Wednesday 1 May 2013


Look up the typical symptoms of appendicitis and you'll likely see the following: Crampy abdominal pain that usually starts in the mid abdomen and then gradually evolves to become an extremely sharp pain in the right lower part of the abdomen, low-grade fever, nausea, and loss of appetite.  The range of symptoms can vary wildly, but that's the typical progression (and coincidentally is exactly how I felt when I had appendicitis almost exactly 20 years ago).   Doctors rely on such typical patterns when we see common (and even some uncommon) diseases, because that's just how things are supposed to go, and patients are supposed to make our lives easy.

HA!  HAHA!  No, that's actually not how it works at all.  It WOULD make our lives easier, and it WOULD allow us to rely on our confirmatory studies that much more.  If I'm suspecting appendicitis because that's what the history and physical examination suggests and the CT scan confirms it, it's an open and shut case.

But what happens when there are no symptoms to go by, huh?  What happens then, smarty pants?

Shane emailed me with a personal story that got me thinking:

"I am an international business and marketing major.  I have always had a passion for sports, playing American football until I was 16.  Around that time I had a devastating knee injury that required me to have my patellar {kneecap} tendon repaired and a tibial tubercle realignment {the part of the shinbone where the kneecap tendon attaches is detached and then reattached in a better location} which required I get three screws.  Two weeks after surgery my doctor took me off crutches and let me walk small distances with my leg brace.  It was smooth sailing.  I went in for my six month post op check up.  I was getting back into fitness again, running, lifting, etc.  The doctor saw my X-ray and screamed "JESUS KID, ARE YOU IN PAIN?  DON'T LIE!"  I laughed and said of course not.  The doctor told me my tibia was not fused where he re-aligned it, and furthermore my screws were all broken.  Now to this day I am still perplexed.  I work at a physical therapist's office and I see this a fair amount.  Broken screws are painful!  Why did I feel no pain and feel undaunted yet still have this major issue under my skin?"

Why indeed.  Unfortunately for Shane I have no answers, because all too often patients don't read the surgical textbook before seeking medical care, so they just don't know what their disease process is supposed to look like to us, so their presentation usually isn't like it appears in books.  Just like veins aren't actually blue and arteries aren't actually red (they're both white, if you're wondering).

A young man was brought to the emergency department by his mother because he had a mild stomach ache after dinner.  Because he had abdominal pain, the emergency room called me without doing any real workup other than basic blood tests and a chest X-ray (because as every ER doc apparently thinks, abdominal pain is a surgical indication).  By the time I got to see him, he felt fine and was actually getting dressed to leave.  I asked him to wait while I looked at his chest X-ray (which the ER doc had ordered but hadn't bothered to look at before calling me).  What I saw made me literally do a double-take - he had free air in his abdomen!  Air is supposed to be contained within your GI system.  When that gas is outside the GI system, that means there's a hole somewhere which is allowing that air (and potentially other bad stuff like stomach acid or poop) to escape.  And that's a surgical emergency.  How the hell did this kid not look sick?

I went back to examine him, and his examination was still completely normal.  He had no abdominal pain when I mashed on his belly.  None.  But there was clearly something very wrong with him.  He had a hole that needed fixing.  STAT.  After explaining the situation to him and his mother, I booked him for immediate surgery.  After he was asleep, I put a laparoscope through his navel and immediately saw a 1/2 cm  (less than 1/4 inch) hole in his stomach.  I repaired it laparoscopically, and he went home 3 days later, still feeling fine.

The fact that he had absolutely no symptoms despite his life-threatening perforated stomach ulcer was strange.  What was even stranger is that he was only 14 years old with no other medical problems.  So how the hell does a healthy teenager get a hole in his stomach like this?  Should everyone with a tummy ache come to the emergency room to make sure they don't have holes in their stomachs too?

If they swallow a fish bone they should.  That's right, this kid had accidentally swallowed a small fish bone during dinner that night, and the bone had eroded through the wall of his stomach.

I don't know why Shane had no symptoms despite his major knee problem, and I don't know why this kid had no symptoms despite having a life-threatening injury.  I think it's nature's way of keeping us on our toes.  If everyone presented just like the textbook says they should, then we wouldn't have to use our brains and any idiot could be a doctor, I suppose. 

Oh, and for those of you keeping score at home, the fact that this ER doc was right is irrelevant.  Or something.


  1. Awesome post doc, keep them coming! I love reading your stories and have a few of my own I should probably share when I have time (I was born 3 months premature and have had multiple neurosurgeries).

  2. I love this post. Very interesting.
    I love the way you narrate your stories so its easy for everyone to understand. Both my Korean parents read your log and they love it, too.

  3. In your post you make ER Docs. sound pretty you personally think they are?

  4. I knew it! It's okay my parents say... Never eat fish, never!

  5. I never had a chance to comment on your post about Boston. We've had CNN on for so long that the "BREAKING NEWS" image (of course, referring to recaps of what has happened in the last few days) is burnt into the TV screen! Anyway, I heard about the first responders and doctors and decided I wanted to post a comment here. (I guess my point is: not every ER doctor is dumb, Adrian and Technocrat.)


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