1. PATIENT PRESENTATION
A 12‐year‐old boy with no past medical or surgical history presented with 2 days of right lower quadrant abdominal pain, nausea, intermittent vomiting, and no fever. There was McBurney's point tenderness and positive Rovsing's sign on exam, with a white blood cell count of 6 and C‐reactive protein < 0.2. Abdominal ultrasound showed a 4 mm appendix (Figure 1) with an appendicolith (Figure 2). With persistent pain and abdominal tenderness, he was transferred for pediatric surgical evaluation. Abdominal examination and a repeat ultrasound were unchanged, with computed tomography of a non‐inflamed appendix with appendicolith but no evidence of acute appendicitis (Figure 3). Further history disclosed that the patient had similar pains 6 years prior. The day after discharge, he returned to the emergency department with persistent right lower abdominal pain and tenderness. Magnetic resonance imaging was negative for acute appendicitis and he was discharged home.
FIGURE 1.
Abdominal ultrasound (transverse view) showing a 4 mm non‐inflamed appendix (brackets)
FIGURE 2.
Abdominal ultrasound (longitudinal view) showing an appendicolith (arrow)
FIGURE 3.
Computed tomography (sagittal view) showing a non‐inflamed appendix with appendicolith (arrow)
2. DISCUSSION
Appendicolithic colic is a syndrome of recurrent peristaltic abdominal pain and tenderness from partial luminal obstruction from mineralized feces in the appendix. This may clinically mimic acute appendicitis, but without fever or elevated inflammatory markers. 1 Appendecoliths are associated with high rates of perforated appendicitis. 2 Although emergency physicians are often concerned that the presence of an appendicolith found on imaging in the setting of right lower abdominal pain may be a precursor to acute appendicitis, 1 subsequent appendicitis has been found in only 0%–5.8% of cases when followed 3–5 years after initial presentation. 3 , 4 Patients with appendicolithic colic often have multiple emergency department visits and recurrent imaging in the absence of acute appendicitis. 5 Awareness of this syndrome may help avoid ionizing radiation, and these patients may benefit from elective appendectomy for pain relief. 5
Romero J, Lipman GS. Recurrent pediatric abdominal pain. JACEP Open. 2021;2:e12364 10.1002/emp2.12364
REFERENCES
- 1. Fraser N, Gannon C, Stringer MD. Appendicular colic and the non‐inflamed appendix: fact or fiction? Eur J Pediatr Surg. 2004;14(1):21‐24. [DOI] [PubMed] [Google Scholar]
- 2. Yoon HM, Kim JH, Lee JS, Ryu JM, Kim DY, Lee JY. Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation. World J Pediatr. 2018;14(2):184‐190. [DOI] [PubMed] [Google Scholar]
- 3. Rollins MD, Andolsek W, Scaife ER, et al. Prophylactic appendectomy: unnecessary in children with incidental appendicoliths detected by computed tomographic scan. J Pediatr Surg. 2010;45(12):2377‐2380. [DOI] [PubMed] [Google Scholar]
- 4. Khan MS, Chaudhry MBH, Shahzad N. Risk of appendicitis in patients with incidentally discovered appendicolith. J Surg Research. 2018;221:84‐87. [DOI] [PubMed] [Google Scholar]
- 5. Fraser N, Gannon C, Stringer MD. Appendicular colic and the non‐inflamed appendix: fact or fiction? Eur J Pediatr Surg. 2004;14(1):21‐24. [DOI] [PubMed] [Google Scholar]