How Often Does Appendicitis Perforate?


Patient Presentation

A 3-year-old male was transferred after 24 hours of abdominal pain, diarrhea and emesis. He had at least 15 loose-watery yellow stools without blood over the past 12 hours but these seem to be decreasing more recently.

The emesis occurred 3-4 times with the last emesis about 4 hours ago. The emesis is yellow stomach contents.

The abdominal pain is described as being in the lower abdomen.
His mother also noted that in the past few hours he has had decreased urine output.

The review of systems was negative.

In the local emergency room he was noted to have a temperature of 101.9 degrees F, laboratories consistent with moderate dehydration, and air fluid levels on the abdominal radiograph. The complete blood count showed white blood cells of 13.5 x 1000/mm2 and a urinalysis with 10 white blood cells/high power field.

The pertinent physical exam shows a tired preschooler in mild pain. Temperature is 101.5 degrees F and other vital signs are normal. Lungs are clear to ausculatation and percussion. Abdominal examination shows mild distention, slightly decreased bowel sounds,
tender to minimal touch with no guarding or localization. Rectal examination showed pain and a mass in the right lower quadrant. Genitourinary examination reveals no inguinal hernia. The remainder of his examination was normal.

The repeated laboratory evaluation shows a complete blood count of 16.2 x 1000/mm2.

The radiological evaluation was a repeated abdominal radiographs demonstrating multiple dilated loops of small bowel with air fluid levels. There is also a suggestion of a soft tissue fullness in the right lower quadrant which is displacing the bowel.

. The patient was taken to the operating room where an exploratory laparotomy revealed the diagnosis of a ruptured appendix and pus surrounding
the appendix. An appendectomy and decontamination of the abdomen were performed. He was placed on intravenous antibiotics.

His clinical course over the next few days showed that he had a decreasing fever curve on antibiotics for 5 days. He was discharged home on day 6 off of antibiotics.


Supine (left) and upright (right) radiographs of the abdomen demonstrate multiple dilated loops of small bowel with air fluid levels. There is also a suggestion of a soft tissue fullness in the right lower quadrant which is displacing the bowel loops centrally.

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