A Fire In the Belly

(From 2014 - A lesson many doctors learn over and over)

Henry Halvorsen was in to see me the other day. 79 years old and usually brimming with optimism and vitality, he seemed subdued and frail. His weight loss and muscle weakness were obvious.

“Good to see you, it’s been a long haul”, I greeted him.

“Three surgeons, two CT scans, two hospital stays before they found out what was wrong with me, and then rehab and everything that happened there”, he said, exasperated.

It had started when I saw him in the office at the end of February. He had been in three weeks earlier with a flare-up of his recurring back problem. That had cleared up, but Henry was having some bowel trouble, mostly constipation but then sometimes a day of loose stools. He thought it was his muscle relaxant that caused his bowels to act up, but his bowels didn’t straighten out after he stopped his cyclobenzaprine.

He wasn’t running a temperature, but his appetite was off. He was definitely a little tender deep in his right lower quadrant, but there was no involuntary muscle guarding when I let go of the pressure with my hands. I ordered bloodwork and a CT scan and told him that even though his pain and irregular bowels had been there for a whole week, he could have a subacute appendicitis.

His white blood cell count came back mildly elevated, and his sedimentation rate was elevated at 40 mm. The wait for the CT seemed long, but he was feeling better. Then, the day before his scan was scheduled, he woke up with worse pain and severe diarrhea, so he went to the emergency room. The ER physician, Jack Morton, told him right away he was suspicious of appendicitis.

His blood count was a little higher, and his sedimentation rate was 50. His abdomen was mildly tender, as it had been in my office. The CT scan showed no definite abnormalities, but the appendix was not visible.

The surgeon who saw him didn’t feel there was quite enough reason to remove his appendix, and with intravenous fluids and bowel rest, Henry started feeling better. Another surgeon did a follow-up evaluation on the weekend and Henry was discharged home on the third day.

Two days later at one o’clock in the morning, he woke up with abdominal pain, followed by a very large, soft bowel movement. He had chills and felt nauseous. He called the ambulance and arrived at the emergency room actively vomiting.

Dr. Morton was on that night, too. He ordered the same bloodwork again and another CT scan. This time there were signs of a small bowel obstruction and free fluid in the abdomen. There were nonspecific inflammatory signs in the right lower quadrant but the appendix was not clearly identified.

The surgeon on duty that morning didn’t hesitate. In short order Henry was on the operating table and had his ruptured appendix removed and two Jackson-Pratt drains placed. He received intravenous antibiotics and spent the next few days mostly sleeping with a Foley catheter draining his urine and a nasogastric tube draining his stomach.

At the rehab, where he was receiving intravenous antibiotics, he developed urinary retention shortly after his catheter was removed. The nurses were unable to reinsert a catheter due to his enlarged and inflamed prostate. Henry had to be transported back to the hospital where his urologist managed to get a Foley in. Then, back at the rehab, he developed diarrhea again and was diagnosed with Clostridium Difficile enteritis, resulting in more, but different, antibiotics.

As we went over everything that had happened to him, he sighed and said “I’m lucky to be alive”.

I nodded and mused out loud. “It’s such a common disease, but it can present in so many ways”. I thought about the first CT scan and the first surgeon’s decision not to perform an unnecessary operation.

I told him when I was a resident in Sweden, surgeons used to talk a lot about what percentage of innocent appendices you needed to operate on in order not to miss any guilty ones. Between 15 and 40 percent of emergency appendectomies have been reported to reveal a normal appendix, and yet 20 percent of appendicitis cases are initially misdiagnosed.

By the time I did my residency here, my hospital had just installed its first CT scanner, and the diagnosis of appendicitis was no longer a purely clinical one. In some centers, the diagnostic accuracy of CT scanning is said to be as high as 98 percent. But, when the tests are inconclusive or, worse, wrong, it is still a hard judgement call whether to operate or not.

Older patients tend to have less typical symptoms and are diagnosed later in the course of the disease than younger patients. While most cases of appendicitis fulminate within 48 hours, in 2 percent of cases the duration is more than two weeks.

“I’m just happy I pulled through”, Henry said as he rose from his chair with obvious effort.

I shook his hand and answered, “I am, too, and we should all be humbled that the great trickster almost did it again.”