Perforated Retrocecal Appendicitis Despite Inconclusive Ultrasonography: The Role Of Integrated Clinical Assessment And Reassessment—A Case Report

Abstract

Acute appendicitis is a dynamic disease process, and clinical findings may evolve during diagnostic evaluation. Ultrasonography (US) is often used as the initial imaging modality; however, nonvisualization of the appendix is an inconclusive finding and cannot, by itself, exclude appendicitis. Therefore, while awaiting further investigations or when imaging remains nondiagnostic, clinical reassessment is essential for detecting changes in the patient’s condition. A 56-year-old woman presented with progressive abdominal pain that began in the epigastrium and subsequently localized to the right lower quadrant, accompanied by nausea and vomiting. On initial evaluation, she was hemodynamically stable but tachycardic, with right lower quadrant tenderness, positive psoas and Rovsing signs, and leukocytosis of 18.84 × 10⁹/L, without rebound tenderness or abdominal guarding. The patient underwent clinical observation and further investigation. Abdominal ultrasonography performed the following morning demonstrated mild localized ileus in the right abdomen; however, the appendix and ileocecal region could not be visualized. Subsequent reassessment revealed new-onset abdominal distension, tenderness at McBurney’s point and in the suprapubic region, rebound tenderness, and lower abdominal guarding. Given the progression of these clinical findings, peritonitis secondary to perforated appendicitis was suspected, and emergency exploratory laparotomy was performed. Intraoperatively, a gangrenous retrocecal appendix was identified, with perforations in the midportion and at the base, accompanied by purulent fluid in the right paracolic gutter and pelvis. Retrograde appendectomy, peritoneal irrigation, and drain placement were performed. Histopathological examination confirmed perforated appendicitis, and the postoperative course was favorable. Nonvisualization of the appendix on ultrasonography does not exclude appendicitis, particularly when clinical findings continue to support the diagnosis. This case highlights the importance of integrating imaging findings with ongoing clinical assessment during the diagnostic evaluation period. Serial reassessment of symptoms and abdominal examination findings is essential for detecting changes in clinical status and determining the need for timely escalation to definitive treatment.