Abdominal pain in a common presentation to the Emergency Department. Differentiating benign causes for this symptom from more serious illness is one of the skills required by the Emergency Medicine clinician and one that if not accompanied by notes that allow an understanding of the process involved in reaching a presumptive diagnosis may lead to allegations of negligence.

In an earlier post I discussed ectopic pregnancy that is a serious and possibly life threatening cause of abdominal pain.

Today I want to discuss how another surgical emergency, appendicitis, can be mis-diagnosed in the Emergency Department. It is important that the diagnosis is made in a timely manner as evidence shows that prompt diagnosis and treatment can reduce the risk of complications, (Lewis, 2011) while the delay of diagnosis and treatment accounts for much of the mortality and morbidity associated with this disease. (Tschuor, 2012).

The classical presentation of appendicitis includes tenderness and pain on the right side of the abdomen, especially when moving, coughing or applying pressure to the area. Additional symptoms may include nausea, swelling. constipation and fever. However, these symptoms and signs are far from present in all cases only being present in around 50% of patients and there can be a wide range of other symptoms that can mimic other illnesses, but can be due to appendicitis.

An appendicectomy, the surgical removal of the appendix, is the main treatment recommended in the care of people with appendicitis. A missed or delayed diagnosis can mean a delay of this necessary surgical intervention, which can lead to a ruptured appendix and serious, life-threatening complications. 

Therefore, to meet the expected level of care, NICE recommends having a low threshold for admitting certain groups of people with suspected appendicitis. These include:

• Infants and young children.
• Elderly people.
• Pregnant women.
• People with signs of complications.

These groups are at an increased risk for a missed diagnosis because they often do not have the classical presentation associated with appendicitis.

Getting a good history in the Emergency Department may be difficult in the very young or the elderly and confounding factors such as the non specific symptoms often associated with common gastro-intestinal upsets such as gastritis may be the prominent presenting complaint.

In pregnant women where the expanding uterus pushes the guts and therefore the appendix upwards and the site of tenderness may be different from that of the non-pregnant patient. Such delays in making the diagnosis can not only be detrimental to the mother but also may cause foetal morbidity and mortality.

If a doctor in the Emergency Department considers that appendicitis is in the differential diagnosis the patient should be referred to the surgical team for further assessment, even if this is only a period of observation or for further imaging.

Not to actively consider the diagnosis  and seek appropriate specialist advice can lead to the diagnosis being missed and to the patient requiring more extensive surgery with the associated risks that this may entail.