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It is only for medical professionals to read for reference.
When encountering patients with chronic abdominal pain, this cause must not be missed.
Chronic abdominal pain is one of the common symptoms in the gastroenterology department.
The receiving doctors often relax their vigilance due to chronic symptoms and ignore some acute causes, leading to misdiagnosis.
Recently, the BMJ case report reported a tortuous medical experience from a young patient with abdominal pain.
Case summary The patient is a previously healthy 18-year-old British boy who presented to the doctor with "chronic paroxysmal colic in the lower abdomen for 4 months".
The patient reported that abdominal pain occurred about 2 times a month, with obvious interictal periods, accompanied by nausea, vomiting, no fever, chills, jaundice, hematemesis, melena and other discomforts.
Abdominal pain occurred again in the past 3 days, the pain was significantly worse than before, and it was accompanied by constipation.
Since the onset, the patient feels a little anxious and eats normally.
Physical examination: The patient’s vital signs were normal, with a soft abdomen, slight tenderness in the lower abdomen, no rebound pain, McDonald’s point tenderness, psoas muscle test, obturator internal muscle test, and Rosving’s sign were all negative.
No abdominal mass.
After the patient was admitted to the hospital, the doctor first thought that he had intestinal obstruction and took a plain abdominal radiograph (Figure 1), but found no abnormalities.
The patient complained of dysuria again, and suspected urinary tract infection.
The blood test showed that the white blood cells and CRP were indeed increased, but the urine test was normal.
After empiric antibiotic treatment, the abdominal pain improved.
Figure 1.
A plain abdominal radiograph at the time of the COVID-19 pandemic in the United Kingdom.
Many examinations were difficult to perform.
The doctor thought that since the abdominal pain improved and released him from the hospital, he still felt uneasy, and finally ruled out all difficulties and gave him an abdominal CT scan.
The truth finally came to light.
CT of the abdomen found that there was an exudation around the appendix.
Consider perforation with abscess formation (Figure 2). Figure 2.
CT of the abdomen, so the surgeon was asked to perform a laparoscopic appendectomy.
The appendix that had been perforated was cut off and the abdominal drainage was placed.
The patient recovered well after the operation and was discharged 3 days later.
Summary of experience Appendicitis is one of the most common acute abdomen.
If it is not treated in time, it is easy to cause inflammation to persist and cause recurring chronic pain.
Take the opportunity of this case discussion to review the main points of the diagnosis of appendicitis.
First, the location of the appendix is not static.
Therefore, the diagnosis of appendicitis cannot be ruled out simply based on the location of abdominal pain.
Because the relationship between the root of the appendix and the cecum is fixed, the position of the appendix can vary with the position of the cecum.
It can be as high as under the liver, or as low as the pelvic cavity, or even across the midline to the left.
The appendix itself can also have a variety of position changes, which can be behind the cecum, under the cecum, before the ileum, behind the ileum, and extending inward to the entrance of the pelvic cavity.
According to statistics, 75% of the appendix is in the posterior or inferior position of the cecum, and about 20% is in the pelvic position.
The pathophysiological mechanism of appendicitis is relatively simple.
The appendix lumen is narrow and rich in lymphoid follicles.
Once blocked, it will cause local expansion and ischemia, bacterial proliferation, and a series of outcomes such as inflammation, perforation, and necrosis.
Various infections, tumors, fecal stones, etc.
can easily cause the appendix lumen to be blocked, so any cause may cause appendix inflammation.
Especially during the epidemic period, cases of new crown combined with appendicitis have been reported many times.
In addition to the virus itself may invade the mucosa of the digestive tract, it is not ruled out that the new crown virus causes lymphoid follicular hyperplasia.
From the perspective of symptoms and physical examination, the classic metastatic right lower abdominal pain in acute appendicitis is only seen in about two-thirds of patients, and appendicitis patients with atypical symptoms are easily misdiagnosed.
To some extent, any abdominal pain should consider the possibility of appendicitis.
For chronic appendicitis, there are often no obvious symptoms between episodes, which increases the difficulty of diagnosis.
Especially for adolescents, due to the immature development of the greater omentum, it is not easy to be wrapped and limited after inflammation occurs, and there is little chance of this occasional "chronic abdominal pain".
Other possible causes need to be ruled out before the diagnosis of chronic appendicitis.
It can be seen that the accurate diagnosis of appendicitis requires necessary laboratory examinations and imaging examinations.
Studies have shown that among adult patients with right lower abdominal pain, only CRP is highly sensitive to appendicitis (96%), but has poor specificity (50%), combined with white blood cell count and neutrophils.
Ratio and CRP can increase the sensitivity to 99.
2%.
In imaging examinations, although abdominal ultrasound is more convenient and without radiation, CT is better for the diagnosis of appendicitis, with a sensitivity of 80%-96%.
It should be pointed out that for chronic appendicitis, the traditional view is that barium enema is necessary to rule out other diagnoses, but with the advancement of endoscopy technology, it may be better to choose colonoscopy.
Surgical treatment is generally recommended after the diagnosis of appendicitis is clear.
Laparoscopic surgery can complete most appendectomy.
Those who cannot tolerate surgery or the relatively clear simple appendicitis can also be treated conservatively with anti-infective treatment, but they need to bear the risk of further aggravation of the disease.
The choice of treatment requires good communication between the doctor and the patient.
There are many medical disputes caused by contempt of appendicitis, a "small problem".
In the future, patients with chronic abdominal pain should not forget to use appendicitis as one of the identification options.
References: [1]Tint NP,Hussain H.
Near miss abdominal pain.
BMJ Case Rep.
2021 Feb 4;14(2):e238883.
doi:10.
1136/bcr-2020-238883.
[2]Scott C,Lambert A .
Managing appendicitis during the COVID-19 pandemic in the UK.
Br J Surg.
2020 Jul;107(8):e271.
doi:10.
1002/bjs.
11752.
Epub 2020 Jun 3.
[3]Kim D, Butterworth SA, Goldman RD.
Chronic appendicitis in children.
Can Fam Physician.
2016 Jun;62(6):e304-5.
When encountering patients with chronic abdominal pain, this cause must not be missed.
Chronic abdominal pain is one of the common symptoms in the gastroenterology department.
The receiving doctors often relax their vigilance due to chronic symptoms and ignore some acute causes, leading to misdiagnosis.
Recently, the BMJ case report reported a tortuous medical experience from a young patient with abdominal pain.
Case summary The patient is a previously healthy 18-year-old British boy who presented to the doctor with "chronic paroxysmal colic in the lower abdomen for 4 months".
The patient reported that abdominal pain occurred about 2 times a month, with obvious interictal periods, accompanied by nausea, vomiting, no fever, chills, jaundice, hematemesis, melena and other discomforts.
Abdominal pain occurred again in the past 3 days, the pain was significantly worse than before, and it was accompanied by constipation.
Since the onset, the patient feels a little anxious and eats normally.
Physical examination: The patient’s vital signs were normal, with a soft abdomen, slight tenderness in the lower abdomen, no rebound pain, McDonald’s point tenderness, psoas muscle test, obturator internal muscle test, and Rosving’s sign were all negative.
No abdominal mass.
After the patient was admitted to the hospital, the doctor first thought that he had intestinal obstruction and took a plain abdominal radiograph (Figure 1), but found no abnormalities.
The patient complained of dysuria again, and suspected urinary tract infection.
The blood test showed that the white blood cells and CRP were indeed increased, but the urine test was normal.
After empiric antibiotic treatment, the abdominal pain improved.
Figure 1.
A plain abdominal radiograph at the time of the COVID-19 pandemic in the United Kingdom.
Many examinations were difficult to perform.
The doctor thought that since the abdominal pain improved and released him from the hospital, he still felt uneasy, and finally ruled out all difficulties and gave him an abdominal CT scan.
The truth finally came to light.
CT of the abdomen found that there was an exudation around the appendix.
Consider perforation with abscess formation (Figure 2). Figure 2.
CT of the abdomen, so the surgeon was asked to perform a laparoscopic appendectomy.
The appendix that had been perforated was cut off and the abdominal drainage was placed.
The patient recovered well after the operation and was discharged 3 days later.
Summary of experience Appendicitis is one of the most common acute abdomen.
If it is not treated in time, it is easy to cause inflammation to persist and cause recurring chronic pain.
Take the opportunity of this case discussion to review the main points of the diagnosis of appendicitis.
First, the location of the appendix is not static.
Therefore, the diagnosis of appendicitis cannot be ruled out simply based on the location of abdominal pain.
Because the relationship between the root of the appendix and the cecum is fixed, the position of the appendix can vary with the position of the cecum.
It can be as high as under the liver, or as low as the pelvic cavity, or even across the midline to the left.
The appendix itself can also have a variety of position changes, which can be behind the cecum, under the cecum, before the ileum, behind the ileum, and extending inward to the entrance of the pelvic cavity.
According to statistics, 75% of the appendix is in the posterior or inferior position of the cecum, and about 20% is in the pelvic position.
The pathophysiological mechanism of appendicitis is relatively simple.
The appendix lumen is narrow and rich in lymphoid follicles.
Once blocked, it will cause local expansion and ischemia, bacterial proliferation, and a series of outcomes such as inflammation, perforation, and necrosis.
Various infections, tumors, fecal stones, etc.
can easily cause the appendix lumen to be blocked, so any cause may cause appendix inflammation.
Especially during the epidemic period, cases of new crown combined with appendicitis have been reported many times.
In addition to the virus itself may invade the mucosa of the digestive tract, it is not ruled out that the new crown virus causes lymphoid follicular hyperplasia.
From the perspective of symptoms and physical examination, the classic metastatic right lower abdominal pain in acute appendicitis is only seen in about two-thirds of patients, and appendicitis patients with atypical symptoms are easily misdiagnosed.
To some extent, any abdominal pain should consider the possibility of appendicitis.
For chronic appendicitis, there are often no obvious symptoms between episodes, which increases the difficulty of diagnosis.
Especially for adolescents, due to the immature development of the greater omentum, it is not easy to be wrapped and limited after inflammation occurs, and there is little chance of this occasional "chronic abdominal pain".
Other possible causes need to be ruled out before the diagnosis of chronic appendicitis.
It can be seen that the accurate diagnosis of appendicitis requires necessary laboratory examinations and imaging examinations.
Studies have shown that among adult patients with right lower abdominal pain, only CRP is highly sensitive to appendicitis (96%), but has poor specificity (50%), combined with white blood cell count and neutrophils.
Ratio and CRP can increase the sensitivity to 99.
2%.
In imaging examinations, although abdominal ultrasound is more convenient and without radiation, CT is better for the diagnosis of appendicitis, with a sensitivity of 80%-96%.
It should be pointed out that for chronic appendicitis, the traditional view is that barium enema is necessary to rule out other diagnoses, but with the advancement of endoscopy technology, it may be better to choose colonoscopy.
Surgical treatment is generally recommended after the diagnosis of appendicitis is clear.
Laparoscopic surgery can complete most appendectomy.
Those who cannot tolerate surgery or the relatively clear simple appendicitis can also be treated conservatively with anti-infective treatment, but they need to bear the risk of further aggravation of the disease.
The choice of treatment requires good communication between the doctor and the patient.
There are many medical disputes caused by contempt of appendicitis, a "small problem".
In the future, patients with chronic abdominal pain should not forget to use appendicitis as one of the identification options.
References: [1]Tint NP,Hussain H.
Near miss abdominal pain.
BMJ Case Rep.
2021 Feb 4;14(2):e238883.
doi:10.
1136/bcr-2020-238883.
[2]Scott C,Lambert A .
Managing appendicitis during the COVID-19 pandemic in the UK.
Br J Surg.
2020 Jul;107(8):e271.
doi:10.
1002/bjs.
11752.
Epub 2020 Jun 3.
[3]Kim D, Butterworth SA, Goldman RD.
Chronic appendicitis in children.
Can Fam Physician.
2016 Jun;62(6):e304-5.
