CLINICAL COMMUNICATION TO THE EDITOR

Chronic Appendicitis: An Often Forgotten

Cause of Recurrent Abdominal Pain
To the Editor:
A 28-year-old woman presented with a 3-day history of
worsening abdominal pain localized to the right lower quad-
rant. Her symptoms began with a sharp discomfort origi-
nating along the right abdomen with associated radiation to
the lower back. She recalled no inciting event and denied
fevers, nausea, vomiting, diarrhea, hematuria, dysuria, or
vaginal discharge. She reported compliance with a hor-
monal contraception vaginal ring prescribed for menstrual
pain. On further questioning, the patient had experienced 6
similar episodes of right-sided abdominal pain over the past
2 years, each resolving spontaneously after 3-4 days with
conservative measures. She was evaluated on several occa-
sions for this pain with no clear diagnosis. At one point she
was treated with antibiotics for a presumed urinary tract
infection. She had never undergone computed tomography
(CT) imaging.
On presentation, the patient was afebrile. Her abdo-
men was soft with no peritoneal signs or palpable masses,
but mild reproducible tenderness was noted in the right
lower quadrant. Laboratory data revealed a white blood
count of 6.11 10 k/uL, normal liver function tests and
urinalysis, and an elevated erythrocyte sedimentation rate
of 30 mm/h. Pelvic examination did not reproduce her
pain, and a transvaginal ultrasound performed by her
gynecologist 2 days prior was unremarkable for an ecto-
pic pregnancy, ovarian cyst, or torsion. Given the recur-
ring nature of her symptoms, accompanied by the lack of
a specic diagnosis, the patient underwent a contrast-
enhanced CT scan of the abdomen and pelvis, revealing
a dilated 10 mm appendix without evidence of abscess or
uid collection, thereby suggestive of chronic appendi-
citis (Figures 1, 2). The patient was referred for laparo-
scopic appendectomy. She was seen in follow-up 3
months later and reported no recurrence of symptoms.
The diagnosis of classical acute appendicitis is generally
straightforward, often manifesting as 48 hours of perium-
bilical pain localizing to the right iliac fossa with associated
anorexia, abdominal guarding, and leukocytosis. Atypical
and chronic presentations are less common but are believed
to result from partial and transient obstruction of the
appendix.
1
The incidence of chronic appendicitis is estimated at
1.5% of all cases.
2
This entity poses a diagnostic dilemma
for clinicians because patients generally do not present with
typical appendicitis symptoms. Oftentimes these patients
are misdiagnosed, particularly sexually active females or
those partially treated with antibiotics for other conditions,
as was the case with our patient. Although no formal diag-
nostic criteria or management algorithm exists for chronic
appendicitis, CT imaging is considered the most accurate
test of choice for patients with an equivocal presentation.
3
Missing the diagnosis can have serious consequences, as
there is a risk of abscess formation and infertility.
4
While it
is generally not considered a surgical emergency, most
patients with chronic appendicitis have resolution of pain
with appendectomy.
Our patient had an interesting presentation of right
lower quadrant pain that went undiagnosed for 2 years
despite immediate medical attention and a negative work-
Funding: None.
Conict of Interest: None.
Authorship: Shenil Shah, MD: Lead author, patient care, Ryan
Gaffney, DO: Corresponding author, Thomas Dykes, MD: Image acquisi-
tion and editing, Jennifer Goldstein, MD: Senior advising faculty member,
patient care.
Requests for reprints should be addressed to Ryan R. Gaffney, DO,
Department of Internal Medicine, Penn State Hershey Medical Center, 500
University Drive, P.O. Box 850, Mail Code H039, Hershey, PA 17033.
E-mail address: rgaffney@hmc.psu.edu
Figure 1 Axial computed tomography scan with contrast of
the right lower quadrant in a 28-year-old woman with chronic
abdominal pain demonstrating a thickened and ill-dened ap-
pendix (white arrow).
0002-9343/$ -see front matter 2013 Elsevier Inc. All rights reserved.
up. Her surgical pathology demonstrated a brotic and
dilated appendix with adhesions, all suggestive of a
chronic, ongoing inammatory process. This case serves
as a reminder to primary care physicians that appendicitis
can resolve and reoccur spontaneously and should be
included in the differential diagnosis for patients with
chronic right lower quadrant abdominal pain. Appropri-
ate imaging studies should be obtained if there is a high
clinical suspicion, and timely surgical referral may be
warranted for denitive management.
Shenil S. Shah, MD
a
Ryan R. Gaffney, DO
a
Thomas M. Dykes, MD
b
Jennifer P. Goldstein, MD
a
a
Department of Internal Medicine
b
Department of Radiology
Penn State College of Medicine and
Milton S. Hershey Medical Center
Hershey, Pa
http://dx.doi.org/10.1016/j.amjmed.2012.05.032
References
1. VanWinter JT, Beyer DA. Chronic appendicitis diagnosed preopera-
tively as an ovarian dermoid. J Pediatr Adolesc Gynecol. 2004;17:403-
406.
2. Hawes AS, Whalen GH. Recurrent and chronic appendicitis: the other
inammatory conditions of the appendix. Am Surg. 1994;60:217.
3. Rao PM, Rhea JT, Noveline RA, et al. Helical CT technique for the
diagnosis of appendicitis: prospective evaluation of a focused CT ex-
amination. Radiology. 1997;202:139-44.
4. Mueller BA, Daling JR, Moore DE, et al. Appendectomy and the risk of
tubal infertility. N Engl J Med. 1986;315:1506.
Figure 2 Coronal computed tomography view of the abdomen
and pelvis showing a dilated appendix (white arrow) without any
associated appendicolith, uid collection, or abscess.
e8 The American Journal of Medicine, Vol 126, No 1, January 2013