General Surgeon Fails To Diagnose Appendicitis In Symptomatic Patient

Case Overview

This case involves a woman who presented to the hospital after experiencing persistent lower abdominal pain. The emergency physician suspected appendicitis and ordered a CT. The report showed thickening of the appendix and accumulation of fluid in the peritoneal cavity. Although the differential on the CT report included a ruptured appendix, the general surgeon diagnosed the woman with diverticulosis and began antibiotic treatment. While the woman was in the hospital, her appendix ruptured and she developed sepsis, prompting a long recovery. An expert in general surgery was requested to review the records and opine on whether the surgeon missed the diagnosis of a ruptured appendix that sepsis in this patient.

Questions to the General Surgery expert and their responses

How often do you treat patients with appendicitis?

I see a lot of patients with acute appendicitis in my practice, as I participate in the acute care surgery call schedule at my institution. I operate on an average of 6-8 patients with acute appendicitis per month, with various degrees of severity, from simple to perforated.

What are the clinical and image findings of a ruptured appendix?

The clinical findings are generally suggestive of acute abdomen with tenderness to palpation in right lower quadrant, but in late stages, diffusely throughout the abdomen. These should warrant an emergent surgical intervention. CT scan images usually show free intraperitoneal fluid, sometimes small amount of free air or extravasation of contrast. The appendix appears thick with surrounding inflammation. These typical findings are not encountered in all patients and the decision to operate should be made based on the clinical exam in the first place.

About the expert

This expert has over 10 years of experience in the field of general surgery. He earned his MD from the Ovidius University School of Medicine in Romania and completed an internship and a residency in surgery at the Constanta County Hospital, also in Romania. Soon after, he moved to the United States, where he earned his PhD in medical informatics from Virginia Commonwealth University and subsequently completed a second internship and residency in general surgery at Saint Mary's Hospital, followed by a prestigious fellowship in minimally invasive surgery at the Yale School of Medicine. Today, this expert is board certified in general surgery and is a member of several professional organizations, including the Americas Hernia Society, the Clinical Robotic Surgery Association, the American Society for Parenteral and Enteral Nutrition, and the Society of American Gastrointestinal and Endoscopic Surgeons. In addition, he is well-published in his field and has been awarded 3 prestigious research grants on various hernia topics. This expert previously was an attending surgeon at Hahnemann University Hospital and at Yale-New Haven Hospital, an instructor of surgery at the Yale School of Medicine, an assistant professor of surgery at Drexel University, an attending surgeon at AtlantiCare Physician Group, and an assistant professor of surgery at Geisinger Commonwealth. Currently, he serves as the president of a gastroenterology clinic and as the surgery division chief at an independent health system in Minnesota.

E-008637

Specialties:

General Surgery