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Perforated appendix not seen on CT scan

From an email received two days ago. Posted with permission and edited for length and clarity.

I came across your blog while looking for information on something puzzling that happened to my sister. I read the blog on CT scans and appendicitis* and went through all of the comments section. I couldn’t find a case like my sister’s.

She has been sick off and on for the last two months. It began with what seemed like a bad stomach virus, fever, throwing up, diarrhea, gas pain, bloating, and stomach cramps. She brushed it off as a 24 hour type thing, stayed home from work a few days, and felt better but never returned to normal. She would have intermittent stomach upset and began to have weight loss. About 3 weeks ago, she went to see her GP who ran some tests (antibody tests, no CBC, chem 7 or normal work up) and diagnosed her with gluten intolerance.

She changed her diet (no gluten), but one week ago, the massive cramps, vomiting, fever, diarrhea came back sending her to the ER. They found she was severely dehydrated with a dangerously low potassium level. Her hemoglobin was 6 (they had to give her blood), and her white blood cell count was through the roof! A CT scan showed what looked like inflammation in her abdomen and two masses near her ovary, one 12 cm the other 14cm. She was admitted to the ICU. Broad spectrum antibiotics were given and blood cultures came back positive for bacteria usually found in the bowel. After a few days on antibiotics, radiology drained the abscesses and removed 280 mL of pus.

At this point, she seemed to recover. The abscess fluid grew the same bacteria as the blood culture. The doctors weren’t sure what the origin of the infection was, but suggested Crohn’s or IBS.

She again spiked a temp. While having her drains irrigated, the tech saw more abscesses. She was scheduled for open surgery the next morning as they suspected a hole in the bowel. Two days ago, the surgery was performed, and a ruptured appendix was found. We were surprised the ruptured appendix had not been seen on the CT performed at the ER on night 1. They have since scanned her twice, and even after the surgery, they found more abscesses on her left side near her ovary. She had another drainage procedure this morning where two drains had to be inserted, because there was infection in the ovary as well. They are now confident all the infection has been cleared.

I can’t get past two things. The GP not doing standard bloodwork 3 weeks ago. More importantly, how does a ruptured appendix not show up on a CT scan? I read your blog and the conventional wisdom you expressed was if you can’t see the appendix on a CT there is no appendicitis. I cannot find a case like my sister’s as of yet. She is in a hospital bed with a vertical cut, drainage tubes, an NG tube, IVs, and just exhausted from this whole situation. I have great respect for the medical profession. My own children’s lives were saved by an incredible world class OB, my oldest daughter is premed and just took the MCAT. I understand doctors are not God and are human, but I’m stunned that a ruptured appendix was missed on a CT scan.

Have you seen or heard of this before?

That is quite a story. Thank you for bringing it to my attention.

I can only assume that the first CT scan did not show an appendix because it was probably already perforated. Due to the surrounding inflammation, it may have been unrecognizable as the appendix on the scan.

I have seen cases like this before. Your sister’s experience reinforces the point that even in the era of sophisticated imaging, appendicitis can be very difficult to diagnosis.

Regarding the GP not doing bloodwork, be aware that appendicitis cannot be diagnosed by bloodwork alone. An elevated white blood cell count is a nonspecific finding. Even if the GP had ordered a CBC, it would not have been definitive.

I already answered your question about why the appendix may not have been seen on the first CT scan. One would have to see the images to be sure, but diagnoses are easier to make in retrospect.

It sounds like your sister has had a rough time. I hope she is better soon.


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