Wednesday, December 5, 2007

Retrocecal Appendix




















I got called late last night by a very insistent ER Attending regarding a young gentlemen with midline suprapubic pain for a week. He had a low grade fever and apparently was having severe pain with the rectal examination. The official report from the CT scan was negative for appendicitis or any significant intra-abdominal pathology. The ER Attending, however, was convinced that this was a case of "retrocecal appendicitis" because of the severe rectal pain. Now, I get this story a lot from the ER and the there's no scientific or anatomic foundation to it whatsoever. The term "retrocecal" implies that the appendix is located retroperitoneally, behind the cecum. The only way this can happen is if the tip of the appendix is pointing superiorly toward the liver. Certainly, the presentation may be a little different from an anteromedially located appendix (back and flank pain, pain with flexion of the psoas muscle) but there would be no reason for pain elicited on rectal exam, unless there was a perforation with resultant pelvic abscess. But this ER guy was adamant. I even got the "I've seen this lots of times before; its a retrocecal appendicitis" bit. When I saw him, he was certainly tender on digital rectal exam. I reviewed the CT on my own and I thought there was a suggestion of perirectal inflammation posteriorly in the pelvis. Then when I talk to the guy I find out he's being treated with high dose Cellcept and Prednisone for Lupus. Of course, no mention of this was made to me over the phone by the ER. So he's an immunosuppressed guy with severe rectal pain and questionable inflammatory changes on the CT scan. Evolving perirectal sepsis is number one on my differential. I'll probably examine him under anesthesia in the OR later today.

10 comments:

Anonymous said...

What a difference a history makes!!!
Stories like this remind of me of the Jery McGuire line " help me help you".

Or perhaps jack Webb "just the facts maam"

rlbates said...

Waiting for the update. What did you find?

Buckeye Surgeon said...

He actually became much less sympotomatic with antibiotics. I sent him for MRI and it was essentially negative. I'm not sure what it is; maybe a weird CMv proctitis or something. I even got ID involved.

Buckeye Surgeon said...

Diagnosis..... cmv proctitis (no help from ID)

rlbates said...

Thanks for the update. Glad he's better.

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Anonymous said...

I didn't get why was the ER attending convinced of a retrocecal appendix with the rectal pain while it's know that rectal examination in retrocecal appendix is negative and it's only positive in the case of a pelvic appendix in the Douglas cul-de-sac?? thanks for clarifying this issue!

Anonymous said...

I had a appendix surgery in june 2007 and they said it was busted and they has to remove it. Then after 2 years in april 2009 i was rushed to a hospital close by and they told me i still have my appendix and needs to be removed but this time it was a retrocecal. I am not sure why my appendix was not removed when they said they did because i was normal after that untill i was taken to the hospital again in 2009 April .. Help me Help me ... Is this normal

Anonymous said...

Hi,
Would you mind telling me if the x-ray at the following link shows a retrocecal appendix? Also, below the cecum is an ovoid calcification that is ~ 1.9 cm x 1.6 cm.

http://s711.photobucket.com/albums/ww115/tarheelx4/

tarheelx4@aol.com is my e-mail address.

Thank you

Anonymous said...

Im 18 years old and about 9 months ago my appendix was removed. I was here in Houston Tx. for my 18 birthday and 2 days later I took of to Mexico where I life. When I got there my upper side of my stomach was hurting, I had diarrea and a lot of vomiting. I went to the local clinic and the doctor told me it was a very bad virus that I had. I was like this for about 5 days but as the days passed by the pain was worse, so I went to another doctor. He lifted up my right leg and then hit my foot. He said that if I would feel pain then it was my appendix but I didn't, so he told me the same thing, that it was a virus. The pain got so worse that I couldn't even walk or sit, I was clunchted into a ball in my bed for the next day still vomiting, with diarrea and not eating untill my brother and mom took me with a speciallist. (I had to be carried from one place to another). We got there and he laid me down, put the testoscope on my stomach and in that moment he walked out. He told me I was getting a teatment for the virus but he told my brother the true. He didn't know what it was but my digestive sistem was parallisis and I needed to be in the hospitallised imediatelly or if not it could of been fatal. I got to the ER around 12pm and the doctores were making blood work done, x-rays and millions of stuff to figure out what it was (while I was yelling because of the pain). It wasn't untill 9pm when I felt very sharp pain focusing on my right side of my stomach. The doctores looked at each other and said 'this might be a retrocecal appendix, she has to be in the OR now'. They kicked out my family from the room and prepared me for the operation in that moment. After that very sharp pain that I felt three times, I couldn't move any more. After I got out of the OR at 3am, with my now removed appendix in a small clear cup, I was with no pain. The appendix was hugh and nasty, it was about three or four times bigger of a normal appendix and it had to be examined because it was with weir colors and shape. Now, thank God I am ok.