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 Although Klass states that a normal appendix can be expected in 10-20% of appendectomies, those numbers are no longer valid.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.
51 comments:
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...
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.
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.
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.
Thank you. If I may ask, how would going to a teaching hospital be in my benefit?
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.
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.
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.
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.
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.
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?
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.
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
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.
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
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.
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!
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Thanks for the follow-up. My faith in the power of the CT scan is still justified.
I hope he is feeling better.
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!
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.
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.
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.
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?
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.
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?
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.
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!
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.
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!!
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.
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...
I am not an expert in the management of pediatric ovarian dermoids. I suggest you consult a competent gynecologist for advice about that.
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.
"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.
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.
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.
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?
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.
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?
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.
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