‘Missed’ Appendicitis: A Continuing Diagnostic Challenge
RICHARD G. FARMER, M.D.
Department of Gastroenterology
RUPERT B. TURNBULL, M.D.
Department of General Surgery
DESPITE advances in diagnostic technics the early recognition of appendicitis continues to be a major diagnostic problem. Approximately 200,000 cases of appendicitis are recognized in the United States each year, associated with an overall mortality rate of about 1 percent.1 Perforation with abscess and/or peritonitis continues to be the most important factor in mortality.2–4 This complication occurs in about one patient in six,1 and the mortality rate increases significantly among those patients with coexisting systemic disease, the very young, the very old, and pregnant women.1,2
In the effort to prevent appendiceal perforation an early diagnosis must be made and an operation be performed within 36 or 48 hours after the onset of symptoms.5 Obviously, this diagnosis requires a high index of suspicion on the part of the physician, and attempts have been made to categorize the early symptoms suggestive of appendicitis. Cope6 described the following sequence of symptoms and findings for appendicitis: epigastric or umbilical pain, nausea or vomiting, local iliac tenderness, fever, and leukocytosis. Bonilla, Hughes, and Bowers5 consider that the features suggesting appendiceal rupture are: duration of symptoms for longer than 48 hours, elevation of body temperature to more than 103 F., physical signs of peritonitis, leukocyte count of more than 20,000 per cubic millimeter, and a palpable abdominal mass. However, development of generalized peritonitis after appendiceal perforation is not inevitable, and a pelvic abscess of considerable proportion may develop without other characteristic features.2,7 Cope6 described the perforated pelvic appendix as “. . . one of the most . . .