The dense fog that rolled into London town and crept up Baker Street seemed to seep into our sitting room at 221B, where my friend, Sherlock Holmes, tinkered at one of his chemistry experiments.
“Holmes, how do you know that you won’t blow us up with a compound gone astray.”
“Elementary, Watson, I trust the classic and proven works of chemistry that allow me to recognize normal from abnormal processes.”
Our apartment door flew open and a harried middle-aged woman, supporting a pale middle-aged man, stood staring at us, with pleading in her eyes. “Mr. Holmes, Dr. Watson, my husband is in serious trouble, I fear. Please help us.”
We moved the 55 year old male cautiously to our examination table.
“His right-sided abdominal pain started one week ago, while we were vacationing at the seaside. We saw a practitioner who prescribed Bentyl. It seemed to ease the pain and we enjoyed a few lovely days. However, the medicine seemed to cause constipation, so he took a laxative which completely relieved his pain. But, two days later his pain returned with a vengeance.
“I had not had a BM in 5 days, and now I have fever, again.” The poor fellow spoke these words while lying perfectly still. I was in robust health, Mr. Holmes, and have only had my gallbladder removed two years ago without any complications.” He denied anorexia, nausea, emesis, diarrhea, melena, hematochezia, and hematuria.
“Watson, please complete a thorough abdominal exam.
Temperature 98.4 Pulse: 80 BP: 110/76 BMI 25
+McBirney Point tenderness
No CVA tenderness
“Classic,” Holmes stated, “ruptured appendicitis.”
Total Bili: 1.3
Alk Phos: 211 (38 – 136)
AST: 28 (10-40)
ALT: 74 (20-75)
Lipase: 73 (70-320)
Amylase: 42 (20-110)
WBC: 14.7 with left shift
UA: Nitrite +, otherwise unremarkable.
There is diffuse abnormality of the cecum. There is irregular wall thickening with a poorly defined mass. This extends approximately 7.6 cm up the transverse colon from the cecum. The overall appearance is most consistent with a poorly defined mass, this could represent a cecal carcinoma. A cecal inflammatory process could cause this appearance as well.
The terminal ileum is visualized and appears unremarkable. The appendix was not separately identified. The inflammatory process appears epicentered in the cecum however, rather than in the expected location of the appendix. There is no secondary CT evidence of appendicitis such as appendicolith.
Holmes contacted the surgeon-on-call, Dr. James Moriarty, who was none too happy being bothered late on a Friday afternoon.
“Dr. Moriarty, I have a patient with a textbook case of ruptured appendicitis. I have started him on IV fluids and enteric antibiotic coverage. I would like you to evaluate him for an interval appendectomy.”
“I have reviewed all the data. This is no ruptured appendicitis. I told the patient that he could go home and have a colonoscopy as an outpatient. Looks more like a cecal cancer to me.”
“Go home! You told him that he could go home?” Holmes was becoming a bit disturbed. “The man has a ruptured viscus and you tell him he can go home. I am not comfortable with that decision, Moriarty.”
“I will not operate until a colonoscopy is done.”
“Colonoscopy!” Holmes’ temporal veins throbbed with suppressed anger. “You would have a scope shoved into the colon of a man with a bowel perforation and fill his peritoneum with air?“
“The CT scan clearly showed that this issue is inside the Cecum, not involving the Appendix. I told the patient that he has a colon cancer.”
Holmes took a deep breath. “Moriarty. Let us reason our way through this case. The patient develops an acute appendicitis seven to ten days ago. The pain is so bad that he goes to a clinic while on vacation. He is given Bentyl, an anti-cholinergic, that stops his bowel peristalsis and provides some pain relief, but it causes constipation. He goes out and gets Dulcolax, an irritant laxative that likely ruptured the already inflamed appendix. He feels terrific for two days, then the pain returns with a vengeance.”
“Never seen it.”
“Never seen what?” Holmes asked.
“A textbook case of ruptured appendicitis: pain relieved by the rupture then the worsening of the pain. It just doesn’t happen in real life.”
“You tell me how you reasoned your way through the case.”
“He has a cecal tumor that has created a large phlegmon of secondary inflammation. The ruptured appy idea is a distractor.”
“He had a normal colonoscopy four years ago. What colonic polyp, if missed, would grow to seven centimeters in four years. Speaking of a distractor.”
The patient’s pain waxed and waned with IV fluids and antibiotics. Dr. Moriarty performed a colonoscopy, after an extensive prep, despite Holmes’ continued warnings against the procedure. The colonoscopy revealed a normal intraluminal area: no polyps, no tumors. And evidence of extrinsic compression of the cecal area.
On the fifth day of hospitalization, the patient was taken to surgery, where Dr. Moriarty found a ruptured appendix surrounded by extensive phlegmon, requiring a right hemi-colectomy and ileo-colic anastomosis. The patient had an uneventful post-operative course.
“Holmes,” I asked him, as we sat quietly in our easy chairs back at 221B Baker Street, “why were you so dogmatic in this case? You couldn’t have been sure of the diagnosis given the patient’s lack of anorexia, his lack of GI symptoms, and the rather inconclusive CT scan.”
“My dear Watson,” he sighed, “trust the classic history for a ruptured appendix. It is classic for a reason. Trust your exam. Don’t let the fog of the 20% false negative rates for CT scans cloud your sound reasoning. Trust your knowledge of the natural history of disease processes to keep you on the right track.”