In general, patients with appendicitis present with a reliable set of signs and symptoms that facilitate early diagnosis. Prompt surgical treatment usually results in low morbidity and mortality rates for this common condition. In patients with spinal cord injury (SCI), the normal visceral and somatic pathways that permit the recognition of symptoms are disrupted. In addition, SCI patients frequently have comorbidities (e.g., Urinary Tract Infection, gastroparesis, constipation, decubitus ulcers) that may mask or mimic the early features of appendicitis. Appendicitis and other acute intra-abdominal conditions can become serious, life-threatening events in patients with SCI and are reported to account for 10 percent of all deaths in this patient population. Strauther and colleagues report the clinical data of SCI patients with appendicitis to identify factors that could facilitate earlier and more accurate diagnosis.
Records of trauma-induced SCI patients who were diagnosed later with acute appendicitis were reviewed. Complete data from Department of Veterans Affairs records were available on 26 patients treated between 1992 and 1997. One half of the 26 men were Paraplegic, and one half were quadriplegic. The mean duration of SCI was 22 years, and all patients had had at least one urinary tract infection.
The pattern of presenting symptoms was not consistent. Of the 26 patients, nine (35 percent) presented with abdominal distention, and nine presented (35 percent) with abdominal discomfort. Fever was the presenting symptom in four (15 percent), two patients (8 percent) presented with vomiting and two patients (8 percent) presented in shock. Appendicitis was the diagnosis suspected on admission in approximately one third of the patients. Other admission diagnoses included pyelonephritis (19 percent), urinary tract infection (23 percent), intestinal obstruction (12 percent), and hernia, constipation and colon cancer (each 4 percent). The mean duration of symptoms was 4.1 days but ranged from one to 14 days. On admission, physical examination was abnormal but often nonspecific. The abdomen was distended in 77 percent of patients, and 23 percent had a palpable right lower quadrant mass. More than 80 percent (16 of 19) of patients showed signs of Autonomic Dysreflexia (e.g., elevated blood pressure, arrhythmias, diaphoresis and headache). Most patients (81 percent) were febrile with an elevated white blood cell count on admission (mean: 18,000 per mm3 [18 3 109 per L]). The diagnosis was delayed after hospital admission in 12 patients (46 percent). Abdominal and pelvic computed tomography demonstrated appendicitis in the 12 patients on whom it was performed. At surgery, 24 patients (92 percent) had perforation, and three (12 percent) required cecal resection. An elderly quadriplegic man who presented in septic shock died, and six patients (23 percent) developed significant postoperative complications. The length of the hospital stay ranged from three to 70 days (mean: 16 days).
The authors conclude that acute appendicitis in SCI patients can be a serious condition with significant morbidity and mortality. Improved outcomes depend on maintaining a high index of suspicion when the SCI patient has vague symptoms or exhibits signs of Autonomic Dysreflexia. Although many conditions can present in a similar manner in SCI patients, clinical acumen and use of computed tomography could lead to earlier diagnosis of acute appendicitis and improved outcome.
ANNE D. WALLING, M.D.
Strauther GR, et al. Appendicitis in patients with previous spinal cord injury. Am J Surg November 1999;178:403-5.
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