Famous Patients, Famous Operations, 2002 - Part 2: The Case of a Royal Pain in the Abdomen

Albert B. Lowenfels, MD


April 22, 2002

Is Computerized Tomography (CT) Indicated as a Diagnostic Aid?

CT scans improve diagnostic accuracy, but take time and add to the cost of care. CT scans are best employed when there is diagnostic uncertainty, such as in older patients; in geographic regions where appendicitis is infrequent; or in females, in whom appendicitis can be easily confused with gynecologic conditions. If a person such as Edward VII developed symptoms and signs of appendicitis today, it is likely that a CT scan would be ordered, not so much because of who he is, but because of his age.

Figure 1 shows a CT scan from an 18-year-old female who presented with a 2-day history of mid-abdominal pain that was treated with ranitidine (Zantac). She presented to the emergency department 4 days later with sudden onset of diaphoresis, nausea, vomiting, and loose stools. The patient described a classical history of appendicitis with initial mid-epigastric pain, lasting approximately 2 days, which shifted to the right lower quadrant. At surgery, a necrotic appendix was removed. The adjacent peritoneal fluid was infected; therefore the surgical wound was left open, anticipating a delayed primary closure. The patient's clinical course was further complicated by a wound infection, which required intravenous antibiotics.

Computerized tomography scan from patient with acute appendicitis. Intravenous contrast-enhanced CT image of the pelvis demonstrates dilated, fluid-filled appendix (arrow). In this case, rectal contrast was not necessary to differentiate the inflamed appendix from surrounding bowel. With permission of Dr. Arun Vade, Loyola University Medical Education Network.


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