Abdomen Pain

[De__0__0]

  Twice my daughter has had severe bouts of abdomen pain focused in the lower right quadrant.  One at age 8, and one at age 12.  Each time, docs were intially certain of appendicitis, but later reversed their opinion.  The last time at age 12, every doc she saw and 2 ERs were convinced she had appendicitis...all physical symptoms were present as far as pain, rebound tenderness, location, inability to pull leg up to chest, etc.  Surgeon was even ready to operate at 3 AM but decided to wait because child has Graves' Disease, and he wanted to be 100% sure before he operated, so ordered tests instead.
  This kid has had barium swallows (twice), colonoscopy, ultrasound, and CT scans.  All were normal.  Docs were in disagreement as to need for laposcotomy, but surgeon decided no.  All these other tests were normal.  White blood cell count was only 4000.  Because of these tests, appendicitis was ruled out, but it is very confusing that her pain matched appendicitis so closely.
  Later she was found to have pos ANA and high pos antidsDNA, but lupus diagnosis has not been confirmed.
  Question:  Is it possible that she could have had a low grade appendicitis each time....that eventually healed by itself (it took 2 months to get over abdomen pain).  Does this ever happen, and can it become recurrent?
  If it happens again, would you recommend laposcotomy exploratory surgery?  Are there other less invasive tests?  Would the surgery be able to tell if the pain could be a type of serositis or inflammation of the lining of the stomach, and could this have been a possible explanation for her mysterious pain?  She also experienced joint pain, fatigue, and onset of migraines during this time period and eventually ended in collapse with inability to walk/stand independently for additional 3 months even after abdomen pain went away, this is why the lupus tests were ordered.
  Do you have any other possible explanations?
_________
Dear Dee,
The diagnosis of chronic low-grade appendicitis is controversial.  Most surgeons believe that there is no such entity, although with close questioning one can usually learn of a case or two in which there was chronic pain that was relieved by appendectomy. Often the symptoms were more frequent than every few years.  In addition to considering recurrent appendicitis, the differential diagnosis of the right lower quadrant pain includes Crohn's Disease (excluded if your daughter has had a normal small bowel X-ray), ovarian etiologies (ruptured cyst or ovulation discomfort [unlikely in view of the duration of pain])  and serositis (related to a possible collagen vascular disease).  
There has been recent literature to suggest that a CT scan is a sensitive test to diagnose acute appendicits. Laparoscopy at the time of the next attack is certainly an acceptable approach,  You may consider discussing with your surgeon, the benefits/risks of removing the appendix should there be another attack.  Appendectomy would reduce your worry regarding a missed diagnosis.
This information is provided for educational purposes only.  Always consult your personal physician for specific medical questions.
HFHSM.D.-rf
*keywords: appendicitis, serositis
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