Real case Discussion Gastroenterology Acute Apendicitis associated mistake

Real case from your hospital/clinic. Never reported elsewhere.
Dec 18, 2021
Name confidential
Age: 10 year Sex: male

Acute abdominal pain

A 10-year-old boy was admitted to the paediatric department with a 9-hour history of abdominal pain that was gradually localised to the right iliac fossa, accompanied by nausea but without vomiting. He had no change in bowel habits or urinary symptoms.

General Appearance
The patient was otherwise well, with no significant medical history, no previous hospital admissions, and no surgical history.

He did not take any regular medications and did not have any known allergies.

Physical examination
There was moderate tenderness on deep palpation of the right iliac fossa. Rebound tenderness was also noted. Roving, psoas, and obturator signs were positive.

Vital signs
All of these, including heart rate, respiratory rate, temperature, and blood pressure, were all within normal limits.

A mildly enlarged appendix and thickening of the appendiceal wall were noted.
dilatation of the appendix to > 6 mm in diameter.
thinning of the appendiceal wall (representing edema).
Periappendiceal streaking (densities within perimesenteric fat).
Presence of an appendicolith

Mistake 1: The radiologist did not take a picture of the appendix and sent the patient to the city hospital for apendectomy verbally.

Needed to be done.
In 90% of cases, we could have found leukocytosis > 10000 with PMN predominance (left shift) in 90% of cases.
And after perforation or abscess formation, it could show WBC greater than 18000
C reactive protein, which might have been elevated

Next action
He went to the city hospital, but his symptoms subsided and he was feeling well at the moment of admission (he had a window period between nerve death at the appendix and peritoneal involvement when the symptoms would come back).

Mistake 2: Doctors thought that the radiologist who did ultrasonography misdiagnosed this boy, so they sent him home.
After several hours, this patient came back to the ER with all the symptoms from before, plus abdominal rigidity and a high fever.

acute appendicitis on first admission and perforation and peritonitis when they came back to the ER on the second day.

emergency surgery, antibiotics, appendectomy, and drainage placement.

It is poor in this case because it was more than 24 hours from the starting of the symptoms.

What should have been done to avoid it?
At first, the radiologist should have taken a picture, and in the city hospital, doctors shouldn’t have underestimated the radiologist’s suspicion.
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