And then ambulance, surgery, waking up from anesthesia, 10 days in the hospital, and discharge (to the old house that was covered with vines). Oh, and a scar on her stomach.
When I was a resident, that was still the story, though hospital stays were generally shorter. Diagnosis was largely by medical history and physical exam; half a century after Madeline's experience, and a full century after appendicitiswas first described and named (in 1886, by Reginald Heber Fitz, a Harvard pathologist), there was still no way to know for sure whether a child's abdominal pain was caused by an inflamed appendix.
I remember the thrill of making the diagnosis my first time, in 1986 or '87. I saw the child in the emergency room and called the surgeons, and sure enough the child went to the operating room. The only thing was, he didn't have appendicitis; when they opened him up, they found a healthy appendix, which, of course, they removed.
But as the surgeons told us, that only showed we were all doing it right. The risk in missing acute appendicitis is that the child will "perf" — the inflamed appendix develops a perforation, and bowel contents leak into the abdominal cavity, making the surgery much more complex and dangerous.
So unless you took out a certain number of healthy appendixes (somewhere from 10 to 20 percent), you were sure to miss cases of acute appendicitis. We were taught that the ability to examine a child's abdomen was the hallmark of the good diagnostician, but we were reassured that even the best diagnosticians sometimes took a child to surgery for stomach cramps or gastroenteritis — a "negative appendectomy."
In the past decade, though, great strides have been made with imaging. At least in younger children, ultrasound can now show appendicitis clearly, or help rule it out. CT scans are even clearer, but they expose the patient to ionizing radiation that has led to recent concerns about future risks of cancer.
There have also been changes in the management of acute appendicitis. Some children with perforations no longer undergo those dramatic middle-of-the-night emergency operations.
Even so, appendicitis remains a source of diagnostic complexity. After all, young children are often unable to describe their symptoms. Steady or crampy, sharp or dull, the whole vocabulary of pain means little to a 3-year-old, who knows only that it hurts.
"The presentation in kids is a lot more ambiguous; you don't always get that classic story of migrating umbilical pain," said Dr. David G. Bundy, an assistant professor of pediatricsat Johns Hopkins and an expert on quality improvement and patient safety.
Almost 20 years after I started my residency, my own son, then 8 years old, woke in the night, crying with pain. When the doctors in the emergency room asked him to point to the spot that hurt the most, he indicated McBurney's point, on the lower right side of his abdomen, the classic site for appendicitis pain.
I was certain he would soon be in the operating room. But this was 2003, and a sophisticated scan not only showed that his appendix was normal and uninflamed, but also indicated where the pain was coming from: a piece of twisted abdominal tissue. It would get better by itself and he would be fine, the surgeon promised — and it did, and he was.
The surgeon, Dr. Craig W. Lillehei, is now an assistant professor of surgery at Harvard Medical School. I asked him how the diagnostic dilemma had changed over his career.
"One of the things we're struggling with in pediatrics is we've become too dependent on the CT scan," he said. "It's become very helpful in terms of identifying appendicitis, but it translates to radiation."
Nor has it been clearly shown that new imaging techniques reduce the overall rate of negative appendectomies in children. But doctors still worry about missing appendicitis, and the medical and legal consequences of sending a child home without doing a scan. Yet surely not every bellyache requires a CT.
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