Pediatric Appendicitis [Bounceback]
Case #75
A 14-year-old girl presented to the ED with abdominal pain.
She was febrile and tachycardic.
She had a poor appetite and the pain localized to the right lower quadrant.
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Labs were done showing a leukocytosis (exact level not listed in court documents).
Her ultrasound was successful in identifying the appendix.
It was not enlarged and there was no surrounding fluid.
However, an echogenic focus was seen in the appendix, suggestive of an appendicolith.
Given no sign of appendicitis on imaging, the patient was discharged home.
She had a follow-up appointment with her pediatrician the next day for a recheck.
Her pain had worsened.
The patient was referred to a different hospital.
At the 2nd hospital, she was taken to the OR for an appendectomy.
She was found to have peritonitis from a perforated appendix.
The patient had a prolonged hospital stay but made a full recovery.
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Her family hired an attorney and a lawsuit was filed.
The expert witness opinion is shown below:
The plaintiff and defense reached an agreement for a confidential settlement, and the lawsuit was withdrawn.
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MedMalReviewer Analysis:
Appendicitis is not just an imaging diagnosis. The ED physician probably felt reassured that the ultrasound report said there was no appendicitis. However, the presence of an appendicolith in the setting of fever, tachycardia, right lower quadrant pain, and anorexia should have prompted a surgical consult. The bedside clinician is responsible for synthesizing the HPI, lab results, and imaging results into a single diagnosis.
This case illustrates the importance of prompt follow-up (especially for pediatric patients with abdominal pain). The fact that the pediatrician saw the patient in less than 24 hours was critical to averting a terrible outcome.
Every potentially-risky discharge process should include 2 key items. These should be discussed with the patient and documented in the record.
Return precautions: What are the signs and symptoms for which a patient should return to the ED? It is wise to discuss 1-3 specific symptoms and include a general statement about returning if any new unexpected symptoms arise.
Follow-up instructions: Which doctor should the patient follow-up with, and what is the recommended time frame?
Even though the ED doctor still got sued despite the rapid follow-up, it prevented a catastrophic (potentially fatal) outcome for the patient. This saved the ED doctor from a far worse legal and financial outcome.
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A child with a history c/w acute appendicitis, RLQ tenderness, leukocytosis, and an abnormal appendix on u/s has previously been a classic, unambiguous indication for its removal. Things are changing and there seems to be a tendency to rely only on labs and imaging rather than considering the value of the H&P. There also seems to be pressure now to make early appendicitis a medical disease, something the surgeons are either uninterested in managing or excluded from involvement until the patient is in trouble. I would add concern as to the nuances of hospital culture in the management of such cases. Maybe their surgeons don't do pediatric cases or the particular surgeon on call is a piece of work. I am a general surgeon. I can't think of any surgeon who thinks a negative exploration in cases like this is worse than a missed appendicitis. This is an easy consult for us. Man up. Just call.
I do believe the PE is extremely important in patient care. I often hear from patients that the ER provider did not examine them. In this case the Physical Exam could have been critical. If the exam was negative and the labs and imaging were inconclusive, discharge and follow up may have been appropriate. If the PE was suggesting appendicitis, observation with serial exams or a Surgical Consultation would be warranted. If there was still concern, a CT scan could have been ordered.
Bottom line, a good History and Physical Examination may have prevented the serious complications.