Tuesday, April 2, 2019

Diagnosing appendicitis

I have a new post on Physician's Weekly. My thoughts on diagnosing appendicitis: What works and what doesn’t .

7 comments:

chronicabdopain said...

Suppose a 28 year old athletic fit male with no comorbities presents to an emergency room complaining about strong abdominal pain since the night before. He says he had difficulty standing up and now it is like being stabbed in the belly. He is in the fetal position whimpering on the ground in the ER.
The day before he had his wisdom teeth extracted and clindamycin was prescribed.
The patient reports having taken 2 300mg pills before the pain started.
There is also evidence of black stools.
Immediately appendicitis is ruled out and "pseudomembraneous colitis" diagnosed instead.
The patient is filled with penicilin-g overnight and the symptoms go away. He is told to finish the clindamycin at home.
He is discharged with an x-ray that reports "some fecal matter in the right colon".
Ever since that trip to the ER, various digestive issues appear that never happened before and indeed to no one else in his family.
Eventually someone diagnoses this as "IBS". 16 years later a series of events unfolds like 4 strong flu-like events that went away overnight, then a tremendous pain through the back that lasted 30 seconds, and the next day a very strange piece of dried-looking hard feces with the imprint of a vein on it is passed.
The next year three episodes of sharp and strong right lower quadrant pain occur each lasting less than five minutes. The third one included the feeling of a very cold liquid seeping somewhere inside the belly.
Now the same person is constantly dizzy, tired, has the feeling of a cold lump inside, and when standing and bending can feel something inside. It is not food related, indeed skipping a few meals makes things worse.

1) Can coincidences occur so that a doctor would rule out appendicitis just because there was antibiotics involved that were prescribed for something totally unrelated? Thereby also ruling out any imaging?

2) Is it realistic that 2 300mg doses of clindamycin would have caused colitis so quickly in a healthy 28 year old?

3) Would this double dose of antibiotics treat acute appendicitis? For how long?

4) Could the initial episode of abdominal pain have been acute appendicitis caused by impacted stool in the appendix?

5) Can't black stools also have been caused by any number of things like swallowing blood from the extraction? Or Pepto Bismol?

6) Would the following "IBS" diagnosis then make every single subsequent symptom be tossed into the bottomless pit of "IBS"? Even for years and decades?

7) Could the fecalith or fecaloma or appendicolith be in the appendix for years causing inflammation and healing over and over until the body expulses it? (Expulsion was reported in the 19th century)

8) Wouldn't that obliterate the appendiceal orifice and make it look "small, probably from the surgery" (from a colonoscopy)?

9) Wouldn't the inflammed appendix continue to produce mucus but it now has nowhere to go? Causing sharp pain and eventually leading the appendix to burst and leak into whatever the body has built over the years?

10) Wouldn't this now be completely missed since non-ER doctors and radiologists don't look for this?

11) Isn't the rush to rule out appendicitis unwise considering how easily antibiotics can mask or even treat the symptoms of appendicitis? (Something that's been know since at least 1962)

No clinical guidelines I've seen say to pay attention to coincidence. Antibiotics are frequently prescribed for all sorts of reasons.

Can't a simple coincidence have led doctors to the wrong hasty conclusion and resulted in a life of pain and misery in a hapless individual?

Skeptical Scalpel said...

First of all, I don’t think you ever had pseudomembranous enterocolitis which is caused by Clostridium difficile. The worst thing a doctor could do to treat that problem is to keep a patient on antibiotics, particularly clindamycin.

1. Never say never in medicine. I am sure that somewhere someone on antibiotics has developed acute appendicitis which is difficult to rule out without imaging.

2. I believe it could happen, but you never had pseudomembranous enterocolitis.

3. It might suppress appendicitis if given over the course of 3-5 days.

4. It’s possible.

5. Yes.

6. Unfortunately, some doctors just believe what the previous doctor diagnosed without critically thinking about the problem.

7. Expulsion of a fecalith may have happened in the 19th century, but I don’t know how they would have been able to prove that. Chronic appendicitis is a real thing.

8. Anything is possible, but I have not seen that. Fecaliths almost always show up on plain x-rays and CT scans.

9. Those are complex questions. Many people who have studied appendicitis feel that perforated appendicitis is a different disease than simple appendicitis, and the previously presumed progression of simple appendicitis to perforation may not occur. This is controversial.

10. If your appendix is inflamed or dilated, it would not be missed by radiologists on CT scan.

11. I don’t understand the question. Why wouldn’t you rush to rule out appendicitis? Yes, antibiotics can treat appendicitis, but the recurrence rate is high. Search appendicitis on my blog and you’ll see several posts about that issue.

Korhomme said...

The pain of appendicitis isn't usually severe. There are two "types" of acute (= sudden) appendicitis; a simple inflammation, or a type of 'closed loop' obstruction where there is a faecolith in the appendix. This can be more severe, but it doesn't (usually) resolve by itself. Rather it leads to a rapid rupture of the appendix, and either a generalised peritonitis, or an appendix abscess. Both these problems would be very obvious.

Despite what Skepto says, I am not convinced that chronic appendicitis exists as a real entity.

Was renal colic excluded?

chronicabdopain said...

Let me try another way.
The patient has been admitted to the ER. The symptoms are real, he's on the ground clutching his belly.
Appendicitis is "ruled out", for whatever reason.
The question is, the patient is still there, what are you ruling IN, why, and what is the treatment? Why?

In engineering, we call these situations "corner cases", a perfect storm of several unlikely events happening at the same time. You can not control coincidence.

So what happens?

Skeptical Scalpel said...

Korhomme, you are entitled to your opinion. I have seen patients with recurrent attacks of appendicitis and cured them with surgery.

Chronic, the difference between engineering and medicine is that we are not always able to make a diagnosis at the time someone presents with a problem. In fact, there are cases where a definitive diagnosis is never made. I believe that medical TV shows lead to unrealistic expectations of what doctors can do. On TV, most patients are diagnosed, treated, and recover within the 45 minutes or so that most shows last. In real life, it's not so simple. Engineering is precise and predictable.

Korhomme said...

Skepto, we may be talking of two rather different things. What you describe sounds more like recurrent acute appendicitis. I'm thinking of the chronic abdominal pain, perhaps with exacerbations, that gets labelled as "grumbling appendicitis". To my mind this "diagnosis" is a way of planting a label, perhaps to give people peace of mind. If this resolves after appendicectomy, I wonder if it isn't a placebo effect.

Skeptical Scalpel said...

You may be right. The cases I have seen all had CT scans showing something wrong with the appendix. I would never operate on a patient with just pain an no objective findings and that includes patients sent to me for pain from adhesions.

As the saying goes, "If you operate for pain, you get pain."

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