Monday, November 12, 2007
Not just appendicitis
A 36 year old construction worker showed up one night in the ER with excrutiating right sided abdominal pain for three days. Of course, he'd been toughing it out, going to work anyway. But then he started to develop fevers and chills and rigors and finally his wife talked him into coming into the hospital. His temperature was 102.5F when I saw him and he certainly had tenderness and fullness on the right abdomen. The ER had already obtained the CT scan. The pertinent cuts are included above.
It looked like a perforated appendicitis with periappendiceal abscess. Generally, it's advisable to simply drain this abscesses percutaneously to clear the sepsis and consider bringing the patient back in 2 months or so for an interval appendectomy (although this strategy is debatable). The problem was that it was Friday night and getting radiology to come in for weekend procedures is like asking my wife to wear Ohio State Buckeye gear. I've handled this situation before simply by going to the OR and evacuating the abscess laparoscopically. He was young and anxious to have something done quickly so he could get back to work ASAP. So I took him that night and, interestingly, there was no pus. Nor did I ever identify an appendix. The cecum, however, was rock hard and indurated. So I did a laparoscopic ileocecectomy. The path is still pending; grossly it didn't seem like a cancer. In the one cut, you can see a suggestion of an appendicolith, so maybe this was complicated appendicitis with an intramural perforation. Weird.