USG to the Rescue: Solving a Case of Atypical Appendicitis

Appendicitis usually presents with a classic Murphy’s triad: McBurney's sign, vomiting and fever. While this presentation is most common, atypical cases can occur, making it difficult to diagnose and treat. The objectives are to explore the use of ultrasound (USG) in pediatric cases and to assess the diagnostic accuracy in unusual presentations of a disease. A 12-year-old female presented with periumbilical pain, vomiting food particles, constipation, and abdominal distension for 3 days, but without fever, leukocytosis, or McBurney's point tenderness. She was afebrile and on abdomen examination, tender over periumbilical region, abdomen was distended, flanks felt full. There were no bowel sounds, no peristaltic movement visible. white blood count (WBC) was normal, Lymphocytes were decreased, C-reactive protein (CRP) was increased. X-ray of abdomen in erect posture did not reveal any perforation or inflammation. USG of the abdomen revealed appendicitis with small bowel obstruction due to fecal impaction. Plain computed tomography (CT) confirmed the diagnosis. The patient underwent an open appendectomy which revealed a sub hepatic appendicular perforation which was gangrenous and abscessed. Child had an uneventful recovery and resumed her daily routine after 14 days. To summarize, USG can diagnose Appendicitis and bowel perforation in children even when they have atypical presentation, such as no fever, no McBurney’s point tenderness, and no WBC elevation, as long as enough time is allowed. USG can also reduce the need for CT, especially in the pediatric population, where radiation exposure should be minimized. Clinicians should be aware of the variability of appendicitis presentation and the value of USG as a diagnostic tool.