With visits to emergency departments at an all-time high, emergency room negligence and malpractice is an ever-present threat. The failure to diagnose appendicitis in children coming to the emergency room with belly pain is a common cause of medical malpractice in the emergency room.
When a child is brought to the emergency room a thorough, careful, and unrushed history is vital in order to differentiate appendicitis from other problems. The presence of belly pain is an important component of the history. Pain is often felt as dull and steady. If the pain has awakened the child from sleep, this is an important red flag for acute appendicitis. Very often the pain is accompanied, preceded, or followed by loss of appetite. Vomiting is common, and almost always follows the onset of pain.
Untreated, appendicitis typically progresses in a predictable way: abdominal pain followed by nausea, vomiting, and localization of the pain to the right lower quadrant.
A hands-on, physical examination is important. It is said that if a child can jump up on the examining table he does not have appendicitis, but this is not a hard and fast rule. Abdominal tenderness or pain is almost always present on palpation and is often greatest at the McBurney point, hence a “positive McBurney’s sign.”
It is vital that blood be drawn for a blood count and that urine is taken for a urinalysis. When appendicitis is present the white blood cell count is most often in the range of 10,000 to 20,000/mcL, with a characteristic slight increase in the number of neutrophils. Urinalysis is performed to rule out urinary tract infection as a cause of the illness.
CT imaging and ultrasound are helpful in making an early diagnosis before perforation and life threatening peritonitis occurs.
It is said in medicine that you must treat the patient and not the imaging studies, so a white blood cell count of greater than 10,000/mcL and the presence of rebound abdominal tenderness should be considered to be highly suggestive of appendicitis and prompt surgical evaluation should take place without the need for imaging studies.