Case 5 A teenager with abdominal pain
Hayley is a 13-year-old girl referred to the surgical registrar with abdominal pain at 2.30 pm. She has a temperature of 38.1°C and vomited once yesterday and once today. Her mum states that Hayley has stopped eating solids and is not drinking much. There is no history of dysuria or frequency. Hayley has not yet started her periods. At 4 years of age she had a urinary tract infection but her mother states that she was subsequently seen in outpatients, had a normal kidney US and was discharged. Following the administration of paracetamol in the ED Hayley is seen at 4 pm and by this time she is apyrexial. However, she does have lower abdominal pain with tenderness across the whole lower abdomen.
What investigations would you do?
A blood test for a FBC, U and E’s and CRP is performed. A urine dipstick shows 2+ leucocytes. The surgical registrar considers the most likely diagnosis to be a urinary tract infection and refers Hayley to the paediatricians.
The paediatric registrar sees her at 6 pm and feels that the pain is worst in the right iliac fossa. He is also concerned that the WBC count has come back raised at 22.6 × 109/L (normal 4–12 × 109/L) with 17.2 × 109/L neutrophils (normal 1.5–6.0 × 109/L) and that the CRP is raised at 305 mg/L (normal<6 mg/L).
What is the likeliest diagnosis and what would you do?
The paediatric registrar diagnoses appendicitis and asks the surgical registrar to see Hayley again. He suggests that she is given nil orally and prescribed iv fluids and iv co-amoxiclav.
The surgical registrar returns at 6.30 pm to review Hayley. On this occasion he also performs a rectal examination and elicits right-sided tenderness. He agrees that the diagnosis is probably appendicitis, prescribes co-amoxiclav and plans for Hayley to have an appendicectomy.
Hayley is seen by the anaesthetist at 9 pm. She has had morphine and this has led to an improvement in her pain. The anaesthetist feels that she may not get to theatre until 11 pm and that it may therefore be best to defer the operation to the next day.
Do you agree?
The surgical registrar discusses the case with his consultant who agrees to delay the operation.
The following day is Saturday. Hayley is reviewed by the surgical team and is found to be in pain and to have marked lower abdominal tenderness and guarding. However, due to the fact that only one theatre is operational and that there has been a build-up of urgent adult cases overnight, she is not taken to theatre until 4.30 pm. In theatre Hayley is found to have a perforated appendix with widespread pus in the peritoneal cavity. Following an appendicectomy and peritoneal lavage she has 5 days of iv co-amoxiclav and gentamicin and goes home after 7 days.
Hayley subsequently has two more admissions with fever and abdominal pain. An abdominal abscess is diagnosed by US on her second readmission and she is taken back to theatre for drainage of the abscess and requires a further course of iv antibiotics.
Hayley’s parents complain about the delay in treatment, stating that if she had been diagnosed promptly she could have been operated on prior to the perforation and that this would have avoided all the subsequent complications.
Expert opinion
The triad of abdominal pain, vomiting and a low-grade temperature is very suggestive of appendicitis. Typically the pain starts peri-umbilically and then migrates to the right iliac fossa. However, many cases are atypical and, as in this case, the pain can be across the whole lower abdomen, especially if there is peritoneal involvement. At 13 years of age Hayley is old enough to complain of the symptoms of a urinary tract infection such as dysuria. One can get leucocytes in the urine dipstick if an inflamed appendix is in contact with the bladder. The normality of her previous renal US suggests that she does not have a predisposition to urinary tract infections. Following the diagnosis of appendicitis at 6.30 pm by the surgical registrar, Hayley should have gone to theatre that evening. Furthermore, the raised WBC count and the very elevated CRP suggest a serious infection and that perforation may have already occurred or is imminent. UK guidelines suggest that patients with appendicitis should not be operated on after midnight unless there is a perforation or a clinical deterioration. In this case the failure to operate on Hayley prior to midnight and the further delay the following day is unacceptable. 10–20% of children aged 10–17 years perforate their appendix and Hayley may have perforated her appendix by 6.30 pm on the day she presented. However, even if she had perforated by that time the delay in operating undoubtedly contributed to the postoperative morbidity.
Legal comment
Hayley’s parents have made a complaint. The treatment was clearly substandard and the hospital should apologize. The investigation of the case should encourage the hospital to review its systems. It should consider how it prioritizes its urgent procedures and whether it should make more theatres available over the weekend period.
If the parents are not satisfied with the outcome of the complaints process, they can ask the Health Service Ombudsman to investigate their concerns. The Ombudsman produces a detailed report of its findings and recommends improvements. This report is laid before Parliament and is accessible to the public.
If the family decide to sue the hospital, their claim should be successful. The level of compensation will depend on whether Hayley’s appendix had perforated before she should have had her surgery. If the perforation could have been prevented, then she should be compensated for the pain and suffering associated with the two additional admissions and further abdominal surgery. But even if the appendix had perforated before 6.30 pm on the day Hayley presented, the Expert Opinion states that earlier treatment would still have prevented some of the postoperative morbidity. In any event, damages are unlikely to exceed £10,000 and may be significantly less.
