tag:blogger.com,1999:blog-4968787219619380438.post4158111784267893558..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Perforated appendix not seen on CT scanSkeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger24125tag:blogger.com,1999:blog-4968787219619380438.post-72076682095632363902021-02-14T14:34:55.075-05:002021-02-14T14:34:55.075-05:00I wonder why she wasn't admitted at the time o...I wonder why she wasn't admitted at the time of the first ED visit. Three liters of ascites is a lot. Add the anemia and it sounds like something is seriously wrong. Yo did not say how old your daughter is, whether she has any significant past medical history, or if she had other symptoms besides pain such as weight loss, nausea, vomiting etc. I don't think it is appendicitis. I hope she recovers. Good luck.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-38386756477517684502021-02-14T10:21:03.647-05:002021-02-14T10:21:03.647-05:00My daughter presented to ED with severe RUQ/RLQ pa...My daughter presented to ED with severe RUQ/RLQ pain,distended Abdomen,fever,high platlet,platelet, hgb,low hematocrit,severe Anemia. Helical CT performed which revealed Ascites in all 4 quadrants,all organs were unremarkable(Appendix was not included/mentioned on report?) She was discharged from ED. She returned to ED 7 days later,was admitted. (Prior to admission Gynecologist prescribed profilacti AB while awaiting STD lab results). Upon admission a Parasyntesis was performed removing 3 liters of fluid. To be continued as this case is ridiculously lengthy to the tune of 3 weeks.Anonymoushttps://www.blogger.com/profile/10702329629424218252noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-24912790816581637322020-02-01T17:20:26.793-05:002020-02-01T17:20:26.793-05:00Noooologic, I can't say for sure whether you w...Noooologic, I can't say for sure whether you were treated wrongly or not. A CT scan is very good at identifying constipation. You didn't say anything about that finding. As you probably know, all that morphine and Percocet you take gives you a 100% chance of having constipation. I suggest you obtain a copy of your record and a CD-ROM of your CT scan and see another doctor. I am sorry I can't be more helpful.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-80075199390969922932020-01-31T14:19:25.259-05:002020-01-31T14:19:25.259-05:00Iam a 59yr female. Who presented herself to the ER...Iam a 59yr female. Who presented herself to the ER with extremely high levels of sharp stabbing pains in my lower left abdomen. This had been getting steadily worse over the course of a month. I blamed being on 60mgs morphine 10/325 percocet X 3 per day. 450mgs of gabapentin and 750mgs robaxin all 3xper day. I explained this clearly to the er dr.that I had continuous problems with constipation. I also clearly expressed that being so medicated that I was not experiencing the pain at a level I could explain. A CT was done with no appendix showing up. I have not had it removed. They did a blood test and also a complete drug screening that tested me positive for PCP. I finally left the er after 12hrs. The closing comments indicated that I was not willing to wait and requested to go home back to my "usual supply" of narcotics. Iam still in excruciating pain. Though it hits in more muted waves due to my medications. Which are prescribed to me for sciatica, a failed lumbar fusion, and also for extremely painful nerve damage that starts at my cervical fusion and extends down both arms to first 2 fingers each hand. Was I treated wrongly? I'm really worried. But refuse to go back to my local ernoooologichttps://www.blogger.com/profile/10767907241349803904noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34540853850176841082018-02-22T21:18:35.131-05:002018-02-22T21:18:35.131-05:00Careful, y'all, there is a MeToo movement goin...Careful, y'all, there is a MeToo movement going on. artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-8163069458166537042018-02-22T14:48:14.583-05:002018-02-22T14:48:14.583-05:00Anon, well put.Anon, well put.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-32991873113626086362018-02-22T14:12:27.908-05:002018-02-22T14:12:27.908-05:00You can't understand two things completely ent...You can't understand two things completely entire your life, no matter how experienced you are: women and presentation of Appendicitis. CheersAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-39677350956423509722018-02-22T11:55:56.067-05:002018-02-22T11:55:56.067-05:00Artiger, as you know, appendicitis presents in man...Artiger, as you know, appendicitis presents in many forms. A lawyer once said to me, "Why do you surgeons have so much trouble diagnosing appendicitis?" He had read about it and it seemed so simple to him. I replied, "The patients don't read the book."Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-5428208251078660612018-02-22T11:19:10.289-05:002018-02-22T11:19:10.289-05:00Scalpel, there will still be proponents of antibio...Scalpel, there will still be proponents of antibiotic treatment of appendicitis, and those of us on the surgical side will still point to higher success rates and definitive treatment with surgery (especially laparoscopic). If all patients with appendicitis were informed of this case as a possible outcome (without surgical intervention), I wonder how many would still choose to avoid surgery. <br /><br />I had a case a year or so ago that was a little similar, except the patient had a CT scan that showed a phlegmonous process in the lower central abdomen, and she had been somewhat ill off and on for a while. It was initially thought to be advanced diverticulitis, and when a F/U scan a few days later looked a little worse, I saw her, and we decided to proceed with laparotomy, where a ruptured appendix was found, with sigmoid colon and small bowel surrounding it. Nothing on CT ever suggested a ruptured appendix. It does happen. <br />artigerhttps://www.blogger.com/profile/13361655152970244221noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-5369611529192647832018-02-22T10:03:29.474-05:002018-02-22T10:03:29.474-05:00Anonymous, thank you for your input. The case took...Anonymous, thank you for your input. The case took place in the US. I agree a CT scan early in the course of this illness would have saved the patient a lot of trouble, and I agree that too much has been made of potential radiation exposure from CT scans. Instead of one diagnostic CT scan in the beginning, this patient has had several.<br /><br />In 2016, a radiologist and I blogged about some misconceptions regarding radiation and CT scanning. Here is the link to that post http://skepticalscalpel.blogspot.com/2016/06/irrational-fear-of-ct-scans-in.html<br /><br />I also agree that appendicitis is a surgical disease as this case clearly illustrates.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-52841458593922921502018-02-21T16:58:54.372-05:002018-02-21T16:58:54.372-05:00This scenario is not unheard of. In fact, quite ty...This scenario is not unheard of. In fact, quite typical of the complications of an untreated ruptured appendicitis. I assume the writer resides in England or Canada (based on reference of family doctor as GP). An otherwise healthy woman with appendicitis that subsequently ruptured. Her own body was able to walled off the inflammation and subsequently it turned into a phlegmon and then an abscess. This chronic inflammation was not bad enough to cause her to be seriously ill, but just indolent enough to cause generalized malaise. It also would explain the elevated white count (a self-limited inflammatory process/abscess on the way to spontaneous resolution would have had a "normal" white count).<br /><br />For some unknown reason her body was subsequently not able to "contain" the inflammation and led to the first ED visit, where the CT scan found an abscess. At this stage it would be AMAZING to find a ruptured appendix as often time its simply obliterated. This said abscess was drained by IR, treated with antibiotics and bowel rest (appropriate treatment given lack of generalized peritonitis). Sounds like she did not respond well to this conservative management and therefore required open surgery, where the definitive diagnosis of ruptured appendicitis was finally made. As part of the surgery a typical thorough washout of the peritoneal cavity was done. For a class 4 contaminated case like that, it's no surprise she developed subsequent pelvic and likely interloop bowel abscess. These again required drainage by IR. Patient is actually fortunate that they are able to technically do so.<br /><br />My own observations:<br /><br />-A simple CT scan upfront by the family doctor/GP would have shaved much time off the diagnosis of abscess and allowed earlier treatment. Is this a case of over-aversion to CT scans for financial/radiation-exposure/old-school-over-reliance-on-physical-exam-syndrome?<br /><br />-cases and complications like this affirms my belief that acute appendicitis IS a surgical disease, definitively addressed by appendectomy (as opposed to antibiotic medical therapy that's currently in vogue)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-46092894008461470632018-02-21T08:25:30.621-05:002018-02-21T08:25:30.621-05:00ROBERT, I didn't say I thought the CBC would h...ROBERT, I didn't say I thought the CBC would have been normal. I said an elevated WBC does not necessarily mean the patient has appendicitis What other investigation would have been done?<br /><br />Antonio. I hope you are doing well in Venezuela. I know things are difficult there.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-34011475240140146662018-02-20T18:07:46.533-05:002018-02-20T18:07:46.533-05:00im not saying that CT scans are over rated, in fac...im not saying that CT scans are over rated, in fact they have change the way of doing medicine... all im saying is that i've seen a lot of practicians depending too much on ct scans, MRI and ultrasound. just yesterday i was oncall... i want to share this case with you:<br /><br />its about a 34 years old females, 24 hours of abdominal pain on the upper right cuadrant, an ultrasound was made and found gallstones, so she was treated as a biliary colic... white blood cells 15.8 gran% 85 ... tenderness was present , fever and nausea... neither of those related to a biliary colic... cholecystitis probably?? no murphy on the physical exam. one thing that caught my atention was that the tenderness also was present in the right lower cuadrant... we decided to go to the operating room... a flegmonouse appendix retrocecal subhepatic... <br /><br />this cases are very interesting, and thanks for sharing on your blog doctor.. ima big fan!! <br /><br />cheers from venezuela!Anonymoushttps://www.blogger.com/profile/03817616139461143194noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-87081461487766495172018-02-20T15:54:48.440-05:002018-02-20T15:54:48.440-05:00I agree that physical exam may not have been impre...I agree that physical exam may not have been impressive, but also probably not normal. It would *probably* have shown more than what one would expect with the proffered diagnosis of gluten sensitivity. I agree the CBC is not a great tool here, but do you really think it would have been normal if the appendix was indeed perforated at that first visit, as it seems like it was? How often is the CBC normal in a perforated appendix? If the exam were somewhat abnormal and the CBC even slightly abnormal I expect a bit more investigation might have been done. But we'll never know. RobertL39noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-46040896948052037242018-02-20T14:57:28.344-05:002018-02-20T14:57:28.344-05:00Antonio, I saw your tweet. Here's how I respon...Antonio, I saw your tweet. Here's how I responded:<br /><br />I'm sorry, but I must disagree. I was trained in the era before CT scans and ultrasounds were invented or routinely used. We misdiagnosed perforated appendicitis back then too, probably more often than we do now.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-28754854387602563712018-02-20T14:54:44.359-05:002018-02-20T14:54:44.359-05:00I do not believe she was given antibiotics before ...I do not believe she was given antibiotics before she was admitted to the hospital.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-26531488348560567132018-02-20T14:53:53.537-05:002018-02-20T14:53:53.537-05:00as i tweeted yoour post... it is very diffcult for...as i tweeted yoour post... it is very diffcult for this to happen, if we only trust our hands, rather than a CT scan to solve a diagnosis. a perforated appendix has unequivocal symptoms at the physical exam, they are well described in the literature, some cases yes, are very difficult to diagnose... but ultimately a late diagnosis cant explain how a surgeon can miss a "surgical abdomen" Anonymoushttps://www.blogger.com/profile/03817616139461143194noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-6872272797975649172018-02-20T14:42:54.559-05:002018-02-20T14:42:54.559-05:00Another question — and if I seem to be hogging the...Another question — and if I seem to be hogging the comments, my apologies. There is no reference to antibiotics before the patient was in hospital. Do we know whether any were prescribed in this time?Korhommehttps://www.blogger.com/profile/02290764661952746389noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-22460432050699483492018-02-20T13:19:50.411-05:002018-02-20T13:19:50.411-05:00Thanks for the explanation. If anyone is still rea...Thanks for the explanation. If anyone is still reading books, the 22nd edition of Cope's "Early Diagnosis of the Acute Abdomen" (2010) is still being sold [https://www.amazon.com/Copes-Early-Diagnosis-Acute-Abdomen/dp/0199730458/].Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-48112745022589308012018-02-20T12:58:27.531-05:002018-02-20T12:58:27.531-05:00As you know, Skepto, I'm a fan of Zachary Cope...As you know, Skepto, I'm a fan of Zachary Cope and his book on the Acute Abdomen. He describes, IIRC, the seven positions of the appendix. While we're all familiar with the "typical" presentation, some of the other positions do modify the symptoms and the signs. A retro-ileal appendix is associated with more vomiting than is "usual"; both it and a retro-caecal appendix may not show much in the way of local tenderness which is the 'cardinal' sign of appendicitis.<br /><br />I was wondering if this patient had had a pelvic appendix. Here, back in the day, as this was associated with vomiting and diarrhoea, such patients were then admitted to a 'fever hospital' with suspected gastroenteritis. It was only when they developed peritonism, rising up from the pelvis, that the penny dropped. There is no abdominal tenderness in early pelvic appendicitis; the local tenderness is found on rectal examination. But you know that; alas, I suspect that our juniors, more used to 'scan first, think later' don't.Korhommehttps://www.blogger.com/profile/02290764661952746389noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-36027745885084916712018-02-20T12:32:50.287-05:002018-02-20T12:32:50.287-05:00Good points. I don't know what the physical ex...Good points. I don't know what the physical exam, if it was done, showed. If, as Korhomme implies, the appendix was retrocecal, physical exam may not have been impressive. I'm not a fan of CBCs for this diagnosis.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-51893760868192998892018-02-20T11:38:32.609-05:002018-02-20T11:38:32.609-05:00Where are the physical exam results??? Was the min...Where are the physical exam results??? Was the minimal lab testing initially done informed by a decent abdominal exam, or just by the history? One would think, but obviously not know for sure, that a decent abdominal palpation would have disclosed an obvious problem early on, one which merited a CBC at the very least, perhaps a CRP, and perhaps further evaluation. "Never returned to normal" "intermittent stomach upset and weight loss" should have led to a more comprehensive evaluation than 'antibody tests'. Is this another story of too much attention to data and not enough to the patient? RobertL39noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-54451036496710974412018-02-19T19:44:59.139-05:002018-02-19T19:44:59.139-05:00Good question. I do not have that information. Good question. I do not have that information. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-91118744583376417462018-02-19T17:17:23.171-05:002018-02-19T17:17:23.171-05:00Do we know the position of the appendix in this ca...Do we know the position of the appendix in this case?Korhommehttps://www.blogger.com/profile/02290764661952746389noreply@blogger.com