It was early in the morning when the woman sneaked into the living room where her 82-year-old partner was sleeping. He didn’t usually sleep in his recliner, but two nights ago he was in and out of bed a lot with diarrhea, so she was relieved when he decided to sleep in his favorite chair. . His eyes opened as she started to close the door. “I can’t get up from my chair,” he said quietly. Her feet were on the floor, but she had no strength to stand up or move, he told her. This man she had known and loved for 21 years, but only when he was still asleep. Now, with his arm hanging limply by his side, his face, still tanned by New Mexico, was pale and looked more emaciated and sickly than she had ever seen him.
She struggled to get him to his feet. Then, she put his arm around her neck and her arm around her shoulder, she limped him to the bathroom, then put on her clothes and got in her car, driving her home in Albuquerque. I headed to the nearby PresNow 24/7 Urgent Care Center.
The emergency room was busy even though it was early Sunday morning, but the man was seen immediately. It was urgent because of the sudden onset of weakness in a man of the same age. They had been in the triage area for only a few minutes when Dr. Lawrence Garnon entered the curtained area and introduced himself. “What’s wrong?” he asked casually.
A man reported having three teeth extracted five weeks ago. He took antibiotics for 10 days as per his instructions and was fine until the beginning of the week. At first it was just fatigue. Thursday he was so tired after his daily hike that he had to take a nap after he got home. And he never takes a nap, he added. Then came the diarrhea. He had to go to the bathroom probably a dozen times during the night. At the same time, his stuffy nose and runny nose got worse. The oral surgeon said the symptoms were typical, but he warned about the possibility of infection. The man wanted his partner to call the dentist for help, but she is a former nurse and was convinced she needed to go to the emergency room instead.
Gernon examined the patient carefully. His heart was beating fast and his oxygen levels were low. His mouth appeared completely normal. Although he was clearly hyperemic, the surgical site appeared to be healing well. When the doctor pressed on the lower left side of his abdomen, he felt quite tender, but importantly, once the pressure was released and the abdominal wall returned to normal, there was no pain at all. That was a relief. If an infection is present, it has not spread to the sensitive lining around the intestines. However, her stomach looked swollen. “You know, I don’t think the problem lies here,” Garnon told the patient, pointing to the man’s nose and mouth. “I think it’s here,” he said, pointing to his swollen belly. Doctors ordered a tube to be inserted through the man’s nose and into his stomach. A dark brown liquid soon poured from the tube into the connected container.
CT scans and X-rays confirmed what doctors found to be no problems with his sinuses and lungs. However, a CT scan of the man’s abdomen showed otherwise. In the part of the intestine where the large intestine and small intestine connect, the wall had become so thick and swollen that the passageway was completely blocked by 4 to 5 inches. Streaks of inflammation shadowed the tissue around the clogged tube. His intestines were obstructed by what appeared to be a tumor surrounding and invading the intestinal wall. That’s why a lot of brown liquid was coming out of the tube in her stomach. The digestive fluids constantly produced by his stomach and intestines had nowhere else to go. It was not yet clear whether the tumor was actually the cause of this blockage. What was clear was that it had to go out. and so on.
surgical options
It wasn’t until an ambulance took the patient to Presbyterian Rust Medical Center that a doctor mentioned the possibility that it was cancer. He got angry when he heard that. Thirty years ago, his wife died of cancer, and he had vivid and terrifying memories of her diagnosis, treatment, and death. He feared he could suffer the same fate and that the disease would change the life he and his partner had planned.
The surgeon assigned to the case, Dr. Kevin Hudenko, comes to introduce himself to the patient and discuss surgical options, using a small camera and instruments that are inserted through a small slit in the patient’s body. , explained that he wanted to perform the surgery laparoscopically. abdominal wall rather than a single large incision. The laparoscopic approach allows for a faster recovery, and you can always return to traditional surgery if needed.
unexpected discovery
The next day, the man was rolled into the operating room, where an incision was made and instruments were placed. Carbon dioxide was injected into the man’s abdomen so the team could observe and manipulate the situation. Fudenko watched on a monitor as he moved a camera and a small gripping tool toward the affected area of the small intestine. He gently separated the ring of small intestine and inched his way towards the blockage. He knew from his experience that when cancer arrives, the outer surface of the intestine becomes wrinkled, irregular, and distorted by infiltrating growths. Instead, the intestine was smooth and strangely sticky, but it came off easily. As we neared the location where we expected to find the blockage, a thick yellowish liquid poured out from between the separated loops. It looked like pus. That was unexpected. He quickly vacuumed up the viscous liquid and looked for the source. Behind the wall of the intestine, beneath the purulent fluid, a hole was visible. It was at the base of the appendix. This wasn’t cancer. It was a ruptured appendix.
The appendix is the little finger of the intestine that separates from the large intestine just beyond the point where it intersects with the small intestine. Appendicitis occurs when the connection to the intestinal wall is interrupted. Normal secretions have no outlet and accumulate within the hollow tube, stretching the walls until they eventually rupture and the now putrid fluid squirts into the abdominal cavity. This usually causes fever and abdominal pain, which is first felt in the area around the belly button, but moves to the lower right abdomen as the infection and inflammation spreads to the highly sensitive lining of the abdominal cavity, known as the peritoneum. Despite this, this man did not experience any pain as might be expected. why?
There are very few pain fibers in the intestines. Most intestinal pain comes from the tissue lining the abdominal wall. If the appendix is surrounded only by the intestines and away from the sensitive peritoneum, the appendix may rupture and cause little or no pain. The small intestine moves freely around the abdominal cavity like a snake in a pouch. When they touched this man’s ruptured appendix, these loops of intestine became sticky with inflammation and formed a wall around the wound, containing pus and other purulent material.
When the surgeon realized it wasn’t cancer, he turned to his assistant and the two high-fived. Thanks to the images provided by CT and her MRI, surgeons are rarely surprised by what they see in the operating room. And when they do, the surprise is usually a bad one. For example, cancer develops instead of what they expected. The entire surgical team was excited about this unexpected discovery.
After the surgery, Hudenko visited the patient in the recovery room. “Good news,” he told the unconscious man. “I’ll explain more when I wake up, but here’s the bottom line: You don’t have cancer.”
The surgery, performed through three small incisions, resulted in a quick recovery and the man returned home after a few days. At age 82, a diagnosis of cancer is much more likely than appendicitis. The man was very happy to be an exception. His surgery was three months before Christmas, but for the patient and his partner, Christmas came early last year and brought with it the greatest gift of being with him in his old life.
Lisa Saunders, MD, is a contributor to this magazine. Her latest book is Diagnosis: Solving the Most Puzzling Medical Mysteries. If you would like to share your solved case, please email us at Lisa.Sandersmdnyt@gmail.com.