Misdiagnosis of Appendicitis


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Misdiagnosis of appendicitis is one of the five most common causes of medical malpractice lawsuits against emergency room physicians. Between five and ten percent of emergency room patients complain of abdominal pain. But only a small portion of those patients have appendicitis. Timely diagnosis of appendicitis is critical because a delay can cause the appendix to burst, resulting in infection and surgical complications.

Diagnosis of appendicitis can be difficult. Studies tend to show that appendicitis is properly diagnosed in 75 – 90% of cases. Diagnosis tends to be easiest in male patients between 18 and 50 years of age. Possible pregnancy-related complications among female patients and a possibly displaced appendix among children, elderly, or obese patients tend to complicate diagnosis for those populations.

This article discusses the diagnostic procedure that doctors will use to determine whether a patient has appendicitis, identify some maladies with symptoms similar to appendicitis, and briefly describe what a lawsuit for misdiagnosis of appendicitis might look like.

Proper Diagnostic Procedure for Appendicitis

Appendicitis is an inflammation of the appendix, which is a 3 ½ inch tube attached to the large intestine. Since the appendix serves no critical function in the body, it should be surgically removed when it becomes inflamed.

The most common signs and symptoms associated with appendicitis are considered “classic indications.” These include:

  • right lower quadrant abdominal pain
  • anorexia, and
  • nausea and vomiting.

However, patients suffering from appendicitis do not always have the same signs and symptoms. Appendicitis can also cause the following symptoms:

  • indigestion
  • flatulence
  • bowel irregularity
  • diarrhea, and
  • generalized malaise.

A doctor who suspects that appendicitis is a possibility will usually order a Complete Blood Count (CBC). Approximately 80% of patients with appendicitis have leukocytosis (an elevated white blood cell count).

By examining a patient’s medical history, present symptoms and CBC results, a physician should be able to diagnose or rule out appendicitis in most cases. One system commonly used for this purpose is the modified Alvarado scale, which creates the following points system:

  • migratory right lower quadrant abdominal pain (1 point)
  • anorexia (1 point)
  • nausea/vomiting (1 point)
  • tenderness in the right lower quadrant of the abdomen (2 points)
  • rebound tenderness in the right lower quadrant of the abdomen (1 point)
  • fever >37.5 degrees C (1 point), and
  • leukocytosis (2 points).

The point totals are used to guide management:

  • A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be discharged with advice to return if there was no improvement in symptoms.
  • A patient with a score of 4 to 6 would be admitted for observation and re-examination. If the score remains the same after 12 hours, operative intervention is recommended.
  • A male patient with a score of 7 to 9 would proceed to appendectomy.
  • A female patient who is not pregnant would undergo diagnostic laparoscopy, then appendectomy if indicated by the intraoperative findings.

When a physician is unable to determine whether appendicitis is present based on the above factors, radiographic imaging, such as a CT scan or ultrasonography may be used to assist in diagnosis. But imaging is generally considered unnecessary in most cases.

Misdiagnosis of Appendicitis

A variety of syndromes can mimic the symptoms of appendicitis. Below are a few that are particularly difficult to distinguish from appendicitis:

Cecal diverticulitis. This syndrome involves bleeding present in the colon. Patients suspected of having appendicitis may be given a colon exam in order to rule out cecal diverticulitis. Aside from the bleeding, the symptoms of cecal diverticulitis are nearly identical to those of appendicitis.

Crohn's disease. Symptoms of Crohn’s disease include fatigue, diarrhea, abdominal pain, weight loss, and fever. When a physician is unsure whether a patient is suffering from appendicitis or Crohn’s disease, an imaging test should be performed of the appendix. If the appendix is not inflamed, Crohn’s disease is likely.

Gynecologic conditions. A variety of gynecologic conditions, most commonly ectopic pregnancy and pelvic inflammatory disease, can also have symptoms similar to appendicitis. But both have additional symptoms, depending on the type of gynecologic condition. When female patients are involved, these conditions should be ruled out before a diagnosis of appendicitis is made.

Proving That Misdiagnosis Amounts to Malpractice

In assessing most patients who present with a potential health problem, a doctor performs what’s called a differential diagnosis. This means making a list of possible medical conditions that could be behind the symptoms, conducting a series of tests, then ruling out different conditions that don’t match up to test results -- until a definitive diagnosis can be made. So, let’s take the case of a patient who presents with potential symptoms of appendicitis, but the doctor fails to properly diagnose the condition, treating the patient for some other condition.

In order to hold the doctor legally liable for medical malpractice, the patient (usually through his or her attorney and a retained medical expert witness) will show how the doctor deviated from the accepted medical standard of care in conducting the differential diagnosis -- first walking the jury through what a reasonably skilled physician would have done under similar circumstances, and then showing how the doctor’s chosen course of treatment in the instant case failed to meet that standard. If the patient is able to convince a jury that the doctor failed to meet the appropriate standard of care and that failure caused harm to the patient, the patient will win the medical malpractice lawsuit.

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