General Surgeon Fails To Diagnose Appendicitis In Symptomatic Patient

This case involves a woman who presented to the hospital after experiencing persistent lower abdominal pain. The emergency physician suspected appendicitis and ordered a CT. The report showed thickening of the appendix and accumulation of fluid in the peritoneal cavity. Although the differential on the CT report included a ruptured appendix, the general surgeon diagnosed the woman with diverticulosis and began antibiotic treatment. While the woman was in the hospital, her appendix ruptured and she developed sepsis, prompting a long recovery. An expert in general surgery was requested to review the records and opine on whether the surgeon missed the diagnosis of a ruptured appendix that sepsis in this patient.

Question(s) For Expert Witness

How often do you treat patients with appendicitis?

What are the clinical and image findings of a ruptured appendix?

Expert Witness Response E-008637

I see a lot of patients with acute appendicitis in my practice, as I participate in the acute care surgery call schedule at my institution. I operate on an average of 6-8 patients with acute appendicitis per month, with various degrees of severity, from simple to perforated. The clinical findings are generally suggestive of acute abdomen with tenderness to palpation in right lower quadrant, but in late stages, diffusely throughout the abdomen. These should warrant an emergent surgical intervention. CT scan images usually show free intraperitoneal fluid, sometimes small amount of free air or extravasation of contrast. The appendix appears thick with surrounding inflammation. These typical findings are not encountered in all patients and the decision to operate should be made based on the clinical exam in the first place. My thoughts about this case: The information presented is limited, particularly regarding the clinical exam and laboratory values. However, it appears that the CT abdomen was pretty suggestive of appendicitis with rupture, which not being surgically treated, led to progressive worsening and patient demise.