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Discussion

Appendicitis? Really???

Young person, early 20s, classic presentation of periumbilical pain, onset 3 days ago, localizing to RLQ today.

No fever. No white count. ESR not ordered. Abdominal CT with triple contrast negative. Pt. appears nontoxic.

Doctor admits for appendicitis. What am I missing???? Is the doctor diagnosing on the basis of the symptoms alone, despite negative labs and imaging? Can appendicitis be subclinical in this way?

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    • Admin

    Yep. I've taken out quite a few angry appendixes (sp?) on people with normal labs. WBC high end of normal, but still within range. Appendix not visualized on CT/US. Doc went with gut intuition and took that bad boy out. In the OR, you should see some of these things! One with normal labs had an 8" long appendix that was quite red, but labs still all normal. Don't understand how that one wasn't seen on CT though. I've also had plenty of people with the classic presentation including the out of whack labs whose appendixes looked absolutely normal. Still took them out to be safe and also, hey, we're in there, have permission to do it, at least this way they don't come back with appendicitis some other time.

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    Yep, I have seen quite a few appy's be the real deal even though labs, scans were neg.

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    I read a case report a while back of a fellow who presented similarly, was d/c'd from the ED, and returned later after it ruptured that same day. I can understand a doc's reluctance to get sued like the doc in the above case.

    I am curious what the plan was for the patient--repeat CBC and CT after a little time passed (maybe 4-8 hours?), or just go for it and cut that puppy out?

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    I had a patient scheduled for appendectomy but on assessment I found buboes in both axilla. Told surgeon. He decided to try ABX for 1-2 doses unless she got worse. She got better. Bubonic plaque is seen in southwest Texas, where tot had visited.

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    Triple contrast? It's always fascinated me, how drastically radiology protocols vary from place to place.

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    I had my appendix removed with NO scans before surgery because the doc was so convinced by my symptoms and I did have a high WBC.

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    • Author

    Altra, at my facility, CT scan to r/o appy requires rectal contrast in addition to PO and IV. Seems like overkill to me, but it's what the radiologists want.

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    Altra, at my facility, CT scan to r/o appy requires rectal contrast in addition to PO and IV. Seems like overkill to me, but it's what the radiologists want.
    You are kidding I hope, when I had appendicitis I would have killed someone if they tried to give me rectal contrast oral was bad enough jeez poor people.Rod RN, BSN
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    • Author

    Not kidding. As I said, the radiologists require it. And guess who gets to tell the patient?

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    • Admin

    Boy, I hope I never end up in your ER with the need of an abdominal CT! I'd probably leave AMA and go elsewhere if I was told I was getting triple hit like that! Swallowing that chalky crud is bad enough, adding in rectal? :eek:

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    • Author

    It's only for RLQ/rule out appys.

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