Correspondence (letter to the editor): Acute Purulent Appendicitis

The authors do not include acute purulent appendicitis in their list of differential diagnoses. Clinical experience as well as the issue of medical liability, however, make an addendum necessary.

Purulent, usually already perforated, appendicitis is the most common and dangerous differential diagnosis for acute infectious enteritis, in children as well as in adults. Unpublished statistics from the North German arbitration board that relate to acute appendicitis show that some 345 cases were handled between 2000 and 2008; 277 of these were in adults and 68 in children. A complaint because of a delay in diagnosis and therapy was made in the cases of 153 adults (55 %) and 42 children (62 %). The misdiagnosis enteritis was the cause of the diagnostic delay in 56 adults (37 %) and 25 children (60 %). In 37 adults (66 %) and 15 children (60 %), diagnostic errors were confirmed. In all cases the diagnostic delay resulted in severe disease courses; in the case of one adult the outcome was fatal. According to our own estimates the ratio of appendicitis associated diarrhea to infectious enteritis is about 1:100. In spite of this, the differential diagnosis should always be considered. Diarrhea as a symptom does not exclude appendicitis; rather, it is a typical symptom in locally advanced appendicitis, especially in patients with interenteric abscesses. I would recommend subtle palpation of the abdomen, paying attention to regionally different pain reactions and muscular guarding, and taking the patient’s rectal temperature. Rectal examination, especially in young children, is not obligatory but often helpful, because pain symptoms in the pouch of Douglas or the right lower quadrant can be triggered in this way. If the diagnosis is likely to be non-enteritis related diarrhea, control examinations should be performed after 6–12 hours, followed by leukocyte and C-reactive protein tests and ultrasonography. Purulent appendicitis may occasionally occur as a comorbidity in patients with infectious enteritis.