UNCOMMON MANIFESTATIONS OF COMMON DISORDERS

A 28 year-old woman comes to the hospital with significant left-sided abdominal pain, and the imaging study is read as showing a small left-sided inflammatory process felt to be diverticulitis, despite no diverticulae being seen. No comment was made about the appendix. Diverticulitis with perforation in the large bowel may occur in the young, but it is an older person’s disease. As a former clinician, I would be bothered about that diagnosis.

But, four days later, the patient was better. A repeat study was performed just to be certain nothing was awry.

Something was.

The patient now had an abscess in her left side of the abdomen, and there was inflammation throughout the peritoneum. This time, a different radiologist looked at the scan in a different plane. There are 3 anatomical planes for viewing: sagittal, coronal, and transverse. In the coronal plane, it was clear that the appendix had ruptured. In the sagittal plane, where the prior reading had been made, the appendix wasn’t visible. Radiologists don’t always look at all the planes. They get paid by numbers of cases reviewed, just like most physicians, and there is a lot of pressure to take care of many patients. Before you say this is wrong, remember that many people complain of emergency department waits. If a radiologist takes a lot of time to read a scan, people wait.

But the appendix is on the right side of the abdomen. What gives?

I have a book from my late father-in-law called “The Early Diagnosis of the Acute Abdomen,” by Sir Zachary Cope, the 8th edition, written in 1940. It should be required reading for every medical student. The appendix is attached to the cecum, and the cecum is on one side of the iliocecal valve, leading from the ilium to the large bowel. The first radiological report did not mention the cecum. This was a major oversight. Unless the cecum is identified, the appendix cannot be identified, either. If those two cannot be seen, appendicitis as a cause of the problem cannot be excluded. In a young person with significant abdominal pain, appendicitis is always a consideration until proven otherwise. When I was a shipboard doctor, I had read Cope’s book 5 times, because diagnosing appendicitis meant either an operation on board (I did two, one by myself) or an expensive Mede-vac, with a helicopter landing on the small flight deck of a ship. I’ve done that many times, and it requires skilled pilots.

The cecum can be not only in the right side of the abdomen, but in the middle or other parts. The appendix, therefore, can be anywhere in the lower abdomen, the pelvis, in the middle, and even in the right upper abdomen, mimicking gall bladder disease, should it be retrocecal, or behind the cecum. The appendix can irritate the bladder, mimicking urinary infection. If the appendix is pelvic, ruptures, and forms an abscess, the abscess will move up the left side of the abdomen, the path of least resistance, exactly what happened here. Two of the best medical adages are: first, uncommon manifestations of common disorders are more likely to occur than common manifestations of uncommon disorders; second, when you hear hoofbeats, think horses, not zebras.

The woman will be operated upon and should survive, but she will have extensive scarring in her abdomen, which will likely lead to future bowel obstructions and multiple operations. If she has children and needs a C-section, it will be a very difficult procedure, since bowel may adhere to the uterus and perforate during surgery. She would have had future problems had she been diagnosed promptly, but not nearly to the extent that she is likely to have now.

It just isn’t the fault of the radiologist, however. Where were the clinicians? Why would a clinician accept diverticulitis in a 28 year-old with no other diverticula being visible? Why was there no statement why this could not be appendicitis? Such a statement would show that the clinician had at least thought of the diagnosis.

I made a lot of mistakes in practice, but any time I was bothered by a diagnosis, I either kept looking at the patient or asked a colleague what he or she thought. I also wrote a provisional diagnosis on my reports for X-Rays, not just “headache” or “abdominal pain.” I wrote, headache, slight left sided weakness, glioma a possibility,” or “abdominal pain, left-sided, high white count.” The radiologists loved having the information I provided them, and I got better reports, too.

I recently learned from a pathologist the astounding fact that with the advent of imaging procedures that supposedly allow us to look inside the body without surgery, that autopsies, the few that are done, show NO CHANGES, repeat, NO CHANGES in the pathology that was MISSED by the clinician and the radiologist during life. This is scary. It means that our assumption that we know what is going on with a patient on the basis of an imaging test may not be correct

This is the second time I have discussed a major problem with appendicitis in a young person. The first patient died. This person walled off the abscess, which the body used to do fairly successfully, in the days before good diagnosis and good surgery. My grandfather had unoperated appendicitis and survived. It can happen, and it did in 1940.

I would like to think in 2012 that we might be a little better. I’m not really so sure we are. And that bothers me as much as a diagnosis that doesn’t make sense. It makes me worry and think, “What else could be going on?”

There is one other adage we would do well to remember, the most basic rule of all: “Listen to the patient. She is trying to tell you what is wrong with her.”