“Appendicitis is one of the most common surgical emergencies in the United States. However, the diagnosis of appendicitis is missed in 3.8%-15.0% of children and 5.9%-23.5% of adults during emergency department (ED) visits. Appendicitis is the second most common condition among pediatric patients and the third most common condition cited in adult malpractice insurance claims.”¹
Case Study #1: 10-year-old Robby
”Robby,” a 10-year-old male presented to the emergency room with poor appetite for three days, vomiting, stomach pain, side pain, nausea, and diarrhea. He was seen by a physician assistant (PA), who did a Jump Test for appendicitis. The test was negative for rebound pain, although this was not documented.
The care plan included antibiotics, labs, Zofran for nausea, Tylenol for pain, and instructions to return to urgent care if his condition persisted or worsened.
Three days later, Robby returned to urgent care and was seen by a pediatrician, Dr. A. Robby continued to have abdominal pain, persistent fever and diarrhea, and a newly increased white blood count (WBC). Dr. A. diagnosed Robby with infectious diarrhea and prescribed antibiotics. Unfortunately, Robby ultimately developed a perforated appendix with peritoneal abscess and sepsis, requiring surgery and a prolonged hospitalization with intubation and multiple blood transfusions. He suffered septic shock and ileus. Luckily, Robby survived, but not without significant clinical decline, suffering, and substantial medical interventions.
The family filed a lawsuit, and the case was settled.
Case Study #2: 75-year-old Thomas
“Thomas,” a 75-year-old male presented to his primary care physician, Dr. D., complaining of abdominal pain. Dr. D. diagnosed him with dehydration secondary to gastroenteritis. Three days later, Thomas was transported to the ED with severe abdominal pain and diarrhea with bleeding. Lab results revealed a WBC of 16,000 with left shift.
The ED physician ordered an abdominal CT for non-specific abdominal pain. Radiologist #1 identified a distended gallbladder, 4.5 cm abdominal aortic aneurysm (AAA) and adynamic ileus. Thomas was admitted to the hospital by Dr. O. Diagnoses were gastroenteritis, acute renal insufficiency secondary to gastroenteritis, hypokalemia, and AAA. Orders were given for overnight Phenergan and IV fluids with a plan to reevaluate the patient the following day. On his first night in the hospital, the night nurse noted that Thomas’ abdomen was firm upon palpation with decreased bowel sounds. However, the nurse did not notify the physician of these findings.
Thomas continued to complain of abdominal pain and serial plain view X-ray images were ordered. Radiologist #2 read the films as suspicious for a mechanical small bowel obstruction and recommended a surgical consult. This recommendation was not acted on until two days later when Surgeon A consulted the patient and suggested conservative care, with no surgical intervention. The following day, Thomas’ condition deteriorated, so Surgeon A performed an exploratory laparotomy which revealed a very large peritoneal abscess, purulent peritonitis, and perforated appendix.
Thomas was subsequently followed by multiple specialists including nephrology, pulmonology, and neurology. Unfortunately, Thomas never recovered from surgery and expired nine days post admission due to metabolic encephalopathy secondary to sepsis. Following the patient’s death, the initial CT scan was reread—findings consistent with appendicitis were evident.
Thomas’ family filed a lawsuit, and the case was settled prior to trial.
Case Study #3: A Family Affair
Appendicitis is the most common cause of sudden (acute) belly pain that requires surgery. It mostly happens in teens and young adults in their 20s, but it can happen at any age. Having a family history of appendicitis may raise your risk, especially if you are a male.²
"Bryan," a 16-year-old male, was one of three sons in his family of five. Both of his brothers had previously had an appendectomy. One night, Bryan developed severe abdominal pain that kept him up all night. When he arrived at the ED for an evaluation, he looked “good” and felt better. During the history intake, Bryan told the ED physician about his two brothers’ prior appendectomies and shared that his father and both of his grandfathers all had appendicitis. Upon hearing this, the ED physician said, “Say no more. I’m ordering a CT, and I expect you will be having surgery today.” Indeed, Bryan was diagnosed with appendicitis and an appendectomy was performed that day.
Interestingly, while Bryan and his family all shared the diagnosis of appendicitis, they each had a different presentation. Bryan’s oldest brother was affected with intense pain intermittently for a few months, thinking that it was a bad case of constipation. Bryan’s middle brother presented to an urgent care center with such intense pain that his eyes rolled back in his head and his blood pressure dropped dangerously low, requiring paramedic transport to the hospital.
Fortunately, in Bryan’s case, the ED physician was aware of his significant family history and ordered a CT scan rather than an X-ray. According to one study, patients with a potentially missed diagnosis of appendicitis were more likely to be examined using only abdominal radiography during the initial ED visit.³
Risk Management Strategies
In light of the cases above, providers should consider these risk management strategies when presented with patients complaining of abdominal pain to help keep patients safe and minimize risk:
Gender Considerations
- Perform a detailed history when evaluating males with abdominal pain. Include questions as to whether other male family members have had appendectomies.
- While the featured cases represent male patients, it is important to note that a missed diagnosis of appendicitis was more likely to occur in women patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation.³
- With pregnant women specifically, providers must maintain a high index of suspicion for appendicitis, as the symptoms can mimic common pregnancy-related discomforts, and the obstetrician should also be involved in the medical evaluation. Similarly, an elevated WBC is not reliable in pregnant women due to normal physiological changes in pregnancy.4
Documentation
Document intake information and assessments carefully. In the first case, the patient and parents reported that the pain was in the right lower quadrant, not the right upper quadrant as was documented. This created a credibility issue between the family and providers. Additionally, the Jump Test and findings were not included in the medical record. Documentation of this test and the corresponding findings may have released the PA from the claim.
Follow-up Visits
Proactively schedule follow-up visits rather than leaving it up to the patient or guardian to determine if a return visit is indicated. Schedule a follow-up visit to reevaluate the patient and the probability of appendicitis.
Independent Clinical Evaluations
Cognitive biases are hypothesized to influence physician decision-making.5 One such cognitive bias is anchoring bias, under which physicians focus on a single—often initial—piece of information when formulating a diagnosis without sufficiently adjusting to later information.5 In the second case, several physicians relied on the original misread CT scan written report without reviewing the actual CT scan images. Had other physicians independently reviewed the CT images, it
may have accelerated the diagnosis of appendicitis
and surgical intervention, and helped to save the patient’s life.
Effective Communication
Timely communication of significant findings, i.e., change in the patient’s condition (firm abdomen and diminished bowel sounds) or abnormal test results with recommendation for surgical consult may not have changed the outcome in the second case due to anchoring bias. However, in other cases, effective communication of this information may alert a physician that a more serious issue is developing, and a surgical consult needs to be completed sooner.
Because symptoms of appendicitis can be diverse, the risk management strategies detailed above become increasingly important for avoiding misdiagnosis and improving patient outcomes.
Dona Constantine, RN, BS, is a Senior Risk Management and Patient Safety Specialist. Questions or comments related to this article should be directed to DConstantine@CAPphysicians.com.
Sources
¹Mahajan P., Basu T., Pai CW., Singh H., Petersen N., Bellolio MF., Gadepalli SK., Kamdar NS., Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department, National Library of Medicine, JAMA Network Open, 2020 Mar 9, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063499/
²Appendicitis, Health, Johns Hopkins Medicine, The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System, accessed September 5, 2024; https://www.hopkinsmedicine.org/health/conditions-and-diseases/appendic…
³P Mahajan P., Basu T., Pai CW., Singh H., Petersen N., Bellolio MF., Gadepalli SK., Kamdar NS., Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department, National Library of Medicine, JAMA Network Open, 2020 Mar 9, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063499/
4Weinstock, M. B., & Longstreth, R. (2017). Bounce backs! Emergency department cases: ED returns. Commentary by G. L. Henry. Anadem Publishing, p. 416.
5Ly DP, Shekelle PG, Song Z., Evidence for Anchoring Bias During Physician Decision-Making, National Library of Medicine, JAMA Intern Med,. 2023 Aug 1, https://pubmed.ncbi.nlm.nih.gov/37358843/