Volume 4, Case 9"
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children"
University of Hawaiʻi John A. Burns School of Medicine
This is a 10-year old male presenting to the E.D. with a history of abdominal pain for two days. He describes the pain mostly in his periumbilical region. The pain is clearly worse today. He has no vomiting or diarrhea. His appetite is poor and he is not able to ambulate well due to pain. There is no history of fever. There is no history of coughing, chest pain, or dysuria. His past history is significant for asthma.
Exam: VS T37.4 (tympanic), P92, R16, BP 120/62. He is alert, not toxic, resting comfortably. His hydration is good. Heart regular without murmurs. Lungs clear. Abdomen is flat and generally soft. There is mild guarding and tenderness mostly over the periumbilical region. Bowel sounds are absent. No hernias are evident. Observing his gait, he ambulates slowly in a bent forward position. He refuses to jump. Asking him to cough results in moderately severe abdominal pain. A rectal exam does not yield any localizing signs.
Laboratory studies: CBC WBC 14,500, 81% segs, 2% bands, 8% lymphs, 6% monos, 3% atypical lymphs, Hgb. 14.3, Hct. 43.0, platelet count 344,000. Urinalysis SG 1.030, trace protein, otherwise negative.
An abdominal series is obtained.
View abdominal series: Flat (supine) view.
View upright view.
Given the patient's clinical findings, consider the differential diagnosis at this point and what we should be most interested in, in examining these radiographs. For example, an obstruction is not likely given the absence of previous abdominal surgery, the absence of vomiting, the flat abdominal contour, and no clinical evidence of an incarcerated hernia. Appendicitis is a consideration given the peritoneal signs exhibited, the patient's gait suggesting peritonitis, his anorexia, and modest leukocytosis. His pain and tenderness are not in the right lower quadrant. However, the absence of this cannot reliably exclude appendicitis.
These films are dark; making the lateral edges of the abdomen difficult to view. The gas distribution shows gas and feces throughout the colon. However, the ascending colon is displaced medially. It appears to be separated from the right flank, raising the possibility of a mass lateral to the colon. There is no bowel dilation and no air fluid levels. No fecolith is seen. No free air is evident.
An abdominal ultrasound is performed. There is evidence of a fluid and gas-containing structure adjacent to the umbilicus consistent with an ectopic appendicitis or a Meckel's diverticulitis.
An exploratory laparotomy is performed. An acutely inflamed Meckel's diverticulum is noted. This is resected. His appendix is normal. He is placed on antibiotics post-operatively, and he recovers uneventfully.
The radiographic findings of appendicitis are highly variable. This is discussed in some detail in Case 19 of Volume 3, Abdominal Pain and the Peritoneal Fat Margins. This case specifically discusses the significance of the peritoneal fat margins. Usually, the bowel is close to the peritoneal fat margins bilaterally, but in this current case, the bowel is displaced far from the right peritoneal fat margin displaying a mass effect.
These radiographs were too dark for the scanner to pick-up the peritoneal fat margins on the image displayed here. However, since this case is extreme, it is evident that the ascending colon is being displaced medially. Often this displacement of the bowel away from the peritoneal fat margin can be subtle. Although this patient's diagnosis is an unusual one, the general principles of identifying a patient requiring prompt abdominal surgery still apply.