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The Case Files: A Common Condition with an Uncommon Presentation

Bharadwaj, Arjun; Raziuddin, Ahmed, MD

doi: 10.1097/01.EEM.0000544602.26501.61
The Case Files

Mr. Bhardwajis a third-year medical student at the University of Medicine and Health Science, and is currently doing his emergency medicine rotation at Weiss Memorial Hospital in Chicago, IL. Dr. Raziuddinis a board-certified emergency physician and internist at Weiss Memorial Hospital, Gottlieb Memorial (Loyola University) Hospital, and Westlake Hospital in Melrose Park, IL.





A 41-year-old man who recently immigrated from Africa came to the ED with abdominal pain. The patient primarily spoke Tigrinya, and an interpreter was used in taking a history. The patient's abdominal pain had started four hours earlier, which he described as squeezing or cramping mid-epigastric and umbilical pain. The pain did not change or radiate.

He had also had three episodes of nonbloody emesis. This was a new problem for him, and he hadn't encountered anyone sick or with similar symptoms. His last bowel movement was the previous night, and no changes in bowel or urination were noted. He had no fever, chills, chest pain, shortness of breath, weakness, or fatigue. He had leftover food the night before, and he drank lemon juice to calm his stomach that morning. He had no past medical or surgical history but a family history of hypertension on his father's side.

Mild tenderness in the epigastric and umbilical regions, normoactive bowel sounds, fullness in the epigastric region, and no abdominal guarding or rigidity were noted on exam. There was no McBurney's point tenderness, rebound tenderness (Blumberg's sign), Murphy's sign, Rovsing's sign, Dunphy's sign, psoas sign, no percussive tenderness, or obturator sign. The history and physical exam indicated a likelihood of viral gastritis, but other possibilities such as gastroesophageal reflux disease, gastric/intestinal ulcers, pancreatitis, gall bladder-associated disease, intestinal obstruction/volvulus, and appendicitis or appendiceal mucocele cannot be ruled out. CBC, CMP, lipase, and abdominal and pelvic CT with contrast were ordered. Blood work showed a WBC count of 4.6k/μL, neutrophil of 74.0%, hemoglobin of 13.4 g/dL, and hematocrit of 39.0%.

CT found calcified or dense appendicoliths (Image 1) within the proximal appendiceal lumen, with an enlarged appendix that has its tip in the epigastric region. (Image 2.) The appendix was traced to the base, and the pre-ileal orientation of the appendix was shown. (Image 2.) Physical exam was performed again for the appendicitis, but there were no significant findings.



The appendiceal tip located in the epigastric region could explain the epigastric and umbilical pain and tenderness. The presence of appendicoliths can be the cause of appendicitis, but appendiceal mucocele and cancer are also possible. (Int Surg 2012;97[3]:266; Acta Radiol Short Rep 2012;1[9]. doi: 10.1258/arsr.2012.120017.) Laparoscopic appendectomy was performed, and no sign of perforation or abscess was found. The pathologist found the appendix to be 1 cm in diameter and 6 cm in length, with an exudate on the serosa, and diagnosed this patient with acute appendicitis and periappendicitis with full-thickness inflammation. The patient was discharged two days later, stable and relieved of his symptoms.

Appendicitis is one of the most common surgically-treated diseases in the ED. When a patient with abdominal pain arrives, appendicitis should be part of the differential diagnosis and quickly ruled in or out with standard physical examinations. The most common orientations of the appendix are retrocecal, subcecal, post-ileal, and pelvic, with their frequencies at 43.5 percent, 24.4 percent, 14.3 percent, and 9.3 percent, respectively. (J Coloproctol 2015;35[4]:212; ISRN Anat 2014;2014:871048.) Theses represent about 91.5 percent of all the orientations an appendix can have. If the patient has an abnormal orientation (roughly 8.5%), the physical exams will be negative, as seen in this case.

Our patient had mid-epigastric and umbilical pain and tenderness but no other signs on physical exam. The physical exam findings for appendicitis vary based on the orientation of the appendix, as shown in Table 1. (BMJ 2006;333[7567]:530.) Pre-ileal and post-ileal orientations don't have a clear physical exam for the diagnosis, so unless these patients have peritoneal involvement, the diagnosis may be missed. (BMJ 2006;333[7567]:530; Postgrad Med J 1965; 41[471]:2.) Blood work doesn't narrow down the area of inflammation; it only informs us of the presence of an inflammation and its severity. Patients with post-ileal or pre-ileal orientation appendicitis usually have some form of peritoneal involvement due to irritation caused by the appendix.

Most common appendix orientations and the physical exams associated with each type in cases with appendicitis. (BMJ 2006;333[7567]:530; Postgrad Med J 1965; 41[471]:2; Cope's Early Diagnosis of the Acute Abdomen, 21st Edition. New York: Oxford University Press; 2005.)

Forty-one percent of patients develop nonspecific abdominal pain in appendicitis but no focal pain at McBurney's point, which can be easily overlooked. (JAMA 1936;106[9]:665.) This case demonstrated a pre-ileal orientation with the appendix tip located at the epigastric region, which resulted in epigastric pain. With epigastric pain and three episodes of nonbloody emesis less than four hours apart, it would be safe to assume some form of virus or gastritis. If the patient had gone to his primary care physician, he would not have had the CT done and the appendicitis would not have been found.

More than 11 million cases of appendicitis were reported globally in 2015. (Lancet 2016;388[10053]:1545.) Forty-one percent of those would have presented with atypical abdominal pain and 16.7 percent would have had a negative physical exam due to pre-ileal and post-ileal orientations, amounting to roughly 6.8 percent of all cases or 794,252 cases in 2015. (JAMA 1936;106[9]:665; J Coloproctol 2015;35[4]:212; ISRN Anat 2014;2014:871048.) These cases resolve on their own or perforate. (Radiology 2000;215[2]:349.) With perforation, they would be sent straight to the ED due to severe abdominal pain, abdominal rigidity, nausea, vomiting, and fever. Depending on the severity of the symptoms, the patient would get an abdominal and pelvic CT. Complications of perforated v. nonperforated appendix can affect the patient's outcome, and it would be better to catch appendicitis early on.

When a patient presents to the ED with abdominal pain, keep in mind the possibility of atypical presentations of appendicitis until they are ruled out. To narrow down the deferential diagnosis, CT scan is the preferred method.

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