A first-time case in a 35-year medical career

A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis.

It was afternoon, and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made me dependent on my support staff to see the big picture of my schedule or pending, unfinished tasks.

The next morning there was a fax from Cityside with a lengthy explanation saying he had an epiploic appendagitis, and it went on to explain that this is a harmless and self-limited condition.

I did some reading. These appendages are little fat bumps that run along the outside of the colon. They can undergo torsion, or twisting, and become acutely inflamed. This condition is found in up to 7 percent of patients suspected of having appendicitis and 1 percent of patients with suspected diverticulitis.

I had never heard of appendagitis, and I wondered how certain the distinction was between this harmless and the other potentially lethal “-itis” was.

Checking with the patient, he was in more pain and more nauseous than the day before.

I suggested going to the ER just to make sure. I just didn’t feel comfortable trusting a CT and a diagnosis I had never heard of. I imagine this is a result of training before CT scans were in use and then not rubbing elbows enough with major surgery to be aware of the finer distinctions of the differential diagnosis in acute abdomens already too sick for the primary care office.

The ER report from Cityside was gracious in its description of why my young patient was there. He got an anti-inflammatory medication and some pain pills and went home reassured. He was still uncomfortable when we called him a day later, but feeling better.

The other day I saw a young woman who had been to Mountainview Hospital for left lower quadrant abdominal pain.

She had a history of diverticulosis, and at her young age had already had a CT proven episode of acute diverticulitis a few years earlier. This time, the CT showed a sigmoid epiploic appendagitis with no evidence of diverticulitis. The ER doctor prescribed antibiotics that would have been appropriate if she had diverticulitis.

I saw her two days after the emergency room visit. She was feeling a bit better. Her exam was benign, and I explained to her that she didn’t really need the antibiotic. But I also told her it was a rare condition that I had not heard of in my first 35 years of practice. I told her the Mountainview ER doc probably hadn’t seen a case before either, or didn’t trust the CT.

My patient was happy to stop her antibiotics and happy that her diverticular disease was not the cause of her symptoms.

You’re never too old to learn.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

Image credit: Shutterstock.com

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