A pitfall of the diagnostic process of differentiating bile peritonitis from acute appendicitis.

BACKGROUND/AIMS: We often encounter patients with bile peritonitis expressing right hypogastralgia who have been easily misdiagnosed as acute appendicitis. The aim of this study is to clarify why patients with bile peritonitis express right hypogastralgia and to recommend a way in which to prevent misdiagnosis of patients with bile peritonitis with right hypogastralgia as acute appendicitis.

METHODOLOGY

Subjects were 12 patients with bile peritonitis who underwent laparotomy in Yokohama City Nambu Hospital or Critical Care and Emergency Center of Yokohama Citizen Medical Center Hospital. The spread of bile and inflammatory peritoneal fluid confirmed during laparotomy was compared with the preoperative abdominal findings.

RESULTS

Five of the 12 cases (42%) showed signs of peritoneal irritation only in the epigastric and right hypochondral region; 6 (50%) in the right lateral and hypogastric region; and 1 (8%) in the diffuse abdomen. Four of the 12 cases (33%) showed widespread inflammation and accumulation of fluid in the whole peritoneal cavity (generalized peritonitis). Five cases (42%) showed limited peritoneal inflammation with green coating, leaked bile, and accumulation of inflammatory fluid within the hepatoduodenal ligament, Morison's pouch, right paracolic gutter, and right ileac pouch. Three of these 5 cases and 3 of the 4 generalized peritonitis cases showed signs of peritoneal irritation in the right hypogastric region. US of these cases showed signs of cholecystitis. Three of the 6 cases underwent emergency operation by right hypogastric incision under the diagnosis of acute appendicitis. One of these 3 cases underwent neither US nor CT; the second of these cases showed ileocecal inflammation by US but did not undergo CT; and the last of these cases expressed peritoneal irritation most strongly in the right hypogastric quadrant despite of signs of cholecystitis by US and CT.

CONCLUSIONS

If patients who complain of right hypogastralgia like acute appendicitis also complain of right epigastralgia or right hypochondralgia, we should suspect biliary peritonitis due to gangrenous or perforated cholecystitis and should perform upper abdominal scanning, especially around the gallbladder, by US and CT.