Don’t ask if you don’t want to know…

Sunday, May 13, 2007

There are always unasked questions in medicine. Patients present for care with a complaint, but under the surface there is always more. If the doctor doesn’t anticipate and answer what wasn’t asked, then the patient leaves worried, unsatisfied and upset. Arrive complaining of a headache and the doc offers some pain medications, but you want to hear the words “I don’t think this is a tumor or a stroke.” Have chest pain? You want reassurance that you aren’t having a heart attack.

Roy Halladay was probably unhappy that his stomach ache was really something serious…appendicitis. A little belly pain and the next thing you know, you’re in the operating room and being told that you won’t pitch again for 6 weeks, all because of a little string of tissue called the appendix. This addendum to the cecum, the area in the right lower part of the abdomen when the small intestine joins the large intestine or colon, causes great worries for doctors and patients alike. The pattern described by Dr. McBurney of pain developing around the belly button, followed by nausea and then having the pain move to the right lower quadrant has been described in textbooks forever, but unfortunately not every patient has read the book.

The appendix is a hollow little tube and can be very short or very long. It can lie near the front of the abdominal wall or wander near the kidney high up in the abdomen. It can lay low in the pelvis or cross over to the left side. It becomes inflamed if the tube becomes blocked, usually by a bit of stool, causing the walls to swell and leak fluid. Eventually, after about 12- 24 hours there is enough inflammation to cause symptoms. After more time, the wall can perforate (the ruptured appendix).

The problem with diagnosis is not the patient who presents classically, with tenderness in the right spot, a fever, loss of appetite, and an elevated white blood cell count. It’s everybody else, who may not have the classic findings. Appendicitis may mimic ovarian cyst pain in women who ovulate, or a kidney infection if is hiding by the kidney. And other diseases may mimic appendicitis.

So how is the doctor supposed to answer the unasked question? Before technology brought us the Computerized Tomography or CT scan, people have appendectomies, operations to remove the appendix, because there was a worry that the appendix was inflamed and to prevent the possibility of rupture. It was accepted that the surgeon would take out a normal appendix 15-20% of the time. But in those patients where uncertainty exists, the surgeon may rely on the CT to look inside the abdomen and decide whether the appendix is inflamed or if something else is going on.

But not everybody needs a CT and the scan is not always helpful. If takes 6-12 hours after onset of symptoms for enough inflammation to show up on CT. And in an awkward twist, thin people are at a disadvantage over those with extra weight, since more fat allows better visualization of tissues in the abdomen. So sometimes the CT can’t help because you can’t see the appendix. Fortunately, the art of medicine is practiced alongside the science and time is often as ally. In people where the diagnosis is in doubt, watchful waiting may sort out the diagnosis. Ultimately the doctor has to decide whether the patient has a surgical abdomen for whatever cause and the thing to do is look inside…or decide that the abdomen is benign and time will cure whatever ails.

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