Wednesday, December 5, 2007
I got called late last night by a very insistent ER Attending regarding a young gentlemen with midline suprapubic pain for a week. He had a low grade fever and apparently was having severe pain with the rectal examination. The official report from the CT scan was negative for appendicitis or any significant intra-abdominal pathology. The ER Attending, however, was convinced that this was a case of "retrocecal appendicitis" because of the severe rectal pain. Now, I get this story a lot from the ER and the there's no scientific or anatomic foundation to it whatsoever. The term "retrocecal" implies that the appendix is located retroperitoneally, behind the cecum. The only way this can happen is if the tip of the appendix is pointing superiorly toward the liver. Certainly, the presentation may be a little different from an anteromedially located appendix (back and flank pain, pain with flexion of the psoas muscle) but there would be no reason for pain elicited on rectal exam, unless there was a perforation with resultant pelvic abscess. But this ER guy was adamant. I even got the "I've seen this lots of times before; its a retrocecal appendicitis" bit. When I saw him, he was certainly tender on digital rectal exam. I reviewed the CT on my own and I thought there was a suggestion of perirectal inflammation posteriorly in the pelvis. Then when I talk to the guy I find out he's being treated with high dose Cellcept and Prednisone for Lupus. Of course, no mention of this was made to me over the phone by the ER. So he's an immunosuppressed guy with severe rectal pain and questionable inflammatory changes on the CT scan. Evolving perirectal sepsis is number one on my differential. I'll probably examine him under anesthesia in the OR later today.