Appendicular Gastralgia Revisited: A Case Series of this Rare Presentations

1. Resident, Department of General Surgery, Armed Forces Medical College, Pune, Maharashtra, India. 2. Professor, Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India.

Abstract

In the myriad of clinical presentations of acute appendicitis, appendicular gastralgia remains a poorly researched entity. In this article, authors present a series of three cases of acute appendicitis that initially presented as appendicular gastralgia. A 35-year-old gentleman initially presented with complaints of epigastric pain of six hours’ duration with an Alvarado score of 3/10 and was managed medically. Re-examination after six hours of unresolved pain revealed Right Iliac Fossa (RIF) tenderness. Similarly, a 13-year-old boy presented with epigastric pain of 12 hours’ duration with a normal clinical examination and an Alvarado score of 5/10. The pain radiated to RIF after 12 hours with RIF tenderness. A 58-year-old lady presented with pain in the epigastrium of six hours’ duration and had a normal clinical examination, haematological and radiological parameters. She was initially managed medically. However, due to the non resolution of symptoms despite treatment, she underwent Contrast Enhanced Computed Tomography (CECT) Abdomen, which revealed a localised appendicular perforation with appendicoliths. All three patients underwent emergency laparoscopic appendectomy and had an uneventful postoperative recovery with no recurrence of epigastric pain. Low Alvarado scores, non specific clinical findings and equivocal imaging delay diagnosis in these cases. Through this article, attempt was made to enhance awareness of this entity amongst clinicians.

Appendicitis, Dyspepsia, Epigastric pain, Gastritis, Preileal appendix

Acute appendicitis is the most common surgical emergency encountered and has a varied spectrum of initial presentation and clinical features. Appendicular gastralgia is one of its rare presentations. Dyspepsia itself is a widespread entity amongst the gamut of clinical presentations and is also found to be associated with acute appendicitis (1). Appendicular gastralgia was first described by Herbert Paterson in 1910 (1). However, it has not been widely researched or described thereafter. In this article, authors present a series of three cases with epigastric discomfort and dyspepsia as presenting features, which were then diagnosed as acute appendicitis. The cases highlight the importance of maintaining a high index of suspicion for acute appendicitis in cases of epigastric pain.

Case Report

Case 1

A 35-year-old gentleman, a known case of hyper-reactive malarial splenomegaly, initially presented with pain in the epigastrium. The pain was acute on onset, intermittent, severe in intensity, non radiating, and migrated to the RIF after six hours. There was no history of vomiting or anorexia, fever, constipation, obstipation, jaundice, or Lower Urinary Tract Symptoms (LUTS). His initial vitals and abdominal examination were normal. The umbilicus was central, inverted, and circular. No scars, sinuses, or dilated veins were noted. All quadrants moved equally with respiration. The abdomen was soft with no tenderness, guarding, rigidity, McBurney tenderness, palpable lump, or evidence of free fluid. Tympanic note was present on percussion, and bowel sounds were present. The Alvarado score of this patient was 3/10 (2). With a presumptive diagnosis of acute gastritis, the patient was prescribed proton pump inhibitors. He returned to the emergency department after six hours with pain in the RIF. On re-examination, he had McBurney tenderness with no rebound tenderness, palpable lump, guarding, or rigidity. Investigations showed leukocytosis with neutrophilia. All other biochemical parameters were normal. An ultrasound of the abdomen revealed a 7 mm blind-ending non compressible aperistaltic tubular structure in the RIF with minimal periappendiceal fluid. The patient underwent an emergency laparoscopic appendectomy. Intraoperatively, an inflamed preileal appendix was found. The postoperative period remained uneventful with complete resolution of epigastric discomfort. The patient was discharged on postoperative day five and followed-up for the next three months. There was no recurrence of epigastric pain (Table/Fig 1) (2),(3).

Case 2

A 13-year-old boy with no known co-morbidities initially presented with pain in the epigastrium of 12 hours’ duration. The pain was acute in onset, intermittent, of moderate intensity, non radiating, non migratory, and associated with two episodes of non bilious vomiting and anorexia. There was no history of fever, constipation, obstipation, jaundice, or LUTS. Examination of the abdomen displayed epigastric tenderness but no McBurney tenderness or rebound tenderness. There was no guarding or rigidity noted. Investigations showed leukocytosis with neutrophilia and a normal abdominal ultrasound. Biochemical parameters, including serum amylase and lipase, were normal. The Alvarado score was 5 out of 10. Therefore, the patient was managed medically with proton pump inhibitors and antiemetics. He returned after 12 hours with severe pain in the epigastrium radiating RIF. On examination, McBurney tenderness was present, but there was no rebound tenderness or palpable lump. There was no guarding or rigidity observed. He underwent emergency diagnostic laparoscopy, during which an inflamed preileal appendix was noted, and an appendectomy was performed (Table/Fig 2).

The postoperative recovery remained uneventful, and the patient was discharged on postoperative day five. There was no recurrence of epigastric pain on follow-up.

Case 3

A 58-year-old lady with a known history of hypertension presented with epigastric pain of six-hour duration. The pain had an acute onset, was intermittent, of moderate intensity, and non radiating. There was no history of vomiting, anorexia, fever, constipation, obstipation, jaundice, chest pain, palpitations, or cough. The patient had normal findings on clinical examination, haematological and biochemical parameters, as well as on abdominal ultrasound. Serum amylase and lipase levels were within normal limits. The patient was initially managed as a case of acute gastritis. However, after 12 hours, the pain migrated to RIF. On repeat abdominal examination, McBurney tenderness was present. There was no rebound tenderness, palpable lump, guarding, or rigidity. A CECT scan of the abdomen revealed a localised appendicular perforation with appendicoliths. Subsequently, the patient underwent emergency laparoscopic appendectomy. Intraoperatively, a 10 mm preileal appendix with a perforated tip and 50 mL of pus collection were noted (Table/Fig 3). The postoperative period remained uneventful with no recurrence of epigastric pain.

Discussion

Acute appendicitis is the most common surgical emergency and has a varied spectrum of presentation, the most common being periumbilical pain migrating to the RIF. It may also be associated with nausea, vomiting, fever, anorexia, tenderness, or rebound tenderness in the RIF. Appendicular gastralgia is described as pain in the epigastrium due to appendicular pathology with no evidence of duodenal ulcer or any stomach pathology. This was first observed by Paterson while visiting the Mayo Clinic in 1907, when he observed Dr. Mayo operating on two patients with suspected duodenal conditions. During laparotomy, appendicular pathology was evident instead of gastric or duodenal causes. Dr. Mayo performed appendectomy on these patients with no recurrence of epigastric pain. Paterson extrapolated this observation to a series of 24 patients with appendicular gastralgia (1).

The pathophysiology behind epigastric pain in acute appendicitis is hypothesised to be intestinal stasis due to an inflamed appendix, based on the duodenal dilatation seen frequently in the cases operated by Paterson (1). Alternate mechanisms conjectured are pain due to protective pyloric spasm, which is secondary to intestinal stasis and hyperchlorhydria. The latter hypothesis was concurred with by Moynihan in his article published in 1910 (4). Both Paterson and Moynihan found haematemesis and melaena associated with appendicular gastralgia (1),(4). Hyperchlorhydria is hypothesised to be the cause of mucosal irritation leading to melena or haematemesis. Alternate explanations are sepsis, omental vessel thrombosis, and toxic influences (5). These mechanisms mimic those of stress ulcers, and hence the symptom spectrum of both stress ulcers and appendicular gastralgia remains similar. It is important to note that the epigastric pain consequent to appendicular pathologies is resolved postsurgery.

Despite advances in imaging modalities, clinical assessment of acute appendicitis remains the gold standard for diagnosis. The clinical scoring systems used are Alvarado and Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA), which provide standard results with a sensitivity of Alvarado and RIPASA scores of 96.2% and 58.9%, respectively, with a specificity of 90.5% and 85.7% (6). In patients with acute epigastric pain, acute pancreatitis, and acute cholecystitis should also be differentiated from gastralgia due to the overlapping spectrum of symptoms. Patients with acute pancreatitis will exhibit pain radiating to the back and relief on bending forwards and will exhibit raised serum amylase and lipase values. Clinical examination frequently displays fever, tachycardia, epigastric tenderness with localised guarding, and hypoactive bowel sounds secondary to ileus (7),(8).

In experience with these cases, it was observed that patients with acute appendicitis with an initial presentation as appendicular gastralgia tend to have a low Alvarado score at presentation, display migration of pain to RIF within 24 hours, and have a preileal position of the appendix peroperatively. However, whether these findings are causal or casual would be apparent in a larger series. Frequently, due to non specific clinical findings, equivocal imaging findings, and low Alvarado /RIPASA score, patients miss early diagnosis and risk failure of diagnosis. Untreated appendicitis poses the risk of a myriad of complications, and early diagnosis is both desired and necessary. The clues to an atypical presentation of appendicular pathology in patients with epigastric pain may be provided by pain remaining unresolved by antacids and subsequent radiation of pain to the right lower abdomen. The history and repeated physical examination are important modalities in diagnosing or excluding appendicitis (9). Ultimately, a high index of suspicion, close observation, and re-examination at frequent intervals, and the utilisation of point-of-care ultrasound and CT scans in cases of diagnostic dilemmas would clinch the diagnosis as the disease process evolves (9),(10),(11).

Conclusion

Appendicular gastralgia remains a poorly studied entity in the spectrum of presentations of appendicular inflammation and requires a high index of suspicion for early diagnosis and treatment. Present article will raise awareness of this condition amongst clinicians.

DOI and Others

DOI: 10.7860/JCDR/2024/69485.19773

Date of Submission: Feb 13, 2024
Date of Peer Review: Mar 20, 2024
Date of Acceptance: May 22, 2024
Date of Publishing: Aug 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin

EMENDATIONS: 7