Ifrah Z. Butt, MD1, Shany M.. Quevedo, MD2, Steven Kaplan, MD1 1HCA Florida Aventura Hospital, Aventura, FL; 2HCA East Florida Division, Aventura, FL
Introduction: Multiple etiologies can contribute to left-sided abdominal pain, however, an easily missed diagnosis is left-sided acute appendicitis. Some studies report rates of misdiagnosis as high as 24% with increasing concern for risk of complications due to lack of surgical intervention in a timely manner. We present a case of an elderly female who was being treated for acute sigmoid diverticulitis as an outpatient but failed medical therapy and was found to have acute appendicitis.
Case Description/Methods: A 92-year-old female presented to the emergency department with complaints of left lower quadrant abdominal pain that started two weeks prior. She was initially seen at another facility and treated for acute uncomplicated sigmoid diverticulitis. Her symptoms improved initially, but she had some residual pain so she was given a prolonged course of oral antibiotics as an outpatient. After a few days of oral antibiotic therapy, her symptoms began to worsen again, now associated with fevers and nausea, prompting her to visit the emergency department. On initial presentation, her vitals were stable and labs were unremarkable. Physical exam showed exquisite left-sided tenderness to palpation with guarding and rebound. Computed tomography (CT) scan of the abdomen and pelvis showed a long and inflamed right-sided appendix, projecting across the midline towards the left lower quadrant. She was treated with intravenous antibiotics and laparoscopic appendectomy and reported complete resolution of symptoms post-operatively.
Discussion: Acute appendicitis is a common surgical emergency. Left-sided acute appendicitis is a frequent cause of misdiagnosis in acute appendicitis, and it should always be considered. The major causes of left-sided acute appendicitis include midgut malrotation, situs inversus totalis or a long right-sided appendix projecting into the left lower quadrant, as in our patient. Immediate diagnosis will allow for prompt surgical intervention, however, a misdiagnosis can delay surgery and lead to complications including abscess formation and perforation. Per literature review, after 36 hours of untreated symptoms, the risk of perforation is increased by 5% for every 12-hour period. Hence, it is important to have a high index of suspicion for a favorable outcome for a condition with a relatively low morbidity and mortality.
Figure: Series of CT abdomen and pelvis images from cranial to caudal (A-C) showing the long and inflamed right-sided appendix projecting towards the left quadrant (arrow).
Ifrah Butt indicated no relevant financial relationships.
Shany Quevedo indicated no relevant financial relationships.
Steven Kaplan indicated no relevant financial relationships.
Ifrah Z. Butt, MD1, Shany M.. Quevedo, MD2, Steven Kaplan, MD1. P3080 - Misdiagnosis of Left Lower Quadrant Pain, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.