Kunitomo Kotaro, Shimizu Taro, Tsuji Takahiro
Department of General Medicine, Kumamoto Medical Center, Kumamoto, Japan.
Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan.
Eur J Case Rep Intern Med. 2022 Nov 9;9(11):003615. doi: 10.12890/2022_003615. eCollection 2022.
Very often in clinical practice, an inflamed pelvic appendix shows left lower quadrant abdominal pain as the primary painful area. The clinicians are anchored to the most prominent symptom, thereby taking an unnecessary detour in reaching an accurate diagnosis. A 40-year-old man presented to our emergency department with persistent lower left abdominal pain with a fever of 38 oC from a day earlier. He had a good appetite and repeatedly complained of severe constipation at the time of his visit. Physical examination revealed tenderness in the lower left abdomen without a peritoneal sign. Abdominal ultrasound and non-contrast-enhanced computed tomography revealed a left hydroureter. The next day, a radiologist pointed out the possibility of appendicitis. An urgent laparoscopic appendectomy was performed. The intriguing point of this case is the diagnostic delay because of three anchoring biases. First, the typical right lower abdominal pain of appendicitis was shielded by the intense left lower abdominal pain. Moreover, the presence of a left hydroureter distracted the physicians from the actual location of the pain. Furthermore, the presence of constipation anchored the physicians to constipation as the cause of abdominal pain. In overcoming these biases, specific diagnostic strategies to avoid biases should be implemented.
If a patient has unexplained lower left abdominal pain, it is advisable to deploy a "searchlight" strategy.When a hydroureter was found to have no apparent source obstruction, a vertical tracing strategy should have been undertaken to detect its root cause.To avoid the wrong diagnosis through anchoring bias, pivot and cluster strategy - deploying differential diagnosis specific to the initial diagnosis (constipation in this case) - should be adopted at the start, considering the important differential diagnosis and thus preventing a missed diagnosis.
在临床实践中，发炎的盆腔阑尾常常表现为左下腹疼痛作为主要疼痛部位。临床医生被最突出的症状所锚定，从而在做出准确诊断的过程中走了不必要的弯路。一名40岁男性因持续左下腹痛伴一天前38摄氏度发热就诊于我们的急诊科。他食欲良好，就诊时反复诉说严重便秘。体格检查发现左下腹压痛，无腹膜刺激征。腹部超声和非增强计算机断层扫描显示左输尿管积水。第二天，一名放射科医生指出了阑尾炎的可能性。遂进行了紧急腹腔镜阑尾切除术。该病例有趣的一点是由于三种锚定偏差导致诊断延迟。首先，阑尾炎典型的右下腹痛被强烈的左下腹痛掩盖。此外，左输尿管积水的存在使医生偏离了疼痛的实际部位。此外，便秘的存在使医生将腹痛的原因锚定在便秘上。在克服这些偏差时，应实施避免偏差的具体诊断策略。
如果患者出现无法解释的左下腹痛，建议采用“探照灯”策略。当发现输尿管积水且无明显的梗阻源时，应采用纵向追踪策略以查明其根本原因。为避免因锚定偏差导致错误诊断，一开始就应采用枢轴和聚类策略——针对初始诊断（本例为便秘）进行鉴别诊断——考虑重要的鉴别诊断，从而防止漏诊。
