Was this man’s weakness related to recent oral surgery?

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 normally sleep in his armchair, but two nights earlier he had been in and out of bed so often with diarrhea that she was relieved when he decided to sleep in his favorite chair. His eyes opened as she went to close the door. “I can’t get out of the chair,” he said softly. His feet were on the ground, but, he told her, he did not have the strength to stand up or even move. This was a man who, in the 21 years she knew and loved him, was only there when he was asleep. Now, with his arms hanging limply at his sides, his face pale behind his constant New Mexico tan, he looked weaker and sicker than she had ever seen him.

She struggled to help him up. Then, with his arm around her neck and hers around his shoulders, she shuffled him into the bathroom, then into his clothes and out to the car to go to PresNow 24/7 Emergency Room near their Albuquerque home.

The emergency room was busy, even early on a Sunday morning, but the man was seen quickly. The sudden onset of weakness in a man his age required urgency. They had only been in the triage room for a few minutes when Dr. Lawrence Gernon entered the closed room and introduced himself. “What is happening?” he asked casually.

Five weeks earlier, the man reported, he had had three teeth removed. He took antibiotics for ten days as instructed and was doing well until earlier that week. At first it was just fatigue. On Thursday he was so tired after his daily walk that he had to take a nap when he got home. And he never takes naps, he added. Then came the diarrhea. He had to go to the toilet maybe a dozen times during the night. Around the same time, his nasal congestion and runny nose worsened. The dental surgeon had mentioned this symptom, which was typical, but warned of a possible infection. The man wanted his partner to call the dentist for help, but she was a retired nurse and was sure he needed to go to the emergency room.

Gernon examined the patient attentively. His heart was beating fast and his oxygen levels were low. His mouth looked completely normal. It was clearly congested, but the surgical site looked well healed. He had significant tenderness when the doctor pushed on the lower left side of his abdomen, but more importantly, no pain at all when the pressure was released and the abdominal wall rebounded. That was reassuring; if an infection was present, it had not spread to the sensitive lining around the intestines. Still, his stomach looked swollen. “You know, I don’t think the problem is here,” Gernon told the patient, pointing to the man’s nose and mouth. “I think it’s here,” he said, pointing to his swollen belly. The doctor ordered a tube to be inserted through the man’s nose into his stomach. Almost immediately, dark brown liquid flowed from the tube into the connected container.

CT scans and X-rays confirmed what the doctor found during the examination: the sinuses and lungs were fine. But the CT of the man’s abdomen was not. In the part of the intestine where the large intestine connects to the small intestine, the walls were thickened and swollen so much that the passage was completely closed for four to five centimeters. The tissues surrounding the blocked tube were surrounded by inflammatory streaks. His intestines were obstructed by what appeared to be a tumor surrounding and invading his intestinal walls. That’s why so much brown fluid came out of the tube in his stomach. Those digestive fluids, constantly produced by his stomach and intestines, had nowhere else to go. It was not yet clear whether the cause of this blockage was indeed a tumor. What was clear was that it had to come out. And so forth.

Surgical options

Only after the ambulance delivered the patient to Presbyterian Rust Medical Center did a doctor mention the possibility that this was cancer. That was disturbing to hear. Thirty years earlier, his wife died of cancer, and he had vivid and terrible memories of her diagnosis, her treatment, and her death. The possibility that he would suffer the same fate and that this disease would change the life he and his partner had planned together worried him.

Dr. Kevin Hudenko, the surgeon assigned to the case, stopped by to introduce himself to the patient and discuss surgical options. He explained that he would prefer to perform the procedure laparoscopically, using small cameras and instruments that would be inserted through small slits in the patient’s skin. abdominal wall instead of a single large incision. The laparoscopic approach would allow for a faster recovery and they could always return to traditional surgery if necessary.

An unexpected discovery

The next day, the man was rolled into the operating room, where the incisions were made and the instruments were put into place. Carbon dioxide was pumped into the man’s abdomen to give the team room to see and maneuver. Hudenko watched the monitor as he moved the camera and small grasping tools toward the affected area of ​​the small intestine. He carefully loosened the loops of the small intestine and slowly walked toward the blockage. He knew from experience that when he got to the cancer, the outer surface of the intestine would be wrinkled and irregular, distorted by the invading growth. Instead, the intestines were slippery and strangely sticky, although they fell apart easily. He was almost to the spot where he expected to find the blockage when a thick yellowish fluid gushed out between the separated loops. It looked like pus. That was unexpected. He quickly sucked up the viscous liquid and looked for the source. Behind the intestinal wall, under the purulent fluid, he saw a hole. It was located at the base of the attachment. This wasn’t cancer. It was a ruptured appendix.

The appendix is ​​a finger of the small intestine that emerges from the large intestine just past the point where it crosses the small intestine. Appendicitis occurs when the connection to the intestinal wall becomes blocked. The normal secretions have no drainage and accumulate in the hollow tube, stretching the walls until they eventually rupture and the now putrid fluid bursts into the abdominal cavity. Normally this causes fever and abdominal pain that is initially felt in the area around the belly button, but then moves to the right lower quadrant as the infection and inflammation spreads to the very sensitive lining of the abdominal cavity, known as the peritoneum. And yet this man had none of the expected pain. Why?

The intestines have few pain fibers. Most pain in the intestines comes from the tissues that line the abdominal wall. When the appendix is ​​surrounded only by intestines, away from the sensitive peritoneum, it can rupture and cause little or no pain. The small intestine moves freely through the abdominal cavity, like snakes in a bag. When they came into contact with this man’s ruptured appendix, these intestinal loops became sticky from inflammation and formed a wall around the wound, trapping pus and other purulent substances.

When the surgeon saw that this was not cancer, he turned to his assistant and they gave him a high five. Thanks to the images provided by CTs and MRIs, surgeons are rarely surprised by what they find in the operating room. And when they do, the surprise is usually bad: cancer, for example, instead of what they expected. The entire surgical team was delighted with this unexpected finding.

After the operation, Hudenko went to visit his patient in the recovery room. “Good news,” he announced to the sleepy man. “I’ll give you details when you’re awake, but the point is this: You don’t have cancer.”

Recovery is quick when the surgery is performed through three small incisions and the man goes home a few days later. At age 82, cancer is a much more likely diagnosis than appendicitis. The man was very happy that he was an exception. His surgery took place three months before Christmas, but for the patient and his partner, the holiday came early last year, with the best possible gift: their old life together.

Lisa Sanders, MD, is a contributing writer for the magazine. Her latest book is ‘Diagnosis: Solving the Most Baffling Medical Mysteries.’ If you have a solved case to share, write to her at Lisa.Sandersmdnyt@gmail.com.