Appendicitis with Unusual Presentation: Mid-Abdominal Vs. Right Quadrant Pain

As a mother of four I've nursed many stomach aches. Three were caused by appendicitis. Appendicitis pain occurs on the right side of the abdomen 95% of the time. In the last bout, pain occurred in the LLQ and termed 'appendicitis with unusual presentation. With a family history of appendicitis and concomitant appendectomy, my husband and I are quick to inquire where stomach pain is located when someone has a stomachache. When we hear that the pain is 'in my right side', we get nervous and begin to think 'appendix'. That appendix pain occurs only in the right side is a common misnomer, shared even by some medical professionals.

Recently, however, this assumption of right side only appendicitis pain, was proven wrong. Our community has been hit with unusually high numbers of influenza and presumed H1N1 virus. One of the symptoms of H1N1 can be nausea and vomiting. When someone mentions feeling in, H1N1 is the first condition that pops out of most folks' mouths. When our oldest son, 19 years old, woke up with intense stomach pain, nausea and vomiting we watched it to see how the illness progressed. We were prepared to take him in to see our physician, but not immediately. This was partly because I was concerned that with the given state of H1N1 panic in our community, I did not want him misdiagnosed with influenza.

Suddenly, about 4pm, our son doubled over with what he described as excruciating pain, like a gas bubble or bowel movement that would not pass. My knee-jerk response was to ask which side the pain was located on his stomach. He indicated that the middle of his stomach around the navel and his left side were the most painful. given the intense pain he was experiencing, I decided to head to the emergency room. Having witnessed one child and my husband's attack of acute appendicitis, as well as our other son's attack of gallstones, I know the symptoms of internal injury vs. a common stomachache or influenza symptoms.

The emergency room physician immediately ruled out influenza. He stated, rather perceptively I thought, that after illness has been ruled out, in a healthy young man, appendicitis is the first concern in cases of acute abdominal pain. He expressed surprise that the pain was mostly around the navel and in the left quadrant rather than the right. However he ordered blood work to see if the white blood count was elevated ( a classic sign of internal infection). The white blood count was elevated and the x-rays taken showed no structural issues. The ED physician then ordered a CT scan to further explore the region. As the doctor suspected, the CT scan revealed an inflamed appendix that was hidden behind the bowel area: thus the mid-section to left quadrant abdominal pains.

Even the phlebotomist that drew our son's blood was convinced that he wouldn't be diagnosed with acute appendicitis, as his pain was not 'on the right side'. My cautionary tale in this article, is not to over look appendicitis just because the pain and symptoms differ from the 'textbook' description. I would also add that it is important not to go in to your physician's office or emergency department with a preconceived idea about the etiology of symptoms. I'm grateful to the ER physician for pursuing his instincts about our son's appendicitis. The surgeon who removed our son's appendix reminded us what we already knew: an inflamed and infected appendix can perforate or rupture very quickly after the first attack of pain. Thankfully our son's appendicitis was operated on before any of these dangerous scenarios occurred.