Article, Emergency Medicine

Acute appendicitis presenting as acute diarrhea accompanying hypokalemia

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American Journal of Emergency Medicine

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Acute appendicitis presenting as acute diarrhea accompanying hypokalemia


Acute appendicitis, characterized as periumbilical pain, migrating to the right iliac fossa, is one of the most common acute surgical conditions. It is usually diagnosed on the basis of clinical signs and symptoms. However, some patients may present atypically and are prone to be misdiagnosed. We report this first case of acute appendicitis who presented initially with complain of diarrhea accompanying hypokalemia. There have been no published data suggesting its existence in any parts of the world.

A 57-year-old woman with no medical and surgical history presented to our emergency department with complains of fever and diarrhea for 1 day. She reported nausea and weakness but denied any abdominal pain and vomiting.

At that time, her temperature was 39?C, heart rate was 100 beats/ min, and blood pressure was 95/60 mm Hg. Cardiovascular and respiratory system was entirely normal. While examining her abdomen, she had flat and soft abdomen with decreased bowel sounds. Furthermore, there was no any rebound tenderness and voluntary guarding while palpating her abdomen. Laboratory results included the following: leukocyte, 15.5 x 109/L with neutrophils 92%; hemoglobin level, 109 g/L; and platelet count, 286 x 109/L. serum potassium level was 2.2 mmol/L. Urinalysis report was normal. Stool examination demonstrated that there was leukocyte (6-8/High Power Field). U-wave and prolonged QT interval were revealed on the electrocardiogram. Ultrasound scan of the abdomen was within normal limit, except that there was some intestinal dilatation.

A diagnosis of acute diarrhea accompanying hypokalemia was made. Empirical intravenous antibiotic and oral potassium chloride treatments were administered for 3 days, but she did not improve and again visited our emergency department. She was still having fever and diarrhea (5-6 times/d). Her abdomen was flat and soft with no rebound tenderness and voluntary guarding. Laboratory results included the following: leukocyte, 19.5 x 109/L with neutrophils 95%. Serum potassium level was 2.9 mmol/L. Stool examination also demonstrated that there was leukocyte (5-6/High Power Field). Therefore, she was admitted to emergency ward because of clinically insignificant improvement.

Suddenly, she complained of lower abdominal pain on day 1 after hospitalization. Her blood pressure was 100/60 mm Hg, and physical examination at this stage revealed mild tenderness, guarding, and rebound over the lower abdomen. A Transvaginal ultrasound scan was performed, and pelvic cysts were found. At last, a diagnosis of pelvic abscess was suspected by the surgeon and gynecologist. As a result, Exploratory laparotomy and abscess incision drainage were per- formed on day 2.

On exploration, a necrotic appendix with rim of pus and 2 abscesses (medial of the appendix and posterior to the uterus, respectively) were identified. In addition, congestion, inflammation, and edema were demonstrated at the cecal wall, Small intestine mesentery, sigmoid colon, right accessories, and uterus.

Finally, the patient was intraoperatively diagnosed as having periappendiceal abscess. Fever subsided after the operation, and she recovered uneventfully. She was discharged on day 14 of hospitalization. We could not identify any distinct reason that induced hypokalemia.

On outpatient follow-up, the surgical incision site was healing well without any signs of infection.

About 70% to 80% patients with acute appendicitis present typically with periumbilical pain, migrating to the right iliac fossa. It is usually diagnosed on the basis of clinical findings such as fever, Right lower quadrant abdominal pain, tenderness, and muscle guarding. However, the accuracy of clinically based diagnoses depends on the clinician’ experience and has been reported to range from 71% to 97% [1].

There may be some variations regarding clinical presentation of appendicitis and due to its varied location in the cecum. The rectum is susceptible to be irritated by certain types of appendicitis (such as pelvic appendicitis) and may lead to increasing frequency of bowel movements. Moreover, the aged patients had acute appendicitis or appendix located posterior to the colon, the clinical presentation of which might be atypical.

The versatility of the technique, increasingly shorter acquisition times of magnetic resonance imaging, and the increasing awareness of radiation-related health risks associated with computed tomography have resulted in more frequent use of MR imaging in the diagnostic workup for several acute abdominal conditions [2]. Inci et al [3] reported that the use of diffusion-weighted imaging was beneficial in the identification of acute appendicitis because the inflamed appendix was conspicuous on diffusion-weighted images. The appropriateness criteria of the American College of Radiology include a recommendation for the use of MR imaging in pregnant women suspected of having appendicitis when ultrasound scan examination results are negative or inconclusive [4].

This 57-year-old female patient we reported only presented with acute diarrhea accompanying hypokalemia, and there was no abdominal pain at the onset of disease. Appendicitis was only confirmed during exploratory laparotomy. This study cannot entirely explain why the patient only presented with diarrhea accompanying hypokalemia but no abdominal pain at the onset of disease. We only speculate that it may be related to the patient’s age and location of the appendix. Furthermore, in this case report, it is unclear whether the acute appendicitis and diarrhea were related or coincidental

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pathologies; it may be the case that primary diarrhea is caused by secondary appendicitis.

Li Jun Wang MM

Department of Emergency Medicine Tianjin Medical University General Hospital

Tianjin, China E-mail address: [email protected]

Samjhana Basnet MM

Emergency Department National Academy of Medical Sciences (NAMS) Bir Hospital

Kathmandu, Nepal

Xiao Qin Du MM

Department of Science and Education, Tianjin Central Hospital of

Gynecology Obstetrics, Tianjin, China

Song Tao Shou MD

Department of Emergency Medicine Tianjin Medical University General Hospital

Tianjin, China


  1. John H, Neff U, Kelemen M. Appendicitis diagnosis today: clinical and ultrasonic deductions. World J Surg 1993;17:243-9.
  2. Leeuwenburgh MMN, Wiarda BM, Bipat S, et al. Acute appendicitis on abdominal MR images: training readers to improve diagnostic accuracy. Radiology 2012;264(2):455-63.
  3. Inci E, Kilickesmez O, Hocaoglu E, et al. Utility of diffusion- weighted imaging in the diagnosis of acute appendicitis. Eur Radiol 2011;21(4):768-75.
  4. Rosen MP, Ding A, Blake MA, et al. ACR Appropriateness Criteria(R) right lower quadrant pain–suspected appendicitis. J Am Coll Radiol 2011;8(11):749-55.

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