Abstract
One of the most common presentations of acute abdominal pain in the emergency setting is appendicitis. Although it can occur in both genders, when it comes to females with appendicitis, reaching a definite diagnosis can be challenging as it can mimic other diseases such as ovarian cysts/torsions, pelvic inflammatory diseases, endometriosis, and urinary tract infection or physiological reasons like menstrual pain which are exclusive to females and can occur as frequently as appendicitis. Therefore, it is crucial to make an accurate diagnosis as early as possible with the right diagnostic tools to reduce morbidity and mortality in females of child-bearing age. This is a summarized case report of an adolescent female who experienced two atypical attacks of appendicitis 1 year apart. Since the patient had mainly right upper flank pain associated with nausea, vomiting, and fever with a largely non-tender abdomen, various diagnoses such as chronic cholecystitis, biliary colic, peptic ulcer, gastroenteritis, mesenteric lymphadenitis, renal colic, mittelschmerz, and torsion of ovarian cyst were considered and treated for. The patient had no relief and underwent numerous investigative procedures in the 2 years she suffered from her illness. The final diagnosis was only obtained when exploratory laparoscopy was performed. This article aims to remind clinicians to have a high index of suspicion for acute appendicitis in all atypical presentations of acute appendicitis. The latest WSES Jerusalem guidelines for the workup for patients at risk of acute appendicitis should be meticulously followed.
Highlights
Appendicitis can happen due to a variety of reasons, such as infection, obstruction of the lumen by a fecalith, enlargement of the lymph nodes in the mucosa of the appendix, or obstruction from surrounding structures, all leading to the same pathophysiology of stasis of secretions which, in turn, leads to inflammation [1]
If the scores calculated lean toward a possible case of appendicitis, the patient should undergo point-of-focus ultrasound (POCUS) as the first-line investigation
The last resort of investigation given that both POCUS and computed tomography (CT) are inconclusive of a final diagnosis is exploratory laparoscopy [3]
Summary
Appendicitis can happen due to a variety of reasons, such as infection, obstruction of the lumen by a fecalith, enlargement of the lymph nodes in the mucosa of the appendix, or obstruction from surrounding structures, all leading to the same pathophysiology of stasis of secretions which, in turn, leads to inflammation [1]. The patient was given paracetamol and acetaminophen to ease the pain Investigations such as a complete blood count, urinalysis, ultrasound, and an MRI were performed, which were clear and not suggestive of any obvious problem, except for a simple ovarian cyst. The patient presented to the emergency room with rib, flank, and upper abdominal pain as well as fever and vomiting, she was given IV saline, ketorolac, and paracetamol to ease the pain. Her abdomen was examined by a surgeon who could not pinpoint where the problem was at the time. There were no further complaints and the patient’s condition was improving
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