The Medico-Legal Advisor ®
FAILURE TO DIAGNOSE APPENDICITISAppendicitis is the most common acute surgical problem of the abdomen, but its early diagnosis and treatment is one of the most commonly mishandled situations in medicine. More than 200,000 cases of appendicitis occur in the United States per year. It occurs most commonly in the second and third decades of life. Diagnosis of this illness is still largely based on clinical findings. It is usually well recognized and appropriately treated surgically. Accurate diagnosis of acute appendicitis is fairly uniform across the country averaging 80 to 85 percent of all cases. Most patients have well recognized symptoms of abdominal tenderness, localizing to the right lower quadrant, over several hours, mild fever and almost always, lack of appetite. Nausea and vomiting occur about 75 percent of the time. Almost 95 percent of the time the patient follows a familiar course of anorexia (loss of appetite), abdominal pain, nausea and vomiting. The abdomen frequently exhibits a characteristic called "rebound tenderness." This implies irritation of the peritoneum (intestinal lining) and is demonstrated by tenderness with downward pressure on the abdomen which sharply increases with sudden release of pressure on the abdomen. Negative laparotomies for appendicitis still occur at a 15 to 20 percent rate; and there are studies which state that rates of less than 15 percent should cause the physicians to wonder if they are missing cases of acute appendicitis. We believe that a rate of negative explorations under 10 percent is more appropriate. Appendicitis occurs equally in males and females up to the age of puberty. Then the ratio changes to almost 2:1, male:female, from age 15 to 25. This gradually equalizes by the sixth decade. It is rare and poorly diagnosed in the very young and the very old. Times of high risk for a delay in diagnosis include pregnancy and the post operative period following another operation. Obstruction of the lumen of the appendix is the dominant factor in appendicitis whether by fecalith, vegetable or fruit seeds, or intestinal worms. Laboratory findings generally show a moderate elevation of the white blood cell count from 10,000 to 18,000. Elevations greater than 18,000 indicate that perforation has occurred or some other inflammatory process is ongoing. Urine examination is usually normal. X-ray studies of the chest can be done to rule out pneumonia and plueral effusions which can mimic an acute abdomen. Anatomical variations can further mask symptoms of appendicitis. With a very long appendix or an appendix lying behind the colon tenderness may occur in the flank or around the rectum if it protrudes into the pelvis. Malrotation of the intestines may give left sided tenderness or even right upper quadrant tenderness. Barium enema is a useful diagnostic tool in difficult cases because an obstructed appendix will not fill. Preschool age children, the very old, mentally retarded, immunocompromised (to avoid unnecessary surgery), teenage girls with right lower quadrant pain, and pregnant females represent tough challenges in the diagnosis of acute appendicitis and experience higher frequency of rupture. Since rupture rates in children are much higher than in adults, the physician must strongly suspect appendicitis when abdominal complaints are voiced in that age group. In women with abdominal pain, the differential diagnosis must include ovarian disease, tubal pregnancy, pelvic inflammatory disease (PID) and uterine masses as well as appendicitis. Pelvic ultrasound exam can be very helpful. Significant differences in physical findings separate PID from appendicitis, PID being much more likely in patients with: 1) prior venereal disease, 2) generalized abdominal guarding and pain, 3) tenderness with motion of the cervix, and 4) tenderness immediately adjacent to the uterus. There is also a significant difference between the time of onset of symptoms and the presentation to a physician. The median time of onset of symptoms for appendicitis is 21 hours. The median time of onset of symptoms for PID is 48 hours. Diagnostic errors often result and diagnosis is delayed when: (1) The family practitioner or pediatrician observes symptoms but does not consult a surgeon immediately. (2) The patient is sent home with vague signs and inadequate instructions. (3) Atypical signs and sypmtoms occur and appropriate diagnostic studies are not done. (4) There is failure to do rectal and or vaginal exams. (5) Obvious signs and symptoms are overlooked. Prolonged morbidity and increased mortality are the resultant factors of either delayed diagnosis or intra or post-operative errors, though in this day with modern antibiotics, long term damage is relatively infrequent and minor, even in advanced cases of perforation and peritonitis. Intraoperative errors include: 1) failure to drain a perforated appendix, 2) failure to culture peritoneal fluid, 3) failure to explore nearby bowel for inflammation or diverticuli, 4) failure to isolate the appendix from the wound while amputating it, and 5) failure to assure adequate hemostasis. Post-operative complications are much more frequent following perforation and include: 1) wound infection 2) peritonitis 3) paralytic ileus 4) bowel obstruction 5) adhesions Antibiotics, usually a cephalosporin, are used preoperatively and intraoperatively once the diagnosis of appendicitis seems likely. In rupture or gangrene of the appendix, coverage should include antibiotics with wide range spectrum of aerobic and anerobic organisms. Generally an aminoglycoside is added to the antibiotic regime. Post-operative errors: In cases where rupture of the appendix has occurred or where the patient has had sufficient sepsis to cause a problem, antibiotic coverage is a frequent source of error. This may be due to lack of cultures or general misunderstanding about the use of antibiotics. Since removal of the appendix involves creating an opening into the cecum (a portion of the large bowel), antibiotic coverage must be sufficient to cover the wide variety of organisms found within the colon. Delays are frequently seen in the treatment of complications from appendectomy. Most of these involve the delayed recognition of abscesses of sepsis. One of the most devastating complications is that of pelvic thrombophlebitis which is frequently associated with bactericides sepsis. This can result in septic emboli and death if not promptly and appropriately treated. The overall mortality rate for acute appendicitis is extremely low (less than 0.5 percent) and rises to approximately 1.5 percent in those cases where perforation occurs prior to operation. Superficial wound abscesses are the most frequent and less troublesome complication of appendicitis and while such measures as leaving the wound open or thoroughly draining the soft tissues of the abdominal wall may prevent many of these infections, the rate may be as high as 30 percent if perforation has occurred. In short, appendicitis, though a common surgical problem, is usually well managed and early diagnosed. Problems occur most often with a "wait and see" approach, non-use of appropriate diagnostic aids in equivocal findings or compromised patients, inappropriate referral, and inappropriate antibiotic coverage. |