Hot Seat #144: A tale of two appys

Posted on: January 20, 2020, by :


Patient #1 (AB): 10 y/o M with lower abdominal pain x1 day.  +anorexia, afebrile, no vomiting and no diarrhea. Sent by OSH for US to rule out appy.

Exam– abdomen soft,  Non distended.  TTP with mild left> mild lower quadrant and suprapubic tenderness to palpation. GU normal.

Patient #2 (CD): 10 y/o M with lower abdominal pain x1 day, right more than left. +anorexia, afebrile, no diarrhea. NBNB emesis x3. Sent by OSH for acute appendicitis- OSH US showed 0.6 cm, non-compressible appendix.

Exam- abdomen soft,  Non distended.  TTP  right> left lower quadrant. tenderness to palpation.  No rebound or guarding. GU normal.

Question 1 AB

Question 1 CD

You obtain an ultrasound to evaluate for appendicitis, but hold on obtaining labwork pending ultrasound for both patients:

AB appy ultrasound:  Noncompressible appendix upper limits of normal in size (0.6cm). No focal fluid collection or lymphadenopathy. Findings may represent early appendicitis in the correct clinical setting. 2. Bladder debris which may represent stasis versus infectious etiology.

CD appy ultrasound: normal appendix, 0.5 cm and no secondary signs. 

Question 2 AB

Question 2 CD

You decide to obtain labs and consult surgery on both cases.

AB: Labs show: UA not suggestive of infection. After seeing AB, surgery recommends starting antibiotics for acute appendicitis and will take to OR for lap appy.

CD: Labs show: WBC: 14.3, segs: 73%, no bands. CMP normal, UA not suggestive of infection. After seeing CD, surgery recommends starting antibiotics for acute appendicitis and will take to OR for lap appy based on clinical suspicion.

Both patients in the ED for prolonged time awaiting surgical intervention  given time of day, volume and acuity. Repeat abdominal exams and course:

AB: Afebrile, vitals stable.  improved pain s/p ibuprofen only.  No TTP on abdominal exam, can jump without pain.  Asking for food.  Surgery team is planning on taking to the OR within the hour.

CD: Afebrile, vitals stable. Received ibuprofen and morphine. sleeping but when arouses, continues to have abdominal pain, right and middle of abdomen. No rebound, no guarding. Negative psoas, negative obturator. GU normal. Can jump without pain.  Asking for food. Surgery team is planning on taking to the OR within the hour.



Question 3 AB

Question 3 CD

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Nichole McCollum

After spending the majority of my life in Georgia, I moved to DC.I spent my first two years at CNMC as an associate in the ED before starting fellowship this year. My husband and I have a feisty and dramatic rescue furchild name Cain who rules our house. I enjoy good food- cooking, eating/searching for the best DC restaurants, traveling, being active and watching college football in the fall (go dawgs!).My research interests include QI, asthma and febrile infants.

Latest posts by Nichole McCollum (see all)

1 thought on “Hot Seat #144: A tale of two appys


  1. The uncertainty from these cases highlights a real problem in the way we now practice pediatric emergency medicine— CTpenia from a real fear of obtaining CT scans! In my mind, if there is uncertainty left after obtaining an ultrasound, that patient gets a CT scan. Test characteristics (sensitivity, specificity, LR) for the diagnosis of acute appendicitis are much better with CT than US.

Leave a Reply

Your email address will not be published. Required fields are marked *