Case Report

Posttraumatic appendicitis: further extending the extended Focused assessment with sonography in trauma examination

Abstract

Several cases of appendicitis after blunt abdominal trauma have been reported in the literature. A 41-year-old man on a cruise ship began to experience acute abdominal pain several hours after cliff diving from a 20-ft height and landing hard against the water on his right side. The patient’s symptoms were treated and he remained on the ship until its scheduled arrival in port 2 days later. In the emergency department, a bedside extended Focused Assess- ment with Sonography in Trauma (eFAST) examination showed no evidence of free fluid in the abdominal cavity, pericardial effusion, or pneumothorax. Next, an ultrasound of the right lower quadrant was performed, which revealed a

1.06 cm, noncompressible appendix consistent with appen- dicitis. Although physical examination remains the gold standard for evaluation of the acute abdomen, the presenta- tion of acute appendicitis is historically unreliable and delays in its diagnosis can result in significant increases in morbidity and mortality. Ultrasonography has been shown to have clear value in the evaluation of the acute abdomen. It is the authors’ opinion that ultrasonography may have an unrealized potential as a diagnostic tool for traumatic appendicitis in the trauma bay and as a triage tool for the cruise ship physician who must evaluate a patient with traumatic abdominal pain and determine the need for medical evacuation.

Several authors have published articles on cases of acute appendicitis after blunt abdominal trauma, yet none have discussed the potential application of an extended Focused Assessment with Sonography in Trauma (eFAST) examina- tion as a diagnostic tool for traumatic appendicitis [1-6].

A 41-year-old man on a cruise ship began to experience epigastric abdominal pain several hours after cliff diving from a 20-ft height and landing hard against the water on his right side. The following day, the pain was associated with vomiting and worsened in severity, localizing to the right lower quadrant. The patient was seen by the ship’s

physician who treated the patient’s symptoms with dicyclomine, metoclopramide, and morphine. The patient reported limited relief and was instructed to go directly to the emergency department (ED) upon scheduled arrival in port the following morning.

Upon arrival to the ED, an ultrasound (US) was performed by the treating emergency physician. An eFAST examination was performed to exclude the presence of posttraumatic hemoperitoneum, pericardial effusion, and pneumothorax. There was no evidence of injury. Next, an US of the right lower quadrant was performed to evaluate for appendicitis. The emergency physician noted the appendix to be noncompressible and have a “target” appearance with an enlarged outer diameter of 1.06 cm (see Fig. 1). The surgeon-on-call was consulted to evaluate the patient for appendicitis. After evaluating the patient, he requested a noncontrast Abdominal computed tomography, which con- firmed the diagnosis.

During laparoscopic appendectomy, a significant amount of fibrinous exudate was noted in the abdomen, but no appendiceal perforation was identified. The patient recov- ered without complications. The outcome in this case is fortunate. A delay in the diagnosis and treatment of acute appendicitis can result in perforation, which significantly prolongs hospitalization and increases morbidity and mor- tality [7,8]. Rupture rates rise significantly after 36 hours [9], and the odds for progressive pathology are 13 times higher in patients with a greater than 71-hour interval between onset of symptoms and surgery when compared to those with an interval of less than 12 hours [10].

Although physical examination remains the gold standard for evaluation of the acute abdomen, the presentation of acute appendicitis is historically unreliable, with the classic findings present in only 60% of cases [8]. In 1986, Puylaert

[11] described a graded compression technique for evaluat- ing the appendix with transabdominal sonography. A high- frequency linear array transducer is most commonly used with a posterolateral approach that allows evaluation of the retrocecal area. An outer diameter greater than 6 mm, noncompressibility, lack of peristalsis, or periappendiceal fluid collection is considered characteristic of an inflamed appendix. Rettenbacher et al [12] found that a diameter of

6 mm had 100% sensitivity, 68% specificity, and 79%

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Fig. 1 A, Short-axis view of the appendix with enlarged outer diameter of 1.06 cm. B, Short-axis view of the appendix with “target”

appearance. C, Long-axis view of the appendix showing enlargement.

accuracy. A diameter of 7 mm or more raises the specificity to 88% and the accuracy to 90% but lowers the sensitivity to 94%. Other useful criteria for diagnosis include hyperechoic periappendiceal fat, increased blood flow of appendix using Color Doppler, and the presence of an appendicolith [8].

Ultrasonography has been shown to have significant value in the evaluation of the acute abdomen. Previous authors have suggested that in the setting of Right lower quadrant pain after blunt abdominal trauma, acute appendi- citis should be considered as a possible diagnosis [3,6]. To our knowledge, there are no reports in the literature of extending the eFAST examination to include evaluation of the appendix in trauma patients with right lower quadrant pain. Although sonographic evidence of appendicitis can take several hours to develop after the initial injury, using US as a diagnostic tool for traumatic appendicitis may be of benefit in patients with a Delayed presentation to the ED. In addition, US may be of use for patients who present immediately after injury and have increasing right lower quadrant pain despite a negative computed tomography.

At sea, US could play a significant role in the decision to request a medical evacuation for a patient. The “Health Care Guidelines for Cruise Ship medical facilities” [13], reaf- firmed by the American College of Emergency Physician’s Board of Directors in December 2007, does not include a recommendation for US, and there remains a yet unfulfilled and possibly underappreciated potential for onboard US. A pilot study by Nikolic et al [14] demonstrated the ability to train merchant ship officers to produce diagnostically usable US pictures, a finding that supports the need for further research into the usefulness of such a tool to the maritime medical practice. Cruise ship physicians could undoubtedly be trained to obtain and interpret such diagnostic images, relying on interpretation by telesonography as necessary.

A recent study concluded that sonography should be the

first imaging technique in the evaluation of the adult patient

with acute abdominal pain [15]. In our case, we found the sonographic evaluation of the appendix to be a useful extension to the FAST examination. It is our hope that emergency medicine physicians will remain at the forefront of sonographic imaging, advocating both its current applications and future prospects.

Charlotte Derr MD

Emergency Medicine Residency Program

University of South Florida Tampa, FL 33606, USA

E-mail address: [email protected]

D. Eliot Goldner AB University of South Florida Tampa, FL 33606, USA

doi:10.1016/j.ajem.2008.09.014

References

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