Working Up Appendicitis...

Cut to the Chase: General Surgery Survival Series — Post 21

She tells you the pain started around her belly button yesterday afternoon. Vague, the kind she can't quite point to. Overnight it slid down and to the right and stayed there. She hasn't wanted to eat since, and she's holding very still on the bed.

Then the white count comes back at 9.4, and you can feel yourself reaching for another explanation.

Don't.

Appendicitis isn't a hard diagnosis. It's a diagnosis people talk themselves out of. The mistake is almost never that you couldn't see it. It's that you saw it and set it back down.

The consult arrives as “rule out appy,” and the verb misleads you. You're not ruling anything out. You're deciding whether a story you already recognize has earned an operation.

The story runs on a sequence. A dull ache settles in around the navel. The appendix is midgut, and early on it genuinely can't tell you where it lives. The appetite quits, nausea follows, and over twelve to twenty-four hours the pain moves to the right lower quadrant and sharpens as the wall itself gets involved.

So ask the question that sorts it: which came first, the pain or the vomiting?

Ask her which came first, the pain or the vomiting, and make her put them in order. If the vomiting led, you are probably working up something else and should say so before the CT gets ordered.

And the patient who's still hungry, asking when lunch is coming, rarely has the appendix you're losing sleep over. Not never. Rarely. Hold that one loosely.

The exam confirms what the story already told you. One finger finds the point of maximal tenderness; ask for a cough instead of digging for rebound. And watch the face on the way in: patients guard with their eyes before they guard with their muscles.

Rovsing's, psoas, obturator: learn them for rounds. A single point of maximal tenderness plus the right sequence outranks all three.

Before anything gets scanned, one test goes first.

Send the pregnancy test before you order the scan, on everyone who could be pregnant, including the ones who tell you there's no chance. It changes what you're allowed to image her with, and it changes who you're calling.

The white count is usually up a little, and a normal one early has never cleared a patient with a good story. The urinalysis can lie too: an appendix resting on the ureter will drop white cells into the urine and hand you a UTI that doesn't exist.

CT with IV contrast settles it in most adults. Ultrasound goes first in children and in pregnancy, with MRI behind it when the ultrasound shrugs. A non-visualized appendix rules nothing out. The scan confirms the case you built at the bedside, or it kills it.

Third year, running consults overnight, I admitted a college student for observation. Her story was right, her white count was normal, and the CT read said it couldn't exclude appendicitis. I wrote serial exams in the note.

I examined her once more, at four, and called it unchanged. By seven she had perforated, and the forty-minute operation became two hours and a drain. I can still see the two words in my handwriting.

Once you believe the story, the patient's day changes: NPO, fluids, antibiotics once the decision is made. And treat the pain. The old teaching that analgesia ruins the exam has been dead for decades.

Order the analgesia when you order the labs, then examine her again twenty minutes later. The belly you feel once she isn't fighting you is the more honest one.

Then call your senior with one committed sentence. “Twenty-two-year-old woman, eighteen hours of migratory right-lower-quadrant pain, no appetite, focally tender at McBurney's, hCG negative. I think this is appendicitis, and I'd like you to see her now.”

You'll hear that some uncomplicated appendicitis gets antibiotics alone these days, and that's true. It's the attending's conversation. The walled-off abscess gets antibiotics and a drain first, the appendix later, if at all. Your job is to build a case clean enough that those decisions can happen.

The classic ones diagnose themselves. The ones that come back to find you are the appendixes that moved.

Retrocecal, tucked behind the cecum, where it spares the front wall entirely. Pelvic, resting low against the bladder. Pushed up and sideways by a gravid uterus, or presenting quiet and late in the old.

The appendicitis you miss won't be sitting at McBurney's point. It'll be retrocecal calling itself back pain, or pelvic calling itself a bladder infection.

When the presentation reads odd, take the story again from the top, and examine her twice a few hours apart before you write that she's unchanged.

She's still on that gurney. She hasn't moved, she isn't hungry, and the pain is parked exactly where the story said it would land. The white count is still 9.4.

Go make the call anyway. Most nights nothing happens next; your senior says fine, get the CT, and you go back to the list.

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What to Read Next: Post 22, “Stones, Inflammation, or Something Worse?” The right lower quadrant has one famous tenant. The right upper quadrant houses a whole family, and sorting stones from cholecystitis from the thing that can't wait is where we go next.