Avoiding appendectomy with an ultrasound probe

Abstract

Acute appendicitis is common in patients with right lower quadrant pain and affects all gender and age groups. Because clinical diagnosis of patients with right lower quadrant pain remains a challenge to emergency physicians and surgeons, imaging is of major importance. Ultrasound has well-established direct and indirect signs for diagnosing acute appendicitis and revealing the presence of an appendicolith. Appendectomy, which can be either open or laparoscopic, constitutes the basic treatment. However, the need for an appendectomy is debatable, particularly in high-risk patients. We report the case of a 42-year-old woman with no relevant medical history who was sent to the emergency department by her family physician with right lower quadrant pain of 18 hours’ duration. Using ultrasound, the emergency physicians identified, inside the appendix, a 0.6cm appendiceal faecolith, migration of which was eventuated by manipulation of the ultrasound probe. The patient was then successfully treated non-operatively without any antibiotic prescription. Despite its rarity, migration of an appendiceal faecolith is possible. When migration of an appendicolith is perhaps actualised spontaneously or by ultrasound probe manipulation, the likelihood of an appendectomy decreases dramatically. This hypothesis provides patients who present an appendiceal faecolith with an alternative treatment approach that will lead to the avoidance of surgery, minimise morbidity and reduce hospitalisation costs.

Background

Appendicitis is the most common abdominal surgical emergency globally, with an estimated lifetime risk of 7–8%. Furthermore, appendicitis appears in any age group, but usually in the second decade of life, and in either gender although with a male preponderance (male-to-female ratio of 1.4: 1).¹ Although acute appendicitis is the most common form of appendiceal illness, existence of an appendicolith without appendicitis is common in patients with right lower quadrant pain. Appendicoliths may cause acute abdominal pain that mimics acute appendicitis.²

Diagnosis of acute appendicitis is typically based on clinical examination but may be supported by laboratory tests and imaging. The Alvarado score was developed to assist clinicians in predicting a patient’s risk of having appendicitis. An Alvarado score of 7 or more indicates a high-risk for appendicitis. Ultrasound should be the first line of imaging because graded-compression ultrasound has excellent specificity.¹ A caecum ultrasound scan can reveal a variety of diseases such as infections, inflammation, neoplastic disorders or caecal abnormalities that can mimic acute appendicitis. Ultrasound has well-established direct and indirect signs for diagnosing acute appendicitis and revealing the presence of an appendicolith.¹ We report a case of appendiceal colic caused by an appendicolith, diagnosed by the emergency department in a middle-aged woman.

Case history

A 42-year-old woman with no relevant medical history was taken to the emergency department with sudden, colicky, moderate, right lower quadrant pain of 18 hours’ duration. She had not experienced any episode of acute pain previously. The pain was associated with anorexia. In addition, she had no fever, vomiting or nausea, and no changes in bladder or bowel habits. She did not have any comorbidities or prior surgical history. Unexplained weight loss was not referred.

On physical examination, her vital signs were as follows: body temperature, 36.9°C; pulse, 88b.p.m.; respiratory rate, 18 breaths per minute; oxygen saturation, 99%; blood pressure, 110/80mmHg. Physical examination revealed right lower quadrant abdominal tenderness on palpation, without muscle guarding or any palpable mass. McBurney and Rovsing signs were positive. She had regular and soft bowel movements. Subsequently, chest and abdominal radiographs taken in the erect posture did not show free air in the subdiaphragmatic area or air–fluid levels. The serum white blood cell count was 12,870/μl, with a segmented neutrophil percentage of 76.0% and a C-reactive protein level of 0.15mg/l. The Alvarado score was 5. A transvaginal ultrasound ruled out gynaecological disease.

Consequently, an ultrasound was performed by an emergency radiologist, and a non-inflamed appendix with a diameter of 6mm was revealed. An appendiceal faecolith was seen inside the appendix (Figure 1). Reactive lymph nodes were not detected. Abdominal ultrasound did not demonstrate a collection of fluid in the pouch of Douglas. During the abdominal ultrasound, the appendiceal faecolith migrated from the appendix to the caecum with the assistance of the ultrasound probe. After this, the appendix returned to normal. Eventually, the abdomen tenderness disappeared and the patient felt relief from her symptoms. The patient was discharged, did not return with a painful event and after one week follow-up her inflammation indices were reduced. No oral antibiotics were given on discharge.

Figure 1 .

Ultrasound imaging was performed. (a) Non-inflamed appendix with a diameter of 6mm and an appendiceal faecolith were revealed. After 2 minutes, the appendiceal faecolith disappeared.

The decision to adopt this conservative approach was reached by mutual agreement between the patient and the physician’s team. The patient was advised to attend the emergency department immediately if she experienced abdominal pain to minimise diagnostic delay should acute appendicitis occur. Scheduled follow-up appointments were planned to screen for any undetectable symptoms.

Discussion

Appendicoliths may provoke acute appendicitis. Acute appendicitis is associated with multiple appendicoliths or appendicoliths larger than 5mm.³ Nevertheless, an appendiceal faecolith could simply cause appendiceal colic or be asymptomatic. The presence of appendicoliths in non-inflamed appendices is an undeniable fact.^2,4

In the majority of medical centres, ultrasound has become the initial imaging of choice in the assessment of acute appendicitis because it has excellent specificity in all patient populations.¹ Ultrasound is the suggested first-line treatment for all patients to avoid magnetic resonance imaging (MRI) or computed tomography (CT) imaging.¹ Consequently, both exposure of patients to ionising radiation and the cost of pre-therapeutic diagnosis of acute appendicitis will decrease. Patients correctly diagnosed can avoid an operation or costly monitoring in hospital.

Nevertheless, much consideration should be given to the limited sensitivity of ultrasound. Non-diagnostic ultrasound examinations with non-visualisation of the appendix are common, and the availability of ultrasound-experienced radiologists is important. Because of a combination of these factors, complementary imaging with MRI and CT is required show that low negative appendectomy and perforation rates be accomplished.¹ A negative appendectomy might not only expose the patient to the risks associated with a surgical procedure, but also provoke serious complications.⁵ Continuous monitoring in patients with significant operative risk and a conservative watchful waiting approach are usually considered reasonable.³

Conclusion

In our case, during ultrasound probe manipulations, the appendiceal faecolith migrated from the appendix to the caecum. Subsequent appendix imaging was normal and the pain disappeared. Migration of the appendicolith either spontaneously³ or by manipulation may result in a cure. Imaging changed the therapeutic options, as there was no reason to undertake an appendectomy. It is undeniable that this treatment is hard to actualise in daily clinical praxis, and might be appropriate only when an accurate diagnosis has been made and appendix inflammation is absent.