Treatment injury case study
March 2012 – Issue 42
Sharing information to enhance patient safety
Delay in diagnosis of
appendicitis
EVENT: Perforated appendix and
peritonitis
INJURY: Case Study
Michaela, a 19-year-old hospitality worker, saw her GP for lower abdominal
pain that had been getting worse during the previous week.
She was normally healthy, and the only medication she
took was a contraceptive pill.
The GP initially diagnosed a urinary tract infection and
prescribed an antibiotic, but Michaela returned two days
later with worsening abdominal pain, diarrhoea, vomiting
and fever. An examination found a raised temperature,
right iliac fossa tenderness with rebound and a positive
Rovsing’s sign (pain in the right lower quadrant elicited
by palpating the left). The GP suspected appendicitis, so
referred Michaela to the local emergency department (ED)
and gave her a letter detailing events so far.
Michaela was seen by a doctor in the ED, who recorded
a slightly different history. He noted the abdominal pain
to be “spasmodic” and was more focused on Michaela’s
persistent watery diarrhoea. The examination found
a temperature of 37.8°C, dehydration and abdominal
tenderness throughout, but no more specific findings
were recorded.
Key points
• The most important sign of appendicitis
is localised tenderness in the right lower
quadrant, but the classical symptoms and
signs are only seen in 60% of patients
• Diarrhoea may be a prominent symptom
in (some) patients with acute appendicitis
• Distinguishing appendicitis from
gastroenteritis can be a diagnostic
challenge; the MANTRELS score can be
useful in judging the risk of appendicitis
• There is no single diagnostic test to
confirm appendicitis, but ultrasound or
abdominal CT may be useful
• If the diagnosis of abdominal pain is
unclear, appendicitis must be considered.
Observation and serial abdominal
examinations may assist.
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Michaela was given intravenous fluids, an antiemetic
and analgesia, and blood tests were taken. These
blood tests showed a very high white cell count (37.1 x
109/L with left shift), but no comment was made in the
clinical record about the significance of this. The doctor’s
impression was of gastroenteritis, and as she appeared
to be stabilising, Michaela was soon discharged.
The following day Michaela came back to her GP very
unwell. She had a temperature of 39.1°C, constant
abdominal pain with tenderness and guarding. Her GP
again referred her immediately to hospital.
That evening Michaela had an open appendicectomy and
drainage. The appendix was found to be gangrenous and
perforated. Her recovery was complicated with multiple
intra-abdominal collections, pleural effusions and persisting
abdominal pain. Owing to these complications she was
transferred to a tertiary hospital where she had several
returns to theatre for abdominal washout and drainage.
A treatment injury claim was lodged for a delay in
diagnosis of appendicitis at the ED, leading to perforation
and recurrent intra-abdominal infections. ACC received
advice from an emergency physician and a general
surgeon, who agreed that the ED doctor should not have
disregarded the GP’s findings and the very high white cell
count. As a result, further observation and investigation
had been warranted at the first presentation. This would
have likely led to earlier surgery, preventing perforation
of the appendix and the subsequent peritonitis, so the
claim was accepted. ACC was able to assist Michaela
with her recovery and gradual return to work.
Expert Commentary
Mr Kenneth W Menzies MBBS FRCS FRACS
This case highlights the difficulties that can occur in the
diagnosis of acute appendicitis.
Symptoms of appendicitis overlap considerably with
other clinical conditions that include gastroenteritis,
urinary tract infection and (in the female) pelvic
inflammatory disease.
The main symptom of appendicitis is abdominal pain.
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Case study
Typically the pain is initially in the peri-umbilical region
and it is colicky in nature. This is a visceral pain that is due
to distension of the appendix. After a period of some hours
the pain shifts to the right iliac fossa where the inflamed
appendix irritates the parietal peritoneum. This is a
constant pain that is aggravated by movement.
Accompanying symptoms include anorexia, nausea and
vomiting. When vomiting occurs in appendicitis, it follows
the onset of pain.
Examination findings include mild tachycardia and lowgrade fever (i.e. approximately 37.5°C) in the early stages.
When the pathology progresses, as in the case of Michaela,
the temperature can increase up to 39°C.
The most important sign is localised tenderness in the right
lower quadrant of the abdomen. This is usually accompanied
by involuntary muscle rigidity (guarding) in that region.
Unfortunately this classical constellation of symptoms and
signs is only seen in approximately 60% of patients with
appendicitis.
The principal clinical manifestation of gastroenteritis
is diarrhoea. The World Health Organization defines
gastroenteritis as three or more abnormally loose or fluid
stools in a 24-hour period.
Abdominal pain is common in gastroenteritis and is most
often described as “diffuse, intermittent, colicky pain”
situated centrally in the abdomen. Vomiting may be
present, particularly early in the illness.
On clinical examination of the abdomen there may be some
general abdominal tenderness.
Diarrhoea can be a significant symptom in a minority of
patients with appendicitis. Diarrhoea is more likely when
the inflamed appendix is post-ileal or situated in the pelvis.
As in the case of Michaela, when a patient presents
with abdominal pain and diarrhoea, the ED physician
often diagnoses gastroenteritis and initiates treatment
appropriate for gastroenteritis. If at this stage the patient is
discharged home, there is likely to be a delay in the surgical
treatment of appendicitis being performed, and this in turn
results in a higher incidence of postoperative complications.
An increase in the white cell count (and neutrophilia) is
present in 80% of patients presenting with appendicitis,
whereas this is much less likely in gastroenteritis.
Michaela’s white cell count was markedly elevated.
Ultrasound may be helpful in the diagnosis of acute
appendicitis, but it is quite often operator dependent.
Likewise abdominal CT has a high sensitivity and specificity
in diagnosing appendicitis.
However, there is no single diagnostic test that can
accurately diagnose appendicitis in all cases.
Uncomplicated gastroenteritis is extremely unlikely if the
abdominal examination reveals localised tenderness or
signs of peritoneal irritation. Guarding may be difficult to
elicit in the obese.
The most useful clinical tools in assessing acute
appendicitis are still: a good history and physical
examination, serial abdominal examinations, and a high
index of suspicion. A study from Hong Kong (1) shows that
discharge at the first visit to an ED is the most significant
factor associated with advanced-stage appendicitis and
postoperative complications.
The MANTRELS (Alvarado) clinical diagnostic score
(migration of abdominal pain to the right iliac fossa,
anorexia, nausea/vomiting, tenderness in the right
iliac fossa, rebound tenderness, elevated temperature,
leukocystosis and shift of leukocytes to the left) can be
useful in the diagnosis of appendicitis.
When the cause of abdominal pain is uncertain, acute
appendicitis should be considered. Serial abdominal
examinations will help to clarify the situation.
References
1. Chung CH, Ng CP, Lai KK. Delays by patients, emergency physicians and
surgeons in the management of acute appendicitis: retrospective study. HKMJ
2000 Sep; 6(3):245-9
2. Cappendijk VC, Hazebroek FWJ. The impact of diagnostic delay on the course of
acute appendicitis. Arch Dis Child 2000; 83:64-66
3. Cameron P, Jelinek G, Kelly AM et al. Textbook of adult emergency medicine. 3rd
ed. Philadelphia: Churchill Livingstone; 2009
4. Dunn RJ. The Emergency Medicine Manual. 4th ed. Tennyson: Venom Publishing; 2003
Claims information
Between 1 July 2005 and 31 December 2011, ACC decided 20 claims for alleged delays
in diagnosis leading to the progression of appendicitis. Of these, six were accepted.
How ACC can help your patients following treatment injury
Many patients may not require assistance following their treatment injury.
The most common reason for declining a claim was that there was no causal link
between the injury and treatment from a registered health professional. This was
most often because external clinical advice did not substantiate that there had
been a delay in timely diagnosis and treatment.
However, for those who need help and have an accepted ACC claim, a
range of assistance is available, depending on the specific nature of the
injury and the person’s circumstances. Help may include things like:
About this case study
•
•
This case study is based on information amalgamated from a number of
claims. The name given to the patient is therefore not a real one.
•
contributions towards treatment costs
weekly compensation for lost income (if there’s an inability to
work because of the injury)
help at home, with things like housekeeping and childcare.
No help can be given until a claim is accepted, so it’s important to
lodge a claim for a treatment injury as soon as possible after the
incident, with relevant clinical information attached. This will ensure
ACC is able to investigate, make a decision and, if covered, help your
patient with their recovery.
ACCxxxx March 2012 ©ACC 2012
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The case studies are produced by ACC’s Treatment
Injury Centre, to provide health professionals with:
•
•
an overview of the factors leading to treatment injury
expert commentary on how similar injuries might be avoided in
the future.
The case studies are not intended as a guide to treatment injury cover.
Send your feedback to: TI.info@acc.co.nz
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