a ct scan done with dye a month and a half ago showed nothing abnormal, yet I was still in pain right side as surgeon said right over my appendix and I've been getting right side groin pain and lower back pain too,no sickness no bowel problems,,I know you can't diagnose, but I can't understand why the surgeon was adamant to take out my appendix and the specialist wasn't so happy too, he cancelled the second trip to theatre telling me I wasnt the age range for other gut conditions, chrons and inflammation of the bowel,said he didn't want to even go ahead with the camera the surgeon's wanted to do,because of risk of nicking the bowel causing further problems, sent me home the same way I came into hospital with some oral morph and paracetamol, I told the nurse I didn't need it as it doesn't work and have co-codamol at home, she was happy with that, so now I'm still with pain that feels like someone has sewn a dagger inside my body were my appendix is and everytime I move it hurts bad and it gives a throbbing spike of pain every now and again while sitting still,the whole thing is so much worse on moving, all I have is a follow up appointment in 4-6 weeks with the abdominal specialist, and no plan, I cried as I had a feeling I'd be returning home with it after second cancellation, so fed up don't know who to believe,I listened to that surgeon she knew what she was talking about said I was a classic patient for chronic appendicitis as she has seen it time and time again, but doctor although lovely held bk on camera or surgery, due to risks, I know u can't diagnos but I need some help on what I can do about this, I'm scared it's going to pop, uss, couldn't see appendix and ct scan was done after the first attack once it had calmed down also gallbladder is normal and no stones kidney or anywhere else,I don't understand this pain, shed some medical light that may make sense if you could please, many thanks.

Skeptical Scalpel said...

Sorry for the delay in responding. I read your story three times because it is a lot to think about.

Did the surgeon tell you why she canceled the case at 2 am? Correct me if I'm wrong, but I believe there is not one objective study showing either an enlarged or inflamed appendix or any blood test that is abnormal. Even patients with chronic appendicitis will have some signs of it on a CT scan.

I don't know what the abdominal specialist is talking about when he says you are not in the age range for Crohn's disease. There is no such age range. It can happen to anyone. But you should still see some sign of it on a CT scan and possibly on the blood tests too. Also, the chances of nicking the bowel during a laparoscopic appendectomy are extremely low. That is not a good reason to avoid surgery.

You are correct in that I can't diagnose anything via the Internet. I would vote for continuing observation and re-testing if no improvement. Perhaps a colonoscopy would help. Another consideration is a nerve problem from a ruptured disc.

Sorry I can't be of more help. Please let me know how this turns out. And good luck.

Lisa Coldwell said...

Hello again
The surgeon wasn't the one to cancel op, it was the abdominal specialist, he said it's abit of a mystery but as all scan (uss) and bloods showed no abnormal issues, he felt operating wasn't the best way to deal with this,then went on to express his concerns,about cameras doing more harm than good,I,e nicking the bowel,said it would be a terrible thing if it were to happen and you did end up with a colostomy bag, he felt with the tests showing nothing it didnt warrant going in,said it's not so easy as just putting a camera inside someone,it comes with risks, I then asked could it be chrons or diverticulitis? He said no because I was too young really!
The CT scan I had done was in-between the two attacks when I felt normal and with no pain,so it was I guess pushed to one side this time round,
The specialist I saw for results of the CT scan said, nothing abnormal showed it all looked fine,that he didn't know what my pain was and that 30% of patients that come into the hospital never find out there problems,and I unfortunately fell into that 30%, but then he said I notice you have fibromyalgia and that it could be something to do with that,said he'd write back to my gp on his findings and let them basically deal with me, I feel pushed from pillar to post with this,the only one who wanted to seem to help was the female surgeon she said even when tests haven't shown, she has put cameras in to take alook inside and has been surprised and other times has taken out the appendix and the patients pain has disappeared,
I was given a out patient appointment for a follow up in 4-6 weeks with the abdominal specialist and given oral morph, I told them I'd rather take co-codamol as oral morph didn't do anything for me, anyway thank you for listening and offering your advice, I'll update you with what happens, :0)

Anonymous said...

I'm a 30 year old male. I started having abdominal pain that was centralized. I've been to the hospital twice in two days because the pain has been severe and I've been doubled over and even crying. I have no appetite, I've vomited so much over the past hour that now I'm dry heaving. The pain has moved into my lower right pelvic region and is severe.

The last time I went to the hospital the other day they did blood work, urinalysis, and a CT scan and all tests were normal. However now the pain has moved and the symptoms are as I previously stated. There is a family medical history of appendicitis. I'm at a loss right now and I need an opinion as I know that you can't give medical advice over the Internet and because you personally haven't examined me. Any insight would be greatly appreciated.

Skeptical Scalpel said...

Anon, I am not sure what is going on. As I have said here many times, a normal CT scan usually rules out a surgical cause of abdominal pain. This assumes that the reading is correct.

I don't think appendicitis runs in families. It is so common that figuring out a hereditary predisposition would be difficult.

I hope you have been seen by either a competent general surgeon or gastroenterologist.

If the pain persists, you should get another opinion at perhaps a different hospital, a teaching hospital if possible. If you go to another hospital, be sure to obtain a CD with the CT scan images, a copy of the CT report, and copies of all your lab work so the second opinion docs can review all of it.

I hope you feel better. Please let me know how this turns out. Good luck.

Anonymous said...

Hi my name is Brittni ! I am a 27 (as of 7/14) year old female. I am 5'3 and about 115lbs. I eat healthy and normally exercise (have been out of commission a while)

Let me start by saying thank you for your time and I know you are not able to give medical advice I just wanted to know I wasn't crazy for looking into the situation further.

7/8/15 Typical story. Thought I had gas all day couldn't stand. Finally couldn't walk after a day of running around being a stay at home mom. I felt like an idiot going to the ER at 11pm but went because I was crying with pain. WBC elevated and after a CT they showed my appendix to be abnormal (nothing screaming) but abnormal. I had a laparoscopic appendectomy by 8am. Surgeon said it was defiantly appendicitis based on the condition of the appendix he removed.

After surgery I had the same old situation pain and moving air. After five days I went to ensure that my shortness of breath and my upper left quadrant pain while breathing in was normal. I was given a script for 30 more pain killers and told it was just an issue of pain management.

I also developed a lump, more like a tiny nub under my naval incision. My mother was worried it was a hernia but I wanted to ensure it wasn't just normal swelling due to pre existing piercing on my naval (incision was right on it).

Well 7/22/15 rolls around and it is exactly two weeks post op. I went to my final wedding dress fitting and I felt bloated I had actually lost weight but I just felt like I had gas or something. I went home and on the way I would have sworn I had appendicitis again. I had shooting pains when hitting bumps and switching lanes. I ended up at the ER at 10:16pm. It was upper left quadrant pains. Pretty severe and it hurt to move again. No pain in the right side.

Upon arrival it was very busy and this hospital does not handle busy well I do not believe everyone was frantic and I was there until almost 6am. I was taken into a room about three hours later and they took labs and I went through another CT scan. Diagnoses elevated WBC a little under what my rate was prior to the appendectomy. In the CT scan they showed moderate inflammation under the skin in the upper left quadrant and they also said near my right ovary there was fluid and a sac ( I assume on the Ovary) that caused them to conclude I also had an ovarian cyst burst. I was released with Cellulitis and a Ruptured Ovarian Cyst. I was put on a strong antibiotic and 6 pain killers as needed.

My pain is still there hurt more to move and now the area it hurts in is bigger and it immobilizes me a bit more. I also am having pains more like pinching under my left shoulder blade behind the area that hurts in my abdomen. I just took my blood pressure it was taken at home so not as defiant but it was 102/47 ( I am not a nurse I have only taken CNA courses and pre nursing courses many moons ago). I am normally 118-120/70s.

I can see the swelling in my abdomen but no discoloration. I can feel it and it is tender to touch. My skin is hot on stomach but it normally is. The pain I feel in my abdomen is a burn/tear. I just feel overall blah. I can not afford to go to another er if I can avoid it and both of my dr and surgeon are out until Mon. Temp is only at 99.3 but I am normally a perfect 98.6.

Thank you for your time. I am adding my abnormal lab results from pre appendectomy... the ones I had taken this week are not yet available.

Alanine aminotransferase 27.0 (low)
Creatinine [Mass/volume] in Serum or Plasma 0.63 (low)

Leukocytes [#/volume] in Blood by Automated count 13.5by10'3/ul (high)
Neutrophils [#/volume] in Blood Neutrophils [#/volume] in Blood 9.25 by10'3/ul (high)

Skeptical Scalpel said...

I had to think about your situation for a while. I'm sorry you aren't feeling better.

I have some questions for you. Did the pathology report confirm that you had appendicitis? This is very important. Why can't you get the latest lab results? They should have been available within 24 hours of having been drawn. Are you eating and moving your bowels?

99.3 is not a fever by anyone's definition. Inflammation in the skin of the left upper quadrant could be a wound infection brewing (possibly from your belly button incision) but it's been quite a long time since your appendectomy. Wound infections usually appear within 7-10 days after surgery.

Assuming your BP reading was accurate, you may be a little dehydrated. They must have taken your BP during your last ED visit. Did anyone say it was low?

You say your doctor and your surgeon are away until Monday. Do they not have other doctors covering for them? It might be a good idea to get the covering surgeon to see you for a fresh opinion.

I wish I could be of more help.

Anonymous said...

I called to get the lab results, medical records dept stated that they could try to get it together but it would depend on the amount of work they had in front of them and it may be until Monday before they would be available. I made an account and logged in online and they are still not available there either just 7/8/15's account.

As far as the bowels go, I have both hard and loose stools, but still nothing alarming I have also used murilax because of the pain killers.

At the hospital 7/22 I was 118/something (nothing alarming). Still no fever right now.

Again not sure of the accuracy of the BP but it is always about the same when I check it the reason I had checked it was because when I was released after the appendectomy I had an 85 over something and it worried me because I am normally so regular. Right now I am getting a 118 over 67 ish.. Also, I WAS dehydrated at the ER Wednesday 7/22, she stated that as she placed an IV for fluids. My vein was not cooperating to well. I did have a bag of fluids. My urine was stated as clear and Hazy.

The exchange has told me to go to the ER because based upon the diagnosed cellulitis and escalation of the tender area and severity of the pain. I am sure you are aware that each CT scan and series of lab draws on top of ER visits can be extremely expensive, for a one income family of four with an insurance policy it is hard. I am trying to not do it if avoidable.

The ER dr stated that he thought it was appendicitis and the surgeon said and I quote "not a doubt in his mind after seeing it".

Let me add that the hospital also asked me prior to surgery, to shave my own private area in the shower with my own razor ( I was on cardiac in overflow) and some of the hospitals shampoo for surgery prep and then wheeled me down to the OR in a wheel chair fully dressed no fluids and fully clothed. I had to get naked and in a gown in the middle of the OR.

Moral of that statement is the hospital didn't really do a great job the first time either. Why I went back, I have no idea I was in pain and scared I suppose. Scouts honor true story on the shaving and OR nightmare. I was fine however, not the end of the world for me.

I agree it is all just to weird. Let me also mention, I had the same upper left quadrant pain when I had the appendectomy. It gets worse at night.

Also, I just had all four wisdom teeth extracted two weeks prior the week before that the one that was curved into my jaw was infected. infected and the week of and following the extraction I had a double dry socket. Not sure if that affects anything. But I have been on steroids and antibiotics as well as pain killers for about two months or so. I have also since last fall lost about 55lbs.

I am so grateful for you fast response. My wedding is ( I am already married but am doing the formal part) in two weeks. I just want to be better and am not sure this diagnoses let alone treatment is the way to do it. I would like to dance with my husband father and children and right now I can barely swing a door open or walk without pain.

Sorry for the informational overload. Just have had a lot of things, I am not sure life could be ironic enough to not mesh all of them together.

Anonymous said...

With the story I am just simply narrating the practice of the hospital to merely explain my doubts in diagnoses.

Skeptical Scalpel said...

Sorry for the delayed response. If you were on steroids, it could have affected your lab work--specifically, you white blood cell count could have been elevated because of steroids.

Most surgeons do not require shaving of the genital area. If they do, it should be done with an electric clipper, not a razor. I can't believe you had to shave with a razor in 2015.

"The ER dr stated that he thought it was appendicitis and the surgeon said and I quote not a doubt in his mind after seeing it." I've heard that one before. Ask to see a copy of the pathology report. You are entitled to see it.

I hope you're feeling better today. If not, you need to see someone.

Anonymous said...

I had an appointment with the surgeon this AM. The pathologist stated that he thought it was an abscess more than cellulitis the surgeon stated that he thought it could be an abscess or possibly just fluid. He stated my white cell count only being 13.8 was nothing. He said and I quote yet again "at your age you could throw up and have an elevated white cell count, at your age your immune system is very responsive". My lab numbers appear to be extremely close to the appendectomy. Creatinine leukocytes and such. He instructed me to continue my medications until Friday (AMOX CLAV 10 DAY) and have a good wedding so I assume I am not required to do a follow up.

As far as the razor shaving, it was insane. I spoke with him and he reassured me he contacted HR and the were "educated". He said the same thing, if he needs it shaved he will and with an electrical clipper. He called upon my arrival in the OR said a few aggressive words about my condition and slammed the phone down so I hope the do not have it happen to someone in the future. I was fine, the next guy might fall. ALSO it was MY OWN RAZOR OUT OF MY GYM BAG MY HUSBAND BROUGHT. It was kind of my fault but I didn't know. I thought I was helping.

She said "do you think you can shave your pubic region" I said I think I can try and my husband can help... She then said I might have something in the back, I said my husband brought my gym bag I have my razor in there if that helps. She said ok I will go get you some shampoo..

When the nurses came to take me to the OR I was trying to use the restroom I had some narcotics in my system and I felt like I had to go potty but couldn't even with the sensation I was already going. She said hunny you need to hurry the OR is waiting for you and then repeated it twice and I was walking at the pace of any typical person with severe abdominal pain. They were probably the most unprofessional thing I have ever seen.ER staff were amazing and the surgeon was very nice.

So for the recap. ER dr states its cellulitis. Pathologist says it could be but thinks its an abscess. Surgeon thinks it may be either but could also be just a pocket of fluid retention he just stated I am more active that most post op patients (he is a vein surgeon or something I assume blood clots and such) and that its going to hurt a lot more. So I will be in pain a lot and it will be normal.

Thank you so much for your help. I was going nuts this weekend and just have been feeling like there is something else, I generally just feel blah. PS I asked them to check my blood pressure and we both forgot.

Anonymous said...

The steroids had been three weeks prior to the appendectomy.

Skeptical Scalpel said...

Sorry, I don't understand some things. Is the pathologist commenting on your original appendix specimen or your current condition? I was interested in whether the pathologist confirmed the diagnosis of appendicitis or not.

Are you saying that you volunteered to shave your pubic area or that the hospital personnel told you to shave?

A white count of 13.8 is not "nothing." I agree there can be many causes of it but in patients who are < 3 weeks postop, a surgical complication must be ruled out.

Anonymous said...

I had my appendix removed many years ago. I just had a ct scan do for something else and part of the report stated appendix normal. How can this be when I do not have one?

Skeptical Scalpel said...

There are only two possibilities. One, the radiologist who read your CT scan made a mistake. I have seen reports of CT scans on men that say "The uterus, tubes, and ovaries have been surgically removed."

The other possibility is that your appendix was either not removed or partially removed. This seems to be a bit more common with laparoscopic appendectomy than it was when all appendectomies were done with an open incision.

If you are concerned about this, you should ask for a second opinion reading of your CT scan from another radiologist.

Anonymous said...

I am very concerned because of the original reason I had to go for the ct scan. They sent me for a ct scan because they found in my MRI there was some mildly prominent veins and or lymph nodes are noted within the retroperitoneum, nonspecfic. The results from the ct scan found nothing wrong. So if they were wrong with my appendix, were they wrong about that too. How do I go about getting a second opinion reading of CT scan from another radiologist. Do I just go back to where I got the tests done and ask them to reread MRI and CT scan?

Anonymous said...

Where do I go for a second opinion reading.

Skeptical Scalpel said...

Either you can go back to where the studies were done and ask that your CT and MRI be reviewed, or if you have a primary care physician, she could make the request. The radiology department might respond better to the latter. Let me know how this turns out.

Anonymous said...

I quite like that one: I have had a gastrectomy and lap choly due to gastroparesis and sludge. Somewhere in there, I had a gastric bypass so sayeth the radiology gods.

Skeptical Scalpel said...

We can excuse that one. The radiologic appearance of the two procedures is somewhat similar.

Anonymous said...

Dear Skeptical Scalpel (and thank goodness for smart skeptical general surgeons)

After a rotating internship in 1973, I worked part-full time for a family practice group. You might be interested in the stories of 2 young women I saw. The first came into the office with about a 12 hour history of mid abdominal pain, moving to the RLQ with loss of appetite. She was clearly uncomfortable but didn't seem seriously ill. She had a low-grade fever and RLQ tenderness with rebound tenderness. I wasn't certain that she had appendicitis, but I wanted the surgeon working at the nearby small community hospital to see her. He seemed a little doubtful that she had appendicitis but agreed that direct visualization of the appendix was indicated. She had a normal appendix and enlarged mesenteric lymph nodes. She did fine post op; the next day the surgeon called to say that the throat culture he had collected pre-op was positive for Group A strep. He said that he had seen several people with strep throat and mesenteric adenitis who presented the picture of acute appendicitis. Most of them had much more prominent throat symptoms/signs, so he found it reasonable to obtain a test for GAS in people suspected of appendicitis, especially if they had respiratory symptoms.

The other young woman presented with clinical acute appendicitis; she did have appendicitis, recovered rapidly post-op and went back to nursing school. However, about 5 weeks later she came back to the office with RLQ pain again. She thought that her last menstrual period had been before her appendectomy. She had RLQ tenderness without rebound tenderness and a very tender right adnexal "fullness". This time I consulted one of the gyns who also permitted me to assist at surgery. Sure enough, she had an unruptured right ectopic pregnancy, and at that moment I flashed on her first surgery. Her long flexible appendix was snuggled up to her fallopian tube, so that they were in contact for at least an inch. We figured that she had probably ovulated just as her appendix became inflamed and that her tube became inflamed also ("sympathetically") just enough to trap the pregnancy. She had an uneventful, happily anticipated pregnancy about a year and a half later.

retired MD

Skeptical Scalpel said...

Great cases. Thanks for commenting.

Unknown said...

My son 14 years old was diagnosed with Early Peri-rectal abscess. I was told to get him in with a surgeon so I did the next day. When the surgeon went to exam him he could not see the abscess so he ordered a Ct Scan with IV Contrast when it came back it not show the abscess at all. But what it did show was my son had a extremly large appendix. The Surgeon said it looked like a tumor in the appendix. He said they can operate but he suggests waiting since my sons symptoms were not abdominal pain no fever no nausea. His symptoms were in his rectum and that problem seem to disappear. He has been on amoxicillin for abscess. Now I don't know if I should go ahead with the surgery for him or wait like the dr said tell he shows symptoms. My worry is that this tumor is going to get bigger and is it going to hurt him more to wait or get it taken out now.

Skeptical Scalpel said...

I am sorry but without seeing the CT scan myself and not knowing how large the appendix is, I cannot advise you.

Since it does not seem to be an emergency, I suggest you get a second opinion from another surgeon, preferably a pediatric surgeon. If you do that, be sure to obtain a copy of the scan itself, not just the report, to take with you.

Just wondering said...

First of all I just want to say thank you for taking time out of your busy life and responding to so many people. Wow that's so cool of you seriously how awesome of you. Secondly I know you can't give medical advice I read that a millon times. I bet you close your eyes and see that phrase in your sleep lol. I would just like your opinion. Third I have dug all through this post and unless I overlooked it somewhere I didn't see the question I was looking for which is kinda general in nature. So here goes..... I went to the ER over really bad pains in my right ribs that came out of nowhere I mean it hurt to take a deep breath or move. It turned out to be a bad bad kidney infection that had no uti symptoms did spike a fever of 102 and broke out in a rash. I was on antibiotics for 48hrs and still in pain went back to ER because I have had kidney stones before and though I might have a stone and it was on the right side. Same side as the previous kidnew stone 10yrs before. I finally got them to do a ct scan and the findings were equivocal right renal edema with pyelonephritis right ovary cyst 2.8cm appendicoith without appendix inflammation. This was on Aug 15 I'm still having pain on that side should I be worried about my appendix and what do I need to be watching for with my appendix. Ive always had pain in that area for the past 6 months? Should I talk to my doctor about getting it out? What should ANY PERSON DO if they have a stone in thier appendix? Will it go out eventually?

Skeptical Scalpel said...

The presence of a fecalith (appendicolith) once was an indication for appendectomy in anyone with abdominal pain. CT scan changed all that. Most experts feel that the mere presence of a fecalith is not an indication for surgery if the appendix is not inflamed.

Here's a link to a recent paper [] with some excellent references on the topic. See the discussion on page 13.

Anonymous said...

Hi Skeptical Scapel,
So here's the story,
I had the symptoms of appendicitis, pain moving from center to right lower quadrant, in Feb but I did the CT and the doctor said that it showed inflammation of the intestine but was treated with as appendicitis with antibiotics. As my condition improved, I was discharged and given a course of antibiotics and I managed to go back to my old lifestyle.
Recently, I suffered some abdominal trauma and soon after that experience pain and symptoms such as vomiting and loss of appetite similar to my previous case. I went to the hospital and they did another CT scan and it did not show appendicitis again but I was told the pain was caused by something to do with the fats. I was again treated with antibiotics and condition is improving.
However, I just wanted a another point of view of this matter, since it is a recurring case and may be caused by abdominal trauma and both CT scan showed no evidence of appendicitis.
PS. I have a review with the doctor in week time and I was told the surgery might still be considered. In your professional opinion, should I go for the surgery since it is a recurring case?

Skeptical Scalpel said...

Of course, I cannot give you medical advice without seeing the x-rays. I don't even know your age or sex. I'm sorry.

I don't know what you mean by "caused by something to do with the fats." If the most recent CT scan doesn't show appendicitis, why is there talk of surgery? And what sort of inflammation of the intestine was seen on the first CT?

Unknown said...

i would like to ask the meaning of "cannot totally exclude beginning acute appendicitis. thanks.

Skeptical Scalpel said...

I think it means "I don't know what the hell is going on."

It's not unique. Here's a similar one from 4 years ago.

Anonymous said...

I was reading your questions and answers page and am desperately seeking advice. My 3.5 year old fell from the top of an 8 foot rock wall she was climbing 2.5 weeks ago. No loss of consciousness, but I had her examined the best day by her doctor. Headaches and extreme fatigue were her only symptoms. Three days later, I rushed her to the ER after she woke screaming of her head and vomiting. A CT scan of her head was done and they confirmed a concussion, but no brain bleed. Since then, for the past two weeks, she complains of her belly hurting around the navel. She pushes it in and says it hurts. She has been eating only a little and may possibly be nauseous. She has always been extremely tough about pain and tolerates it well. She is not seeking attention regarding her pain, but it consistently seems to bother her. When we discuss it, she says her head pain feels less, but her tummy (same area near navel) hurts a lot. She poops multiple times a day. A week ago, I took her back to the doctor for her stomach pain and they said they thought she wasn't getting out all her feces and to give her miralax. I followed, but she has been going plenty. I took her back yesterday and they claim that four year olds complain of pain near belly button due to stress. She told me to stop discussing it with her. I demanded a blood test, which she took today. We took another urine test too and she ordered an abdominal X-ray. I am afraid the trama of the fall may have affected her appendix. Is this possible? Could symptoms be going for this length of time? Would an X-ray help in seeing this? Is a CT of her belly worth the radiation at this pint?If not, what would you recommend? I am feeling lost on what to do next for my child and don't feel that the doctors are taking me seriously. Any leads in the right direction would be greatly appreciated.

Skeptical Scalpel said...

Please note the numerous disclaimers in my previous comments, at the beginning of this post, and in the "Read Before Commenting" tab above. This is not medical advice.

I doubt that trauma could cause appendicitis especially 2.5 weeks later. I've never heard that childhood stress can cause pain at the umbilicus.

There are several other possibilities for the source of abdominal pain after a fall of 8 feet. Almost none of them will be diagnosed by a plain abdominal x-ray.

If the pain persists and the child continues not eating, I suggest you ask you doctor for a referral to a competent surgeon. If the surgeon examines your child and recommends a CT scan, you should follow that advice.

Please let me know how this turns out and good luck.

Anonymous said...

Hi Skeptical Scalpel,
Firstly, i would like to thank you for taking time to answer questions from people who want to get more answers. Hats off to you!
Here's my case. I'm a 48 yr old female, goes to the gym 2 to 3 times a week. Taking maintenance for the heart and bp for 4 yrs now. Had cholecystectomy year 2001. Had history of duodenal ulcer year 1999. Myomectomy last 2008. 4 days ago, had abdominal and back pains. Thought it was just pulled muscle. Pain gradually increased as days passed by. No pain when standing, only when in bed sleeping specially early am. Went to er yesterday. Was really painful when i woke up. Moving in bed is difficult specially on the right side. Blood test, urinalysis and ct scan were all normal. 2.2 cm umbilical hernia was found but dr said it wont cause pain. Was given solpadeine for pain. Just muscle pain he said. Went back home puzzled about the pain. Thought maybe i was just getting old...woke up with severe pain again early am. Cant move. I was in tears. Took solpadeine and pain was gone. Went back to a general surgeon today. Same hospital. Checked my lab results and ct scan. He said everything was normal. He told me to have liver test which i just did. Results will be after a few hrs. My question is, if everything are normal, and i still have severe pain, what other tests can be done? I am somewhat not satisfied that this is just muscle pain. I have a high pain tolerance and had 4 kids, 2 major surgeries at that. And i know what muscle pain is, being active at the gym. Another thing, when i had my ct scan, there were automated instautomatedin english at the beginning when to hold your breath and breathe. But the latter part was already in arabic so i did not hold my breath. Then saw the sign that i should be holding my breath but it was too late. Would this somehow affect the ct scan result? Sorry for the long post. Thanks in advance

Anonymous said...

Update- my liver test says amylase serum is 126. Normal range is 28-110. Should I go back to the dr?

Skeptical Scalpel said...

Anon, thanks for writing. This is not advice.

Amylase is a test revealing inflammation of the pancreas, but it is non-specific. That means the amylase can be elevated for other reasons. A serum lipase should be drawn because it is a more accurate test of the status of the pancreas.

If you had pancreatitis, you would not be able to eat and might have vomiting. The pain is not usually intermittent. The amylase could be up due to an ulcer, which you have a history of.

This could be a spine problem with a nerve root compression.

Your doctor should be calling you to discuss the mildly elevated amylase. You probably need to see him again. Call him if he doesn't call you.

Good luck. Let me know how it turns out.

Anonymous said...

Hi again Skeptical,
I had another bloodtest for lipase today. It was normal. Dr wanted to probe further because of my history and he finds my case unusual. He ordered MRCP and i will have it done tomorrow. If he finds nothing then he will refer me to a another dr who specializes in muscle pains. I hope we will finally find what is really causing my pain. Will update again once i get the results. Thanks so much for your time

Anonymous said...

Dear skeptical I'm writing to ask what you might think is going on. I'm a 35 yr.old female and after having my third child (2 1/2 yrs.ago) I started having pain in the lower right side abdomen and my periods got much much heavier. In November2014 I had a hysterectomy witch my doc said would help the periods(lol) and hopefully help the pain. However the pain is still present and has worsen it feels swollen,on fire,can not get into a comfortable position,have been back to the doctor's and two the er I have had blood work done (normal) Ct (normal) ultra sounds have showed "something" no one's sure what.( a shadowy spot) at er docs immediately think appendix( all clear it's not)my ob doc thinks maybe endometriosis but says surgery will be the only conformation for that I have seen stuff about inflamed lymph nodes is this something I should have them check or would that have been seen by now? Any suggestions would help. thanks.worried.

Skeptical Scalpel said...

Gynecology is not my area of expertise. I cannot comment on the correct workup for endometriosis. I assume your ovaries were not removed at the time of your hysterectomy. You should inquire about their status and whether they were seen on the CT scan or ultrasounds.

If the appendix was normal on the CT scan, it is unlikely to be the cause of your pain. Inflamed lymph nodes would probably not hurt and what would be the cause of the inflammation?

Sorry I can't be of more help. Good luck.

Anonymous said...

Is it medically reasonable to have negative blood work, an intravaginal sonogram and a CT with contrast to rule out appendicitis? Dx was constipation. Is this just bad medicine?

Skeptical Scalpel said...

Of course, one generally would not need such extensive testing to diagnose constipation. However, without knowing a lot more about your history and physical examination, I can't answer your question. For example, your age, the severity and duration of your symptoms, your vital signs, whether you had nausea or vomiting, whether the pain increased with activity or coughing and many, many other factors would need to be taken into consideration.

Adam said...

Dear Skeptical Scalpel,
Like many others writing to see if you might have any insight to my situation. Woke up this last Sunday morning with strange pain in lower right abdomen. Not a crippling pain, but definite discomfort with sharp pains coming and going. I eventually went to urgent care who recommended ER for CT scan. ER doctor performed blood/urine and CT scan. Blood/urine all normal, CT scan was "inconclusive." She stated that my appendix cannot be seen. surrounding area checked and looked good. Dr. had concern as I had pain in the right area and at right time when manipulated. She offered surgery as solution, however, surgeon declined as I am not exhibiting most typical symptoms. No vomiting, fever, nausea, etc. Normal eating and bowel movements. Was discharged and told to monitor it. Since then I have had the same discomfort and periodic pain in same area and last night felt pain and a lot of pressure. As if I was going to sneeze or lift something heavy that it would burst. Today still constant discomfort with pain coming and going. still no other typical appendicitis symptoms. I can feel that something is not right but nothing seems to be showing up on any tests. what options would you suggest?

Thank you

Skeptical Scalpel said...

Adam, I assume you've read some of my other responses. This is not medical advice. Appendix not seen is a good sign. It usually means the appendix is not swollen or it would have been easy to see. Normal blood and urine tests are also reassuring.

You have met a thoughtful surgeon who does not want to operate unless convinced you have a surgical disease.

I think your best option is to wait and see what happens. Obviously, if it gets worse, go see your surgeon or go back to the ER. I hope it turns out OK. Let me know.

CGH23 said...

Dear Skeptical Scalpel,
I wrote to you some years back about my persistent right lower quadrant pain, and I wanted to give you an update. I was found to have a dermoid cyst on my right ovary. The gynecologist that I consulted recommended a laparoscopic excision of the ovary. She did not inform me that she intended to use a single port procedure. Unfortunately, she lacerated my intestine and caused a large abdominal hernia in the process. She did not recognize the injury before I was discharged for home. I had an emergency laparotomy with an excision of part of my small intestine approximately 42 hours after the injury. Since then I have had a second laparotomy and excision of part of my small intestine due to recurrent episodes of intestinal obstruction. I have had only mild to moderate episodes of obstruction since the second laparotomy. Unfortunately, I have also had repeated CT scans as a result of the medical complications. The surgeons who saved my life provided outstanding care. Thank you for responding earlier to my inquiry.

Skeptical Scalpel said...

CGH23, thank you for the follow-up. I am so sorry to hear of all your complications. I hope your are feeling better. Good luck.

Robert Rose said...

Damn, that's a lot of responses to a blog post. I truly feel for you having to sort through all of this.

Skeptical Scalpel said...

Robert, that's true. And I have lost count of the number of emails this post has generated. Most of them are from patients who have seen a doctor or gone to an ED and have persistent abdominal pain with negative imaging studies and/or lab work. Some have not had satisfactory explanations from their doctors. I've even have a few with CT scans positive for appendicitis, but the surgeon declined to operate because of a normal white count. Recently, I've had a few questions about treating appendicitis with antibiotics.

I try to answer them all with the disclaimer that there's no way what I say can be considered medical advice.

Anonymous said...


I have been in pain since last two years in my lower right abdomen.

One doctor suspect appendicitis and told me to take barium X-ray. The result was "Non filling"and suggest for appendectomy.

I seek for second opinion from different doctor who told me to take CT Scan and the result was negative for appendicitis.

Should I follow X-Ray barium result or CT Scan ?


Skeptical Scalpel said...

This is not medical advice because I would need to take a complete history, examine you, and see both studies and their official reports.

Barium enemas for the diagnosis of appendicitis (or anything else) are rarely done in the 21st Century because CT scans are more accurate.

Maybe you should see a surgeon.

Shayla Smith said...

I went to the ER due to pain in the right area of my stomach. No fever, although sweating from just standing. Blood pressure was very high and the pain got worse when I would walk around. Very uncomfortable to wear my pants buttoned up.
I was given a pelvic exam, urine came back positive for UTI, blood test reported that my WBC was elevated, CT SCAN showed appendicitis. Once the CT SCAN results were in, I was immediately given antibiotics, IV, as I waited for Surgeon. Surgeon removed appendix within hours due to inflammation, but stated after that my appendix looked fine when he went in.
I'm confused on what the CT SCAN showed versus what was saw with surgery. I feel much better, and am happy overall that I am no longer in pain.

Skeptical Scalpel said...

Shayla, I have had cases where the appendix looked ok in the OR, but the pathology report confirmed that appendicitis was present. The fact that you felt better after the surgery suggests that it was appendicitis. I would ask the surgeon what the path report showed.

Anonymous said...

My 9 yr. old son had an appendectemy 1-15-2016. He had sever abdominal pain and had Mri and Ct aand xrays. The MRI said it could not rule out appendicitis and had surgery the next night. After the surgery he had phnominea and limpnodes. That went away, but he still has sever chronic abdominal pain, on 5-19-2016. He had colonostrophy, upper and lower, pill cam and all tests come back normal. He still has chronic sever stomach pain. His GI recommended pain management and counceling to help him manage his pain. He is also taking amnitrityline to help his stomache nervs calm down so he can slepp at night. His pain is interfearing with daily activity, school, playing, name it! He doesnt even want to leave the house because of his pain.Hes been admitted to the hospitals several times for cleaning his system, blood test, stool test, every test the dr thought of. His pain is every day! He is also taking stool softner maralax, antasids, stomache coaters, tylenol. Can you think of anything? I really wish I could show you the scans, MRI, xrays, and all his tests. Can you think of anything that can help. He is also waiting for pain management appointments and GI appointments. Please any ideas?

Skeptical Scalpel said...

I am so sorry to hear of your son's problems. You do not say whether he is losing weight or has any other symptoms besides pain, such as diarrhea, constipation, or vomiting. Also, it would be good to know if the pathology report of your son's appendix confirmed that he had appendicitis.

One of the characteristics of a good doctor is knowing went to say "I don't know." I like to think of myself as being a good doctor, and I regret that I don't know what is wrong with your son.

I don't know where you live, but if it's anywhere near a university hospital, you should take your son to see a pediatric gastroenterologist or surgeon at that institution.

You need to obtain copies of your son's medical records and CDs of all of his imaging studies so that you can show them to the doctor you see.

I apologize for not being more helpful, but if you have looked at some of the other answers I have given here, you will know that it is difficult to diagnose illnesses in the context of comments on a blog post.

Please let me know how things turn out and good luck.

Alyson said...

I've read through as many comments as possible. Saturday July 2nd my daughter started complain of abdominal pain and ran a low grade fever. Headed to ER where they did the run of the mill tests. Returned home. On July 4th while at a parade for the holiday, my daughter began to vomit stomach bile and almost fainted. Back to the hospital. They did urine labs, blood labs and did IV fluids with zofran and ketrolac. Once again we returned home, except with a UTI diagnosis. I should mention that she began to have the runs Sunday July 2nd. All seemed to be doing better, headed to our GP for follow up on Tuesday the 5th. With rebound pain and abdominal tenderness they sent her for a ct scan and blood work. Notes from radiologist revealed terminal ileitis w/abscess and fluid in pelvic area. By Wednesday we were researching Crohn's disease, my daughter seemed to be turning a corner. Thursday the 7th hit. My daughter woke up with a 99.4 temp. She seemed and even stated she was feeling better...within an hour she couldn't stand, walk...and her temp was 103.2. By the time we hit our doctors office her temp was 104 and she was taken by ambulance to hospital. This resulted in an immediate admit. They proceeded to do more bloodwork and cultures and another ct scan. A surgeon was brought in. He stated he didn't feel her terminal ileum being that remarkable but did point out the access and free standing fluid (substantial amount is what he said) in her pelvic region. Her WBC was at a 4.5, her infection number was at a 62, her SED rate at an 11...

By Friday afternoon after 24hrs of IV fluids, her numbers had improved except for her WBC which was now at a 3.5. Her pain was still at a 5/6 and she was still having rebound pain and tenderness.

My question is- is it possible for an appendix to rupture and cause the terminal ileum to inflame. If so, would and MRI see more than a ct scan when it comes to looking at the free standing fluid and abcess? I'm just not convinced that my 12yr old daughter has Crohn's disease after no prior symptoms until this last week.

I'm not looking for a diagnosis- just your thoughts. We are going to be seen by a pediatric GI this next week. My fear is, that come tomorrow after 24hrs being off IV fluids whatever this is will rear its ugly head again.

Thank you in advance and apologize for being all over the place.

Alyson said...

I should also note they were able to see her appendix and some swelling of the mesenteric lymph nodes.

Skeptical Scalpel said...

Alyson, sorry that your daughter is ill. You did a nice job of summarizing the situation.

Questions: If she has an abscess, has anyone suggested draining it? Is she on an antibiotic? Is she able to eat? Is she having pain that awakens her from sleep.

A ped gastroenterologist is definitely worth seeing. Crohn's is possible in a child, not not common. The appendix can rupture and cause an abscess, but you said they saw it on the CT scan. Maybe the tip was inflamed and ruptured and the rest of the appendix is normal. The mesenteric nodes could be swollen in Crohn's or a ruptured appendix as well as a few other diseases.

Alyson said...

Thank you for your quick response. Actually the surgeon never mentioned the abscess or draining it- it was the radiologist who noted it in the scans. The surgeon even stated the things the radiologist pointed out weren't that remarkable. We could see the entire appendix on the scan he showed us. No antibiotic- they discontinued it when they decided she didn't have a UTI.

She's eating a little. Her pain isn't waking her, so much as just when she's moving around.

A new symptom arose today- while going to restroom she noticed blood. Now either she's begun her cycle or the surgeon was way off...

Skeptical Scalpel said...

I'm confused. Does the child have an abscess or not?

Alyson said...

After a follow up yesterday- the doctor informed us the free fluid is what the radiologist was calling an abscess. So I'm not sure if we are being jacked around or not. Sounds like too many cooks in the kitchen really and no one is talking to the other. She's headed to see a pediatric GI now. She's eating a bit better, she's lost close to 10lbs though.

Skeptical Scalpel said...

I agree with you. You need to get all the doctors including the radiologist in the same room.

I hope she feels better and that she doesn't have Crohn's disease.

Mariah said...

Hi I have been having some serious abdominal pain on my lower right side right by my hip bone. I am epileptic and have acid reflux, and also had many cysts before since I was around 10 years old, but this feels nothing like that.. I was in the hospital when I was in middle school because I had fluid around my appendix and obviously that isn't normal so they were going to do an appendectomy, but at the last second they decided not too.. But I am getting almost the same pain now again for maybe a week. It all started out as just cramping in my stomach kind of around my belly button I figured I was gonna start my cycle soon, then it worsened I'm now getting cold sweats, clamy hands and feet, chills, dihhera, constantly nauseous, and countious pain on my right lower abdomen.

Skeptical Scalpel said...

Mariah, you need to see a doctor or go to an emergency room. It could be any of a number of different illnesses including appendicitis.

Anonymous said...

I had kidney stones about 10 years ago. Recently, the same symptoms started to surface. These symptoms are pain in the right side (right below rib cage) and back. These are the same precursors I experienced 10 years ago prior to passing a stone. So, I had a unineanalysis and full blood work done and they came back normal. I then had a non-contract CT scan done and was told there was no evidence of kidney stones.

I'm puzzled now, because the pain I experience comes and goes (like in the past). My doctor said it could be related to a car accident I was in 6 months ago or it could be pain from scarring inside (not sure if he is taking about the accident or when I passed a stone before, as it was a very large stone).

I'm not sure where to go from here. I only experience the dull pain if I sit for extended periods of time.

When they did my Urologram (CT Scan) do they check for other things too?

Skeptical Scalpel said...

Yes, the radiologist reading a CT scan always checks the entire abdomen to look for other problems. The omission of contrast which is necessary to better see kidney stones makes some other organs harder to evaluate.

Other than saying it is dull, you didn't mention the intensity of the pain you are currently having. I had a kidney stone a few years ago. The pain was so intense that it was all-consuming. I could do nothing until the spasm passed. If you aren't having that kind of pain, you probably don't have a kidney stone.

If the pain persists, a second opinion might be worthwhile.

Of course this is not medical advice.

Anonymous said...

The dull pain comes and goes and is about a 4 or 5 on a scale of 1-10. When I had my kidney stones years ago this was the progression. I had these dull pains, which went on for about a year before the intense pain of passing a kidney stone came up. It was quite strange when I passed my kidney stone years ago, because I woke up twice (in intense pain), which I assume is from build up of pressure behind stone of fluid trying to push it forward. This happenned twice before it actually passed to my bladder. The right side pain went away completely after the passing of the stone. Now that it's come back 10 years later I just assumed it was a kidney stone.

Could the stone have been missed with the non-contrast CT scan? Could there be something else that mimics the same precursors I experienced 10 years ago?

Just to be clear. When I had kidney stones before it was a progression in pain. My early symptoms I assume came from prior to the stone exiting the kidney. Once the stone exited the kidney and became stuck that's when the real pain started.

Skeptical Scalpel said...

Interesting. Mine wasn't so subtle.

Like all medical tests, CT scans are not 100% accurate. It is possible that the scan did not identify your stone. If it is one of the 10% that do not contain calcium, it may not have been visible.

If you continue to have pain and no evidence that a stone is passing, you need to go back to the doctor.

Anonymous said...

Thanks for all the useful information. I did make a follow-up appointment with my doctor for next week. I've known a lot of people that have passed kidney stones. The majority seem to go right to the intense pain phase and pass the stone. My progression was slow, but when the stone left the kidney wow was that some awful pain.

If someone has a large kidney stone that hasn't started to pass yet. Can't it cause pain in your kidney? The stone I passed 10 years ago was quite jagged and I can't imagine it not causing a lot of damage on the way out (it was at least 5mm). Funny story. When I took the stone to the lab for testing the person that took my stone said "OMG you passed this?"

Skeptical Scalpel said...

If someone has a large kidney stone that hasn't started to pass yet. Can't it cause pain in your kidney?

Good question. Generally staones that have not started to pass by entering the ureter [tube leading from the kidney to the bladder) do not cause pain. The jaggedness of the stone isn't really the problem. It's the spasm caused by the ureter trying to push the stone along.

KJ said...

Hello, I have a general question regarding appendix leakage during a non-acute/non-emergency planned appendectomy done laparoscopically. First, what is the time frame for that surgery? How long does it generally take to remove the appendix in this way? What are some reasons that an appendix would leak during this situation?
Thank you!

KJ said...

I'm sorry, I didn't see the "ask a question" button and mis-posted as a comment. I will try to email it.

Anonymous said...

My 8yr old son is on day 5 of severe belly pain near belly button. Nausea , no diarrhea,no vomiting,normal BM extremely poor appetite,tired & pale.keeps him up at night
Trip to ER labs normal except for slightly RBC, hemaglobin & hematocrit,urinalysis came back fine. Ultrasound was only done on spleen & came bk good. Xray of Chin to groin was negative. Told probably viral. Sent hone with toradol. Next day still in pain, barely eating.
pushing fluids..
Can something viral last this long?
Pain radiates in belly button, lying down helps, jumping/walking doesn't aggravate it. I'm at a loss, is there still a chancertain it coukd be appendix??

Skeptical Scalpel said...

Once again this is not medical advice which can only be obtained from an interview and personal examination of the patient.

Appendicitis is a tricky disease and there's always a chance the pain could be due to an inflamed appendix. Viral diseases certainly can linger. I am told there is a lot of flu going around.

I do not understand why only the spleen was investigated during the ultrasound. Is it possible you misunderstood what you were told about that study? I assume you meant that the white blood cell count was slightly elevated. That is a nonspecific finding and does not necessarily mean the child has an infection

Since it has been five days, I suggest you return to the ED or take him to your pediatrician for another exam.

I would be interested in hearing how this turns out. Good luck.

Anonymous said...

Not a single word about Yersinia enterocolitis in the entire blog? It presents with symptoms identical to appendicitis, the patient goes in for surgery, and the appendix is a beautiful, healthy pink.

Skeptical Scalpel said...

They don't go to surgery if they have a CT scan that shows a normal appendix and ileitis.

Tony de la pena said...

hello dr. i had pain near my belly button and lower right ab area. WDC was normal, CT with IV contrast normal. no rebound pain, no fever or vomiting but it hurts when i move and now my right testical hurts. no ultrasound was performed and urine was clean. im still in pain. are any muscles in that area that can be strained?

Skeptical Scalpel said...

Tony, sorry for the delay in responding.

I'm not sure what is going on. If your right testicle still hurts, it might be the source of your problem. The blood supply may be cut off by an abnormal twisting (torsion) of the testicle. That's a real emergency because the testicle can be lost if it's not treated promptly. It can be diagnosed by ultrasound. Yes, there are muscles that can be strained in the area too.

Anonymous said...

Took my daughter to the ER on Wednesday night hurting in her right side, did a ct scan everthing was ok but still runs a fever every night of 100.1. They said her appendix was fine, now she got bad smelling gas, still hurt in her right side feels sick on stomach, this being going on for 4 1/2 days now don't know what else to do.

Skeptical Scalpel said...

Anon, you didn't give me much information to work with. How old is your daughter? Is she eating? Vomiting? Sleeping at night? Going to school? Sudden or gradual onset of pain? Pain first or sick to stomach first? 100.1 is technically not a fever. Do you have a pediatrician?

Olivia said...

Hi I’m a 15 year old girl. I woke up with sever pain Sunday night and went to the doctors the next morning. They told me I had all of the symptoms of appendicitis and I went to the hospital to get an ultrasound. Nothing showed on the tests. And I don’t have an infection. I woke up this morning in more pain than on Monday, but the doctors don’t think anything is wrong. What should I do?

Olivia said...

If it helps some of my other symptoms are nausea and vomiting, the pain started out in general around the center of my abdomin then gradually it’s changed more to like a dot a little lower and to the right of my belly button. It hurts when I walk and move my right leg. It also is like a rebound pain when you press on it now.

Skeptical Scalpel said...

Olivia, when you say nothing showed on the tests, does that mean the appendix was seen but was normal or the appendix was not seen at all? There's a big difference. Even if it was seen on ultrasound, the test may not be accurate.

If your symptoms are progressing, you might need a CT scan which is more accurate than an ultrasound.

Your history sounds a lot like appendicitis, but it could be other illnesses.

I suggest you see your pediatrician or return to the emergency department as soon as possible. Please let me know how this turns out, and good luck.

Olivia said...

The test showed that the appendix was normal.

Skeptical Scalpel said...

As I mentioned in my disclaimer at the beginning of this post, I cannot give you medical advice because I have not taken your history, examined you, or seen your lab and x-ray results myself.

The other thing about a CT scan is that it may show an ovarian cyst or some other abnormality that is causing your pain.

If your symptoms are worse, you should be seen by a doctor again.

Anonymous said...

Not sure if this space is still being monitored. Skeptical Scalpel has been spectacular with respect to answering questions and providing support over the years. I simply wanted to update my experience; the last post/response I provided was on Feb 4, 2014.

I presented with limited to zero symptoms, yet a CAT scan with a 11mm distended appendix. Further details are listed in the prior 02-04-2014 post. About two years later, I felt pain in the same LRQ, but felt short term comfort about what it was. Hoping it would subside, waited almost 24 hours as the pain became worse. Eventually went to large teaching hospital that knew my history. They assumed upon presentation that my appendix was stressed. Found that appendix had burst, curled upon itself. Secondary peritonitis, green infected fluids, comments about intro-abdominal sepsis. Eventually a 104 degree fever, but was in a good spot at the hospital to address that. The terms they used were: acute suppurative appendicitis, periappendicitis, transmural perforation, mesoappendiceal abcess, secondary peritonitis (generalized and localized), adbominal sepsis. The appendix they eventually removed was 14mm, with a large wall defect (guessing that was the bursting). The surgeon said it was interesting to deal with challenging situations. So we all had some fun. But I slowly recovered over the following weeks, months - and have felt comfortable and confident over the months/years since...

Skeptical Scalpel said...

Anon, thank you so much for the follow-up which I rarely get here. I'm glad you are doing well. Yes, the "large wall defect" was where it burst.

It was bold of your surgeon to not remove an 11 mm appendix in 2014. I would have taken it out and suspect most surgeons would have.

Anonymous said...

Hi, I'm not asking for medical advice. I'm looking for help interpreting a report. Last month, I started having increasing lower-right abdominal pain. After two weeks of this (and a week of Cipro for a suspected UTI), my doctor told me to go in for an ultrasound to see if they could locate my appendix. They didn't find my appendix, so I was sent to the ED for a CT. I was told the CT was normal, was given referrals to GYN and gastroenterology (which have taken forever to get into--that's especially frustrating since my gastroenterology appointment ended up being canceled and rescheduled weeks later), and was sent home. I recently got the report back, and I'm a little confused.

It says "Evaluation of the bowel loops is limited due to lack of oral contrast. No bowel obstruction. Small bowel loops are unremarkable. Normal appendix is not identified. However, there are no inflammatory changes in the right lower quadrant to suggest appendicitis. There are a increased number of small right lower quadrant lymph nodes, non-specific."

When I had come back from the CT, the ED doc said she was surprised they didn't give me oral contrast. They only gave me IV contrast. Is this normal? I understand from the other comments that not finding an appendix on the CT usually means it's not appendicitis. But I'm confused as to why they didn't administer oral contrast or say anything to me about the clarity of that part of the scan. There is a note saying I may be constipated, but I just hadn't gone yet that day.

It's probably just me obsessing over it, which is easy to do when there are no answers in sight. All my subsequent test results (blood, urine, GYN ultrasound, and the rest of that CT) have been normal -- right now I'm waiting on the GI appointment and whatever tests they decide on. But I'm really not sure what it means when they say that " limited." To me, that points to the possibility of missing something (like appendicitis), but is it just a general comment?

Skeptical Scalpel said...

I am sorry for the delay in posting your comments. I did not realize Blogger is no longer sending me emails notifying me of comments awaiting approval.

I hope you are feeling better. To give or not give oral contrast for a CT scan done to investigate appendicitis is the subject of much debate. It seems to be a matter of institution or radiologist preference. Oral contrast adds little to the accuracy of the scan and delays doing the scan by hours. This is because patients take a while to drink it, and it doesn't do any good unless some time elapses so the contrast can reach the right colon.

When the appendix is not seen on a CT scan it is normal nearly every time. This is particularly true if there are no signs of inflammation in the right lower abdomen.

If you are still having pain, you should keep the G.I. appointment.

I'm sorry I cannot be more helpful, but a lot of information is missing such as your age, whether your pain is associated with any other symptoms such as nausea, vomiting, diarrhea, or constipation although you did mention that the scan showed you had some stool in your colon which is not unusual. Other findings of importance would be whether the pain prevents you from sleeping or wakes you up from sleep where the pain is worse with activity.

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