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Spotlight Case June 2003

Missed Appendicitis

webmm.ahrq.gov


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Source and Credits This presentation is based on June 2003

AHRQ WebM&M Spotlight Case in Surgery

See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: James Adams, MD, Feinberg

School of Medicine, Northwestern University

Editor, AHRQ WebM&M: Robert Wachter, MD Spotlight Editor: Tracy Minichiello, MD

Managing Editor: Erin Hartman, MS
http://webmm.ahrq.gov/http://webmm.ahrq.gov/


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ObjectivesAt the conclusion of this educational activity,participants should be able to:

Appreciate the variable presentation of appendicitis

List complications of missed appendicitis Understand the advantages and disadvantages of

CT in diagnosing appendicitis

Define anchoring and metacognition and state their

impact on missed diagnoses List potential strategies to enhance patient safety in

the emergency department (ED)


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Case: Missed AppendicitisA 37-year-old woman with no past medicalhistory went to ED complaining of vomitingand periumbilical abdominal pain for 6 hours.On physical examination, she was afebrile,BP 110/70, HR 85. Abdomen was soft, with norebound or guarding. She was diagnosed withgastroenteritis, discharged with antiemetics,

and told to return for persistent vomiting, pain,or new fever.


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Abdominal Pain in the ED Most common chief complaint in the ED

6% of the 100 million yearly ED visits

Appendicitis is the most common surgicalcause of abdominal pain 7% of population affected over a lifetime

Small percentage of abdominal pain is due

to appendicitis 1%-3% of ED visits for abdominal pain are

appendicitis

McCaig LF, et al. CDC 2002;326:April 22.

Graff L, et al. Acad Emerg Med 2000;7:1244-55.


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Challenge of Diagnosing Appendicitis Diagnosis uncommon; clinicians accustomed

to ruling out rather than ruling in disease

High incidence of missed diagnoses due tolow suspicion

20%-40% misdiagnoses in some populations

Implementation of diagnostic algorithm may

combat this effect

Reduce misdiagnosis rates to 6%

Naoum JJ, et al. Am J Surg 2002;184:587-9.


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Challenge of Diagnosing Appendicitis Classic signs of appendicitis increase

likelihood of disease

Epigastric pain, radiating to RLQ, rebound, fever

Classic presentation not typical

WBC count normal in 10%-30%

Early disease often presents with normal vitals,

physical examination

Wagner JM, et al. JAMA 1996;276:1589-94.


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Abdominal CT in Appendicitis CT can enhance diagnostic accuracy

Sensitivity 80%-100%

CT can delay diagnosis Reserve for men with atypical presentation and

for women in whom pelvic pathology may mimicappendicitis

CT in low-risk population will lead to increase

in false positive readings Potential increase in unnecessary surgery

Ege G. et al. Br J Radiol 2002;75:721-5.

Maluccio MA. et al. Surg Infect 2001;2:205-11.


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Abdominal Pain in the ED Maintain suspicion for early disease

Consider CT in appropriate population

Consider inpatient observation

Always provide detailed follow-up anddischarge instructions

Include warning signs and symptoms to promptreturn visit to ED


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Case (cont.): Missed AppendicitisPatient went to PCPs office 2 days later with

persistent abdominal pain; vomiting had resolved.

On physical exam, patient was afebrile, with normal

vital signs. Abdomen was diffusely tender, with

localization around the umbilicus. Pelvic exam

revealed no cervical motion and mild adnexal

tenderness. Diagnosis: mittelschmerz vs. ovarian

cyst. Transvaginal ultrasound ordered for followingweek. Patient told to take naproxen for pain.


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Anchoring Cognitive error due to reliance on diagnostic

assumptions and prior reasoning of previous

assessments Transition of care points are high risk for

propagation

To minimize this type of error, take a stepback and think broadly about the casei.e.,apply metacognition


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Case (cont.):Missed Appendicitis

The next day, the patient returned to the ED

with persistent pain. She was seen by the

same ED attending, who then asked acolleague to evaluate the case. This second

ED attending performed a pelvic exam and

ordered a CT scan of the abdomen and

pelvis. CT revealed a perforated appendix.


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Perforated Appendix


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Case (cont.):Missed AppendicitisThe patient was seen by general surgery

and it was decided not to take her to the

operating room immediately due to theperitonitis. She was admitted and started

on IV antibiotics. Her hospital stay was

prolonged due to ileus. On hospital day

number #8, her WBC count began to rise.A repeat CT scan was obtained.


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Intra-abdominal Abscess


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Case (cont.):Missed AppendicitisCT revealed an intra-abdominal abscess

the size of an orange. The patient

underwent percutaneous drainage byinterventional radiology. On hospital day

#13, she was discharged home with a plan

to follow-up for elective appendectomy.


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Complications of Perforated Appendix Wound infection and dehiscence

Intra-abdominal abscess

Sepsis Prolonged ileus

Pneumonia

Bowel obstruction Infertility

Graff L, et al. Acad Emerg Med 2000;7:1244-55.

Mueller BA, et al. NEJM 1986;315:1506-8.


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Case (cont.):Missed AppendicitisShortly after discharge, the abdominal pain

returned. The patient returned to the ED and

underwent a repeat CT scan, which revealeda small bowel obstruction. The patient went

to the operating room the next day for lysis

of adhesions and appendectomy. Eight days

later, the patient was discharged home. Shehas returned to her previous state of health.


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Challenges to Patient Safety in ED Excessive cognitive burden

Time pressure

Multiple interruptions

No pre-existing relationship withpatients


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Implement strategies to provide doctorswith post-discharge feedback

Encourage providers to use ED patientsafety resources

Increase teamwork

Improve providerpatient communication

Enhancing Patient Safety in ED

Wears RL, et al. Top Health Information Mgmt. 2002;23:1-12.


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Take-Home Points Appendicitis is an uncommon but important

cause of abdominal pain in the ED

Presentation is often atypical

Complications of missed or delayeddiagnosis are multiple and morbid

To decrease missed appendicitis, considerCT scan, inpatient observation, and/ordetailed follow-up instructions

Use CT scan with caution


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Take-Home Points (cont.) Avoid anchoring

Always question conclusions of previous providers,particularly as new information accrues

Consider implementing diagnostic algorithmsto ensure that appendicitis is in thedifferential, even in atypical cases

Close the loop by obtaining follow-up onclinical outcomes

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Webmm.ahrq.Gov.17 Slideshow