Page 129 - Journal of Special Operations Medicine - Spring 2015

In this setting, you are limited largely by your resources. • Rebound tenderness
Your range of differential diagnosis possibilities is quite • Nausea or vomiting
wide. He could have a viral illness, gastritis, infectious • Anorexia (loss of appetite)
diarrhea, biliary colic, testicular torsion, urinary tract • Leukocytosis (more than 10,000 WBCs/µL in the
pathology, or the beginning of something more serious, serum)
like appendicitis or diverticulitis (although this is less
likely in this age group). The differential diagnoses are Up to one­third of patients with appendicitis, however,
even more extensive for a female patient. In that case, may present with three or fewer of these symptoms,
you need to consider pregnancy or other gynecologic making the application of such clinical decision scoring
conditions, such as pelvic inflammatory disease, ovarian tools difficult. 1
cysts, endometriosis, ovarian torsion, or tubo­ovarian
abscess. Pathophysiology: What is really happening?
The appendix is a diverticulum (out­pouching from a
hollow organ) that always arises from the base of the
What are your next steps?
cecum. The tip of the appendix may lie in a variety of
At this point, it would be reasonable to order some ba­ positions, including in the right lower quadrant, retroce­
sic tests (if available) or to observe and re­examine him cal, subcecal, or in the pelvis (Figure 1). In appendicitis,
after a period of time. inflammation of the appendiceal wall occurs, followed
by ischemia, tissue necrosis, and then perforation with
You have a scheduled training scenario, so you promise the development of a contained abscess or generalized
to recheck him in 3 hours and you give him some acet­ peritonitis. 2
aminophen. Three hours later, he looks largely the same,
his vital signs are unchanged. His abdomen is more ten­ Figure 1 Anatomic variation in the position of the appendix
der in the right lower quadrant, but he does not have (author-supplied image).
signs of peritonitis, rebound, or referred pain. You hap­
pen to have the ability to do point­of­care laboratory
tests. Your laboratory results show a white blood cell
(WBC) count of 9,300 cells/µL (9.3mL). His chemistry
and glucose values are within normal limits. Urinalysis
is unremarkable.

What now?
You call a higher medical authority to discuss the case.
After explaining the patient’s history, and physical ex­
amination and laboratory results to your consultant, he
has some suggestions. He discounts appendicitis because
the WBC count is normal. In addition, he suggests that
if you really are considering the diagnosis of appendici­
tis, that you perform a digital rectal examination.

Appendicitis
In many patients, the initial features of appendicitis are
very atypical and nonspecific. Appendicitis occurs most Obstruction of the appendix has been proposed as the
commonly between the ages of 10 and 30 years and primary cause of appendicitis, but it is not always iden­
slightly more frequently in men than women. tified during surgery. This obstruction can be caused by
fecaliths (hard desiccated stool), debris, parasite infec­
Various scoring systems to evaluate appendicitis have tion, inflammatory tissues, or even neoplasm. Inflam­
been developed, with limited success. Common elements mation of the appendix causes activation of the visceral
from the patient’s history, physical examination, and nerve fibers in the spinal cord. This accounts for the
3
laboratory tests include: vague central abdominal pain that typically occurs.
• Temperature of 37.3°C or higher In the first 24 hours of symptoms, inflammation and ne­
• Abdominal pain that migrates to the right iliac fossa crosis develops. Over time, as necrosis develops, there is
• Tenderness in the right iliac fossa a risk of perforation, which can lead to localized abscess

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