Appendicitis Missed in the Oregon ER: Adults and Children

When appendicitis is found in a patient who was earlier sent home from an emergency department, the question this post looks at is not the first impression. It is what was planned for the hours and days after it: another examination, another test, a surgical opinion, or a plan for coming back.

What a return visit looks like in the research

A 2020 study in JAMA Network Open used insurance claims to look for this pattern in adults and children. It treated appendicitis as potentially missed when a patient came to an emergency department with symptoms linked to appendicitis, was not diagnosed that day, and was diagnosed within 30 days after that visit.¹ Among the commercially insured patients in its data, appendicitis was potentially missed at the first emergency visit in 6.0% of adults and 4.4% of children.¹

In the potentially missed group, the median time between the first visit and the return visit at which appendicitis was diagnosed was 2 days for children and 4 days for adults.¹ The authors report that most of the imaging and laboratory tests in that group, including CT, ultrasonography, radiography, complete blood counts and urinalysis, were performed at return visits rather than at the first visit.¹

Why the first presentation can mislead

The 2020 update of the World Society of Emergency Surgery's Jerusalem guidelines states that establishing the diagnosis from clinical presentation and physical examination may be challenging, and that the value of individual clinical findings in predicting appendicitis is low.²

In the 2020 claims study, missed appendicitis was more likely in women, in patients with other medical conditions, in patients whose abdominal pain came with constipation, and in patients with no abdominal pain at the first visit.¹ Adults whose appendicitis was potentially missed were older on average than adults diagnosed the same day.¹

For children, the guidelines state that early diagnosis remains challenging because of atypical clinical features and the difficulty of obtaining a reliable history and physical examination, and that in preschool-age children appendicitis often presents with atypical features, more rapid progression and a higher incidence of complications.²

A 2021 study of 748 children at five US pediatric emergency departments counted a delay when two emergency visits within 7 days led to the diagnosis and case review showed the child likely had appendicitis at the first visit, and compared those children with children diagnosed at their first visit.³ Children with a delayed diagnosis were less likely at the first visit to have pain with walking, pain felt most in the right lower part of the abdomen, or abdominal guarding.³ The five most common diagnoses given at those first visits were gastroenteritis, abdominal pain, constipation, urinary tract infection and viral syndrome.³

For pregnancy, the WSES guidelines state that nearly all clinical signs and symptoms, taken one at a time, do not significantly discriminate between pregnant women with and without appendicitis, and they suggest not making the diagnosis in pregnant patients on symptoms and signs alone.²

The follow-up steps the literature describes

Among the children with a delayed diagnosis in the 2021 study, nearly every classic symptom or sign of appendicitis was more likely to be present at the later visit, and migration of pain to the right lower abdomen was the symptom most likely to have developed in between.³ The authors write that for children with a low clinical probability of appendicitis, who should not undergo immediate imaging, longer periods of observation or a white blood cell count could contribute to a correct diagnosis.³

For children, the WSES guidelines suggest ultrasound as the first imaging test, and suggest against routine use of CT as the first test in children with right iliac fossa pain (pain in the lower right abdomen). They state that MRI should be preferred over CT as second-line imaging in children, and for an inconclusive ultrasound they suggest choosing the second test based on local availability and expertise.² The 2021 pediatric study adds that a normal-looking appendix on ultrasound in a child with a high clinical probability of appendicitis should typically prompt further evaluation, such as cross-sectional imaging, and cites a 19% false-negative rate for those ultrasound tests.³

For adults, the guidelines describe a stepwise pathway. Low-risk adult patients according to clinical scores could be discharged with appropriate safety netting, high-risk patients are likely to require surgery rather than diagnostic imaging, and intermediate-risk patients are likely to benefit from systematic diagnostic imaging.² After a negative ultrasound, the guidelines describe either CT or further clinical observation with repeated ultrasound.² In pregnancy, they suggest MRI, if available, after an inconclusive ultrasound, and state that a negative or inconclusive MRI does not exclude appendicitis.²

For patients with normal investigations but right iliac fossa pain that does not resolve, they recommend cross-sectional imaging before surgery. After negative imaging, they describe initial non-operative treatment as appropriate, but for patients with progressive or persistent pain they recommend explorative laparoscopy to establish or exclude the diagnosis of appendicitis or alternative diagnoses.²

The authors of the 2020 claims study write that identifying patients at higher risk of a missed diagnosis could lead to a more careful discussion with the patient and family about the further need for imaging, the type and timing of imaging, and follow-up.¹

What the delay changes

In the 2021 pediatric study, children with a delayed diagnosis had longer hospital stays, by a mean of 2.8 days, higher perforation rates (odds ratio 7.8), and a higher likelihood of two or more surgical procedures (odds ratio 8.0) than children diagnosed on time.³ The same study describes perforated appendicitis as associated with substantial morbidity, including abdominal abscess, small bowel obstruction, sepsis, bowel resection, longer hospital stays, more health care encounters and higher cost.³

The WSES guidelines state that appendiceal perforation is associated with increased morbidity and mortality compared with appendicitis that has not perforated, and they report a mortality rate of around 5% for perforated appendicitis.² They also note growing evidence that perforation is not necessarily the inevitable result of appendiceal obstruction, and that not all patients with appendicitis will progress to perforation.²

What Oregon law states about the duty

Under ORS 677.095(1), a physician licensed to practice medicine or podiatry by the Oregon Medical Board "has the duty to use that degree of care, skill and diligence that is used by ordinarily careful physicians in the same or similar circumstances in the community of the physician or a similar community."⁴

The pathways above are recommendations published by a medical society or suggestions made by study authors, and the percentages are findings from medical research. They are set out here as what that literature says. The statutory duty quoted above is a separate question, and this post does not connect the two.

Oregon's wrongful-death statute makes causation part of the condition for an action. It opens: "When the death of a person is caused by the wrongful act or omission of another …"⁵

Oregon's time limits

A claim for injuries arising from medical care runs under ORS 12.110(4), which requires an action "to recover damages for injuries to the person arising from any medical, surgical or dental treatment, omission or operation" to be "commenced within two years from the date when the injury is first discovered or in the exercise of reasonable care should have been discovered."⁶ In Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994), the Oregon Supreme Court held that "injury," as used in ORS 12.110(4), "consists of three elements: (1) harm; (2) causation; and (3) tortious conduct."⁷

The subsection also sets an outer limit: "notwithstanding the provisions of ORS 12.160, every such action shall be commenced within five years from the date of the treatment, omission or operation upon which the action is based …"⁶ The statute's own exception applies where no action was commenced within five years because of fraud, deceit or misleading representation.⁶

For a child, a second statute matters. ORS 12.160(1), which reaches actions mentioned in ORS 12.070 to 12.250 among other sections, provides that if the person is younger than 18 when the cause of action accrues, "the statute of limitation for commencing the action is tolled for so long as the person is younger than 18 years of age."⁶ ORS 12.160(2) provides: "The time for commencing an action may not be extended under subsection (1) of this section for more than five years, or for more than one year after the person attains 18 years of age, whichever occurs first."⁶ The five-year limit in ORS 12.110(4) is stated to apply "notwithstanding the provisions of ORS 12.160".⁶

Where appendicitis causes a death, ORS 30.020(1) governs. Under that subsection, "The action shall be commenced within three years after the injury causing the death of the decedent is discovered or reasonably should have been discovered by the decedent, by the personal representative or by a person for whose benefit the action may be brought under this section if that person is not the wrongdoer."⁵ It then provides: "In no case may an action be commenced later than the earliest of: (a) Three years after the death of the decedent; or (b) The longest of any other period for commencing an action under a statute of ultimate repose that applies to the act or omission causing the injury, including but not limited to the statutes of ultimate repose provided for in ORS 12.110 (4), 12.115, 12.135, 12.137 and 30.905."⁵ Three years after the death is an outer bar rather than a starting point, and it is not always the operative one.

This article is educational

This article describes Oregon law in general terms. It is not legal advice and does not create an attorney-client relationship.

Time limits matter. Most Oregon personal-injury and auto-accident claims must be filed within two years of the injury or accident. Medical malpractice claims must be filed within two years of when you knew or reasonably should have known of the negligence, with an outer limit of five years from the act itself (with a fraud exception). Wrongful death claims must be filed within three years of the date of death. Claims against public bodies (cities, counties, state agencies, public hospitals) require a notice of claim within 180 days. Missing these deadlines typically ends a case.

If you think you may have a claim, call Huegli Law at 971-317-6436 for a free case review. Todd Huegli is licensed in Oregon and consults on cases in Oregon only.

Footnotes

1. Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department. JAMA Network Open (2020). https://pmc.ncbi.nlm.nih.gov/articles/PMC7063499/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

2. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery (2020). https://wjes.biomedcentral.com/articles/10.1186/s13017-020-00306-3 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

3. Clinical Features and Preventability of Delayed Diagnosis of Pediatric Appendicitis. JAMA Network Open (2021). https://pmc.ncbi.nlm.nih.gov/articles/PMC8408667/ ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸

4. ORS 677.095 — Degree of care and skill required. https://www.oregonlegislature.gov/bills_laws/ors/ors677.html ↩

5. ORS 30.020 — Action for wrongful death; when commenced. https://www.oregonlegislature.gov/bills_laws/ors/ors030.html ↩ ↩² ↩³

6. ORS 12.110 and ORS 12.160 (ORS chapter 12 — limitations of actions). https://www.oregonlegislature.gov/bills_laws/ors/ors012.html ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

7. Gaston v. Parsons, 318 Or 247, 864 P2d 1319 (1994). https://static.case.law/or/318/cases/0247-01.json ↩