Appendiceal Colic Caused by Enterobius vermicularis J Am Board Fam Pract: first published as 10.3122/jabfm.9.1.57 on 1 January 1996. Downloaded from

RogerJ Zoorob, MD, MPH

Appendicitis is the most common acute surgical the emergency department before her discharge condition of the abdomen. It occurs at all ages but on symptomatic treatment, and she was advised is rare in the very young. l In contrast, appen­ to follow up with her family physician. diceal colic was first reported in 1980.2 It is char­ Physical examination in the office showed an acterized by recurrent episodes of crampy ab­ adolescent patient with no acute distress. She dominal pain referred either to the right lower was afebrile, had a heart rate of 84 beats per quadrant or to the periumbilical area. There is minute, a blood pressure of 110170 mmHg, and tenderness to deep palpation over the appendix.3 respiratory rate of 16/min. Her lungs were clear. It is theorized that appendiceal colic is due to Her abdomen was soft with good bowel sounds. an incomplete luminal obstruction of the appen­ There was minimum right lower quadrant ten­ dix most often caused by inspissated fecal mate­ derness at McBurney's point with no rebound. rial.3 Other pathologic findings, however, include There was no costovertebral angle tenderness. torsion of the appendix and narrowed appen­ The external genitalia examination showed an diceallumen.4 intact hymenal ring, and the findings on rectal I report a 13-year-old patient with appendiceal examination were normal. colic whose recurrent right lower quadrant ab­ A complete cell count done in the office dominal pain was due to Enterobius vermicularis showed a white cell count of 88001llL with a dif­ infestation of the appendix. ferential of 72 percent neutrophils, 2 percent monocytes, and 26 percent lymphocytes, and Case Report normal platelets (253,0001IlL). Urinalysis was A 13-year-old girl came to the office with an 8- normal; urine Gram stain did not show any bacte­ week history of right lower quadrant abdominal ria or white cells; and a pregnancy test was nega­ pain that was described as intermittent and col­ tive. Flat and supine films of the abdomen were icky. The pain did not radiate to the perineum or nonspecific. the right lower extremity. It would recur at any Because the patient was afebrile and mostly had time during the day or night and on occasion recurrent intermittent pain, and because the labo­ http://www.jabfm.org/ would wake the patient up from a sound sleep. ratory evaluation was nonrevealing, the differen­ Each attack lasted from 3 minutes up to 1 hour tial diagnosis included ovarian cyst, renal colic, each day for 1 to 3 days, followed with a pain-free and irritable bowel syndrome, as well as functional period lasting up to 1 week. and psychosocial abdominal pain. She was treated She reported no history of urinary tract symp­ symptomatically with dicyclomine hydrochloride toms, fever, chills, nausea, vomiting, anorexia, An (Bentyl). intravenous pyelogram, a barium en­ on 26 September 2021 by guest. Protected copyright. change in bowel habits, or weight loss. The pa­ ema, and a sonogram of the pelvis were ordered, tient was not sexually active and had not reached and the urine was cultured. Stools for ova and par­ menarche. asites were collected. A follow-up visit was sched­ The patient was seen in the emergency depart­ uled in 48 hours. The patient and her mother ment with a similar episode 1 week before she were instructed to come back earlier if the pain re­ came to the office. The findings from her physi­ curred, fever developed, or the patient vomited. cal examination at that time were within normal The patient returned as scheduled. During the limits. She had a normal white cell count and nor­ 48-hour interval the pain recurred two to three mal findings on urinalysis. Her pain resolved in times each day with complete resolution of the symptoms in between. She had no fever, nausea, or Submitted, revised, 19 September 1995. vomiting. The pain, however, was always located From the Department of Family Practice, University of Ken­ in the right lower quadrant. Findings on the pelvic tucky, Lexington. Address reprint requests to Roger J. 2oorob, MD, MPH, Department of Family Practice, Kentucky Clinic, sonogram, barium enema, and the intravenous University of Kentucky, Lexington, KY 40536-1284. pyelogram were all normal. Stool samples were

Appendiceal Colic 51 negative for ova and parasites. Dicyclomine hy­ The patient I describe here had no evidence of J Am Board Fam Pract: first published as 10.3122/jabfm.9.1.57 on 1 January 1996. Downloaded from drochloride gave minimal relief of the symptoms. inflammation on pathologic examination of the Because of the location of the pain, recur­ appendix by the pathology laboratory, and her rences, and normal findings on examination, the condition fit more with the diagnosis of appen­ diagnosis of appendiceal colic was entertained, diceal colic. The cause of the symptoms was not and a pediatric surgeon was consulted. The pa­ inspissated fecal material; the symptoms might tient underwent an exploratory laparoscopy and have resulted from intermittent obstruction of consequently a laparoscopic appendectomy. The the appendiceal lumen by the Enterobius worm. IS pathology report described an appendix 6 cm in On a review of the medical literature, I found a length with pinworms in the lumen. There was 1939 report of patients who had recurrent right no evidence, however, of any inflammation. lower quadrant abdominal pain relieved with ap­ The patient made an excellent recovery after her pendectomy. Pinworms were recovered on exam­ surgery. She was prescribed pyrantel pamoate, and ination, and in some of the cases no inflammatory she was seen for follow-up care for 1 year in the of­ changes in the appendix were found. 16 fice without any recurrences of her pain. Although pinworm infestation is still common, its incidence is reported to be decreasing in some Discussion communities.17 One wonders whether Enterobius Abdominal pain in children is a diagnostic chal­ causing appendiceal colic is less common because lenge. S Thirty-six percent of children younger physicians are not looking for it or because the in­ than 16 years of age who come to the emergency cidence of pinworm infestation is decreasing, thus department complaining of abdominal pain have resulting in lower occurrence of the disease. abdominal pain as a final diagnosis on discharge.s Another question is whether a perianal tape test Recurrent abdominal pain in children is de­ should be recommended to patients with recurrent fined as at least three episodes of abdominal pain right lower quadrant abdominal pain in the ab­ during a 3-month period. Prevalence of recurrent sence of typical symptoms of pinworm infestation. abdominal pain among school-aged children is 11 Because the test is relatively easy and inexpensive, percent.6 Although a survey of pediatricians' it is worth doing, especially if the preliminary practices showed that pediatricians were guided workup of right lower quadrant pain is nondiag­ by signs and symptoms in determining the need nostic. It will be interesting to see whether medical for additional testing in recurrent abdominal treatment of patients with recurrent appendiceal pain,7 some authors reported that organic causes colic and evidence of pinworm infestation will ob­ http://www.jabfm.org/ were detected in only 7 percent of the cases.8 This viate the need for surgery. fact might bias physicians toward making nonor­ Finally, recurrent abdominal pain in children is ganic diagnoses and missing the unusual causes of very common. If the initial workup is negative, it , abdominal pain. could be helpful to examine the patient for pin­ Enterobius vermicularis is one of the most com­ worm infestation, especially if the child presents mon intestinal nematodes.9 It is manifested by with symptoms mimicking appendiceal colic. on 26 September 2021 by guest. Protected copyright. perianal itching, mostly nocturnal, when the fe­ male worm exits through the anus to lay its ova. to References Recently pinworms have been reported in patho­ 1. Schwartz S1. The appendix. In Schwartz SI, Shires logic specimens of acute appendicitis outside the GT, Spencer Fe, editors. Principles of surgery. 6th ed. New York: McGraw Hill, 1994: 1307 -17. United States.ll,12 All the reported specimens 2. Schisgall RM. Appendiceal colic in childhood: the showed acute inflammation, and the patients' role of inspissated casts of stool within the appendix. . clinical presentations have been consistent with Ann Surg 1980;192:687-93. acute appendicitis. 3. Schisgall RM. Radiographic features of appendiceal Acute appendicitis is a well-accepted entity. colic in children. Pediatr RadioI1986:16:392-9. Many clinicians, however, are unwilling to accept 4. Lee AW, Bell RM, Griffin WO Jr, Hagihara PF. Re­ current appendiceal colic. Surg Gynecol Obstet recurrent abdominal pain as a symptom of appen­ 1985;161:21-4. 13 diceal disease. There are sporadic published re­ 5. Reynolds SL,Jaffe DM. Diagnosing abdominal pain ports of patients who have had appendicitis with in a pediatric emergency department. Pediatr Emerg chronic or recurrent symptoms. Ii Care 1992;8(3}:126-8.

58 JABFP Jan.-Feb.1996 Vol. 9 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.9.1.57 on 1 January 1996. Downloaded from 6. Appley J, Nash N. Recurrent abdominal pain: a field acute appendicitis.J Clin Patholl992;45:456-8. survey of 1000 school children. Arch Dis Child 13. Berdon WE. Editorial note on paper by RM Schis­ 1958;33:165-70. gall. Pediatr RadioI1986;16:392. 7. Edward MC, Mullins LL, JohnsonJ, Bernardy N. 14. Sarvin RA, Clausen K, Martin EWJr, Cooperman M. Survey of pediatricians' management practices for re­ Chronic and recurrent appendicitis. Am J Surg 1979; current abdominal pain. J Pediatr Psychol 1994; 137:355-7. 19:241-53. 15. Richmond HG, Guthrie W. Enterobius vermicularis 8. Apley J, Hale B. Children with recurrent abdominal and the vermiform appendix. J Pathol Bacteriol pain: how do they grow up? Br MedJ 1973;3:7-9. 1964;87:415-8. 9. Jones JE. Pinworms. Am Fam Physician 1988; 16. Botsford Tw, Hudson HW Jr, Chamberlain]w. 38:159-64. Pinworm and appendicitis. N EnglJ Med 1939;221: 10. Van Riper G. Pyrantel pamoate for pinworm infesta­ 933-6. tion. Am Pharm 1993;33:43-5. 17. Vermund SH, McLeod S. Is pinworm a vanishing in­ 11. Wiebe BM. Appendicitis and Enterobius vermicularis. fection? Laboratory surveillance in a New York City ScandJ GastroenteroI1991;26:336-8. medical center from 1971 to 1986. Am J Dis Child 12. Herd ME, Cross PA, Dutt S. Histological audit of 1988;142:566-8. http://www.jabfm.org/ on 26 September 2021 by guest. Protected copyright.

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