In Missed Appendicitis Cases, Presentations Are Early, Atypical
The authors of a recent study discovered that a triage chief complaint that was less indicative of appendicitis correlated with a higher rate of missed appendicitis in one pediatric ED.1
“The motivation for this study was encountering several patients who were near misses after they had atypical presentations for appendicitis,” says Zachary Drapkin, MD, the study’s lead author. The researchers wanted to investigate whether EPs are biased by the chief complaint that is assigned to a patient on a tracking board as part of the triage process. Further, they tried to determine whether certain triage chief complaints are associated with missed cases of appendicitis.
Researchers retrospectively reviewed charts of 1,680 patients who presented to a pediatric ED and were diagnosed with appendicitis over a five-year period. The authors found 67 patients visited the ED at least one more time in the week before receiving their diagnosis. Triage complaints were classified as “suggestive of appendicitis” (abdominal pain, right lower quadrant pain, or patients sent to the ED by another physician to rule out appendicitis) or “nonspecific” (fever, vomiting, dehydration, or other symptoms). Of patients with a triage chief complaint that was suggestive of appendicitis, 3.8% were missed on their initial ED visit, compared to 8.8% of those with a nonspecific triage chief complaint.
The researchers concluded that these findings suggest the potential impact of anchoring bias by a triage chief complaint when trying to diagnose appendicitis. However, Drapkin says the results should be interpreted with caution because the study authors did not look for the denominator of chief complaints.
“For example, while some patients who are diagnosed with appendicitis present with diarrhea, among all patients who present to the ED with a chief complaint of diarrhea, very few are ultimately diagnosed with appendicitis,” Drapkin explains. Ordering labs and conducting imaging studies on all children who present with diarrhea likely would cause more harm than good. Instead, Drapkin advises EPs to “always consider appendicitis, and discuss good return precautions in atypical cases.”
Typically, missed appendicitis cases in the ED feature early presentations that do not meet the EP’s threshold to order an imaging test or atypical appearances, according to David Talan, MD, FACEP, FIDSA. Initially, it sometimes appears that the pain is located in the middle or right upper quadrant of the abdomen. The EP might perform an ultrasound on the right upper quadrant, suspecting cholecystitis or a liver problem. Still, the tests return negative.
“It’s not unusual to go back and examine the patient, who is still in pain, and find out that the pain now appears to be more toward the lower part of the abdomen,” Talan says.
At this point, the doctor orders a CT scan, which reveals appendicitis. This common scenario points to the importance of re-evaluating the ED patient. “Once you get negative results from testing your initial hypothesis, maybe you should consider another disease process,” Talan offers.
Appendicitis remains high risk for missed or delayed diagnosis in the ED setting, says Mark F. Olivier, MD, FACEP, FAAFP. EPs are less likely to miss patients with a classical presentation of appendicitis or an obvious surgical abdomen. “However, classic presentations are not the standard,” Olivier says. To avoid missing atypical presentations of appendicitis, Olivier says EPs should bear in mind that:
- fever may not be present, especially in the elderly. (“The temperature is helpful only if febrile,” Olivier notes.);
- depending on the location of the appendix, the patient may not report right lower quadrant abdominal pain;
- early in the disease process, the patient may not demonstrate any rebound or guarding;
- a normal white blood cell count does not exclude appendicitis since it may be normal early in the disease process. (“The white blood cell count is significant only if elevated,” Olivier offers.);
- pyuria and/or hematuria may occur if the appendix location is near the ureter. (“Be careful not to incorrectly diagnose the patient with a urinary tract infection, especially if it was a contaminated specimen,” Olivier warns.);
- atypical presentations, which carry a higher risk for perforation, occur in children, the elderly, pregnant patients, and immunocompromised patients;
- be aware that false-negative CT scans can occur.
Olivier says there are legally protective practices for EPs, such as documenting abdominal reevaluations while in the ED. This is especially important at the time of discharge. “Disease progression may become evident if the patient is there for a prolonged period of time,” Olivier explains. If the patient is discharged with nonspecific abdominal pain, Olivier says staff should explain the disease process to the patient. Be specific on signs and symptoms to watch out for. “Explain uncertainty in the diagnosis,” Olivier adds.
To see if there is disease progression, Oliver recommends re-evaluating the patient within 12-24 hours. “In patients with complaints of abdominal pain, unless they had a previous appendectomy, don’t tell the patient they have no risk for appendicitis,” he stresses.
After evaluation, if the EP believes a patient has nonspecific abdominal pain, Olivier says the EP should not feel pressure to provide a definitive diagnosis. Early in the course, the disease may not have presented itself yet. “Therefore, it may be too early to diagnose appendicitis,” Olivier explains.
Offering a benign diagnosis such as gastroenteritis or cystitis can give patients a false sense of security.
“When the patient later is diagnosed with appendicitis, they are upset with the initial evaluation — and more likely to seek litigation,” Olivier warns.
Missed appendicitis cases have decreased in emergency medicine over the last decade. “This is likely due to increased availability of CT scans,” says Susan Martin, Esq., a former ED nurse manager who now works for a medical professional liability insurer. She explains that missed appendicitis cases against EPs typically involve whether appendicitis was considered on the EP’s differential, if CT with contrast should have been considered, and surgical consultation.
One such case involved a 26-year-old female who visited her OB/GYN over concerns about a right ovarian cyst. The patient presented with a history of a cyst on the left ovary and reported similar pain. Concerned that the cyst may have ruptured, the OB/GYN sent the patient to the ED. Upon arrival, the patient registered no fever but reported severe pain.
“The history is given to the ED physician, and the physician travels down the ovarian cyst pathway,” Martin notes.
The EP ordered labs and a CT scan of the pelvis, which showed some fluid in the right lower quadrant. Labs showed an elevated white blood cell count. “But the EP reasons that could be due to pain and inflammation in her pelvis,” Martin says.
The EP called the OB/GYN, who agreed to admit the patient for overnight evaluation and repeat labs in the morning. The patient waited several hours in the ED for an inpatient bed to become available. The next afternoon, the OB/GYN arrived and confirmed that hemoglobin and hematocrit dropped. Likely, the cyst had ruptured and started bleeding. The patient is brought to the OR. After a short time, a surgeon is emergently notified to the OR.
“The surgeon found a large abscess and purulent material in her right quadrant and concluded the patient had a ruptured appendix with abscess,” Martin reports.
After surgery, the patient underwent a complicated treatment course and remained in the hospital for several weeks. She later sued the EP. “Upon reviewing the ED records, the defense counsel saw some problems with this case,” Martin says. The ED defense team was concerned about these questions:
- Did the EP ever consider acute appendicitis? The answer was no. “It was not part of his differential,” Martin says.
- Was the EP misled by the patient’s history and conversation with her OB/GYN? It appeared as though the EP had “anchored” on the diagnosis given by the OB/GYN. “The EP believed that since the OB/GYN had referred and seen her recently, the diagnosis of the cyst was appropriate,” Martin says.
- Did the radiologist notate in his dictated report the possibilities or causes of the fluid? The radiologist noted that there could be abscess formation and that he could not visualize the appendix.
The ED defense team was unable to overcome these challenges. “The case was eventually settled in the mid six-figure range,” Martin says.
- Drapkin Z, Dunnick J, Madsen TE, et al. Pediatric appendicitis: Association of chief complaint with missed appendicitis. Pediatr Emerg Care 2018 Jan 11. doi: 10.1097/PEC.0000000000001390. [Epub ahead of print].
- Zachary Drapkin, MD, Clinical Assistant Professor, Department of Pediatrics, University of Utah, Salt Lake City. Email: [email protected].
- Susan Martin, Esq., Executive Vice President, Litigation Management/Loss Control, AMS Management Group, Plano, TX. Phone: (866) 520-6896. Email: [email protected].
- Mark F. Olivier, MD, FACEP, FAAFP, Risk Management Medical Advisor, Schumacher Clinical Partners, Lafayette, LA. Phone: (337) 609-1125. Email: [email protected].
- David Talan, MD, FACEP, FIDSA, Chairman Emeritus, Department of Emergency Medicine, Olive View-UCLA Medical Center; Faculty, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, CA. Phone: (818) 364-3107. Email: [email protected].
The authors of a recent study discovered that a triage chief complaint that was less indicative of appendicitis correlated with a higher rate of missed appendicitis in one pediatric ED. The researchers concluded that their findings suggest the potential impact of anchoring bias by a triage chief complaint when trying to diagnose appendicitis. However, one analyst advises that the results should be interpreted with caution because the study authors did not look for the denominator of chief complaints.
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