Hot Seat #144: Denouement

Posted on: January 30, 2020, by :

Recap: 10yo boys both presenting with acute onset of abdominal pain, anorexia (+/- vomiting), found to have lower quadrant abdominal pain on exam and equivocal ultrasounds (and clinical courses).

Here’s how you answered:

Question 1 AB

Question 1 CD

Question 2 AB

Question 2 CD

Question 3 AB

Question 3 CD

Denouement:

AB: had not yet received antibiotics. POCUS team around, obtain US: no visualization of the appendix but mesenteric adenopathy, hyperactive bowels. Notably, there was no pain with ultrasound.  With this information, team decides to repeat comprehensive US which shows same size but compressible appendix without any secondary signs of appendicitis. Discussed US findings with radiology and surgery attendings. Decision to PO challenge, which patient tolerated without worsening symptoms. He was ultimately discharged home with strict return precautions. Did not return to ED.

CD: received antibiotics. Discussed with radiology attending who agrees structure visualized is indeed appendix and is normal. Discussed with surgical attending who is certain this is early appendicitis, based off clinical picture/exam, laboratory findings. Taken to OR, appendix described in op report as: “torturous and dilated.” Path report details (among other things): “hyperemic and shaggy mucosa and mesoappendix; fecalith containing hemorrhagic fecal material.” Patient had an uncomplicated post-op course and was ultimately discharged home.

For those of you wishing to read more, here is an article on pathological criteria and negative appendectomy rates. Additionally, here is one on use of clinical and sonographic data in diagnosing appendicitis, and finally a meta-analysis on diagnostic accuracy of multiple imaging modalities in acute appendicitis.

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.

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