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Appendicitis: Abdominal Pain
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Although whether chronic appendicitis exists is controversial, most surgeons have managed patients with chronic abdominal pain that resolved with appendectomy. In some cases, patients have noted intermittent right lower abdominal pain and, in fact, the appendix which is subsequently removed has chronic changes consistent with bouts of appendicitis. Some surgeons have suggested that when the appendix does not fill or only partially fills with barium during a barium enema or when barium does not drain from the appendix after a few days following a barium enema, suggests that chronic appendicitis may be present. Laparoscopy with appendectomy has provided a means for evaluating the appendix in the child with persistent lower abdominal pain.
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Except for trapped hernias, appendicitis is the most common cause of sudden, severe abdominal pain and abdominal surgery in the United States. Over 5% of the population develops appendicitis at some point. Appendicitis most commonly occurs in the teens and 20s but may occur at any age.
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The surgeon's goals are to evaluate a relatively small population of patients referred for suspected appendicitis and to minimize the negative appendectomy rate without increasing the incidence of perforation. The emergency physician must evaluate the larger group of patients who present to the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the diagnosis in a time-, cost-, and consultation-efficient manner.
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Abdominal pain is the most common symptom of appendicitis.3 In multiple studies,3-5 specific characteristics of the abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis (Table 1). A thorough review of the history of the abdominal pain and of the patient's recent genitourinary, gynecologic and pulmonary history should be obtained.
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It is important to realize that not all surgical explorations for appendicitis reveal an abnormal appendix. Approximately 10-15% of operations for suspected appendicitis reveal either no obvious abnormality, or a disease process other than appendicitis. This relatively high rate of "negative appendectomies" is tolerated because the consequences of not diagnosing appendicitis in patients with abdominal pain can be severe and sometimes life-threatening.
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There are no specific tests for appendicitis, but blood tests (such as a white blood cell count) and x-rays may help a physician make a diagnosis. Abdominal ultrasound has proven to be useful in differentiating causes of abdominal pain.
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Abdominal Pain