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Mr Smith is a 26-year-old man with no significant past medical history who presents with diffuse abdominal pain that began 12 hours ago and is described as a pressure sensation, most intensely in the mid-abdomen. He has a decreased appetite but no nausea or vomiting. His last bowel movement was 2 days ago. He denies fevers and chills as well as hematuria, dysuria, and chest pain. The patient has no h/o gallstones, kidney stones, or abdominal surgeries. He takes no medications (no aspirin or NSAIDs) and reports occasional use of alcohol. Vitals are stable. Patient is afebrile. Cardiac and lung examinations are normal. Abdominal examination reveals a flat abdomen with hypoactive bowel sounds. There is mild, diffuse tenderness present. No guarding or rigidity is present. Rectal examination is normal. Stool is Hemoccult negative.

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1. What should be included in your DDX?

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Answer

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  1. Appendicitis (always to be considered in young adults)

    • Peptic ulcer disease
    • Pancreatitis (may present with epigastric or mid-abdominal pain)
    • Early bowel obstruction

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Appendicitis

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The classic presentation is diffuse abdominal pain that migrates to the right lower quadrant (RLQ) to McBurney point (1.5–2 in from the anterior superior iliac crest toward the umbilicus). The pain is associated with nausea, vomiting, fever, and anorexia. Appendicitis develops due to obstruction of the appendiceal orifice with secondary mucous accumulation, swelling, ischemia, necrosis, and perforation. Complications include perforation and abscess formation. The risk of perforation increases steadily with increasing age (50% in patients >75 years old). Fever, tenderness, guarding, and rebound may be absent in patients with appendicitis. Nonetheless, when present, they increase the likelihood of appendicitis. Eighty percent of patients with appendicitis have a WBC >10,000 with a left shift. Urinalysis may reveal pyuria and hematuria due to bladder inflammation from adjacent appendicitis. CT of abdomen and pelvis with IV and oral/rectal contrast is the test of choice. Although ultrasound is inferior to CT scan, it is the test of choice in pregnant patients. Frequent clinical observation is critical in patients with an unclear diagnosis. One should start intravenous fluids and broad-spectrum antibiotics and obtain a STAT surgical consult as urgent appendectomy is the treatment of choice.

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Other diagnoses to consider in patients with RLQ pain include cecal diverticulitis, Meckel diverticulitis, acute ileitis, Crohn disease, and gynecologic conditions.

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Cecal Diverticulitis

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Cecal diverticulitis usually occurs in young adults and presents with signs and symptoms that are virtually identical to those of appendicitis.

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Meckel Diverticulitis

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A Meckel diverticulum is a congenital remnant of the omphalomesenteric duct. It contains all layers of the intestine and may have ectopic tissue present from either the pancreas or stomach. It is located on the small intestine 2 ft from the ileocecal valve, and is about 2 in in length. The small bowel may migrate into ...

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