26 April 2007

Pride goeth before the fall

So says the book of proverbs. You may recall the pride I expressed when I picked up a difficult appendicitis case a couple of months ago. Karma is a real bitch, sometimes, and this week has been payback time. It began in what is for me typical fashion:

It was a classic presentation. A young man, about 19 or so, with 36 hours of anorexia, malaise, low grade fevers, and generalized abdominal pain which subsequently localized to the right lower quadrant. He has a elevated white count, tenderness over McBurney's point, involuntary guarding, and rebound tenderness. Now, as a digression, one drawback of modern technology is that is it nearly impossible to get an appendectomy without a CT scan any more. It used to be that a "negative laparotomy" rate of something like 25% was acceptable. Now any negative laparotomy is viewed in much more negative terms, and the surgeons almost always demand a CT scan before even seeing the patient. So it goes. This was, I thought, one of the few cases which was clear cut enough to justify skipping the CT scan and going straight to the OR. And the surgeon on was one I knew well and who trusted me. I called her up:

"I've got an appy here for you."
"What did the CT scan show?"
"I actually think you may want to just take this one to the OR. I am sure this is an appy. I don't own a hat, but I will go out, buy a hat, and eat it if this is not an appy. I'll get a CT if you like, but I think it'll be a waste of time."
"If you say so, it's good enough for me. I'll come down and see him now."

She examined and interviewed the patient, agreed, and up to the OR he went. An hour later, I got a call from the surgeon. With barely-disguised malicious glee in her voice, she said, "It's time for you to go shopping. What's your hat size?"
It turned out the young man was experiencing a first presentation of inflammatory bowel disease and had terminal ileitis, which is notorious for mimicking appendicitis. (and the surgeon was very nice about it -- we are friends and she too, had been convinced enough to take him to the OR.)

So then the next day when I saw another young man with a classic case of appendicitis, I was more cautious. I told the patient that I was quite sure it was an appy and he would need to go to the OR, but to be certain, he would get the CT scan before I called the surgeon. His CT came back showing epiploic appendagitis, a bizarre and rare, but benign condition which mimics appendicitis but does not require surgery. I have seen it maybe three or four times in my career.

Thoroughly snakebit, I saw yet another "classic" case of appendicitis last night. Once again, it couldn't have been any more obvious, as if from the textbook, in a young male. (It's never straightforward with females. Um, I say that in reference to appendicitis only. Really.) He also got a CT scan, and at this point I was no longer even surprised to have an unusual and rare thing turn up on the CT scan. In this case, it was cecal diverticulitis, which I have never seen before, let alone in a 22 year old (diverticulitis typically occurs in the sigmoid colon and in patients 50-60 years old).

It's almost is if I was living in some Greek tragedy in which the fates were eager to punish me to the crime of hubris, of which I am undoubtably guilty. Enough, already!

If I get a chance, one day I will tell you about the case that truly set me up for this karmic payback. Here it is. I can't argue that I don't deserve it.


  1. "It's time for you to go shopping. What's your hat size?"


  2. Wow. Time to add those to my RLQ differential.

  3. You're so right. It's like my ninth grade production of Antigone. Or you know how once you learn a new word, suddenly everyone around you starts using that word? In this case, Dr. Jerome Groopman writes this book How Doctors Think and talks about the problems of pattern recognition, gets a lot of press, and then... surprise!

  4. When it rains, it pours!

  5. Twice since I started as an attending I've gotten a call from the radiologist where they tell me the diagnosis and all I had to offer was "um, what's that?"

    The first was hematocolpus, and the second was epiploic appendangitis. Now I've actually seen the latter twice in eight months.

  6. just came across your blog during random internet surfing on EM. I'm going to be a first year EM and your stories are awesome/inspiring/scary!

    p.s. I saw an epiploic apendagitis in a 18 yr somewhat obese female as a MS IV. Totally didn't think that was on the DDx (both my attending and I were banking on Ovarian torsion)


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