Delayed Diagnosis of Gangrenous Appendix Leads to Life-Threatening Infection

Case Overview

This case involved a patient who complained of severe epigastric pain that was not well characterized. The pain waxed and waned over the course of the past few days but became progressively worse before arriving at the hospital. The patient’s working diagnosis in the ER was Gastritis and the doctors began treatment with Maalox, Oral Lidocaine, Pantoprazole, Hydromorphone, and Ondansetron. The patient was deemed stable and discharged the same night with instructions to avoid stomach irritants such as alcohol, caffeine, or spicy food.

The patient returned to the hospital that same day with increased pain and further CT workup showed a dilated appendix to approximately 12mm at which point the patient was taken for an emergent laparoscopic appendectomy. Medical records indicate that at the time of removal the appendix was nearly gangrenous and burst upon being grasped. The patient suffered post-operative infection/abscess due to the rupture and spillage of infected fecal tissue into the abdominal cavity.

Questions to the Emergency Medicine expert and their responses

What is the standard operating procedure for ruling out emergent cases such a severe abdominal pain and a possible ruptured appendix?

It is believed that it was a departure from the standard of care for the physician's inability to recognize an acute appendicitis and the subsequent discharge of the patient without further clinical workup resulted in debilitating complications.

About the expert

This expert has been practicing for nearly a decade. He assists with the management and leadership of the Emergency Department providing emergency medical care to low-high acuity patients at a 38,000/year visit emergency department in a suburban setting. He also has his certification in hyperbaric treatments for wound care patients, and performs quality assurance reviews. He has been published, has significant research experience, and serves in both clinical and administrative roles. He has also won numerous awards, honors, and grants.

E-000365

Specialties:

Emergency Medicine