Appendicular Mass

Tummy Trouble

1

It is your third on-call night for the week. You sit down and prepare to gobble up a sandwich before the next admission comes in. Just before you take the first bite, the beeper buzzes again. Sighing, you give up on dinner...


2

You walk back into the emergency department, where you are introduced to 11-year-old Jason, and his mother, Mrs. Parker. Jason has experienced mild central abdominal pain for the last two days, but was otherwise asymptomatic. His parents did not think too much of this, putting it down to 'indigestion'. However, a couple of hours ago, the pain shifted to the right side, and became severe. Highly alarmed, Mrs Parker rushed Jason to your hospital.


3

Jason is curled up in the bed, wincing in pain. He keeps on clutching the right side of his abdomen. His charts show a temperature of 100.5°F (38.1°C) with stable vitals. He shields his abdomen at first, but following gentle persuasion, allows you to palpate it. You discover a tender mass in the right iliac fossa.


5

The nurse in charge hands you the phone. The radiologist is on the other end. "Have you already performed an ultrasound scan on this child?". You answer in the negative. "I will not expose a child to ionizing radiation without good justification. Please send over a request form for an ultrasound scan immediately."


6

During the preoperative assessment, the anesthetist requests to see Jason's preliminary imaging results. Upon hearing that you have not performed any imaging studies, she retorts "Before rushing to surgery, shouldn't you try to image the lesion?". Sheepishly, you agree that an ultrasound scan would be a good idea.


7

The ultrasound scan reveals a hypoechoic mass in the right lower quadrant measuring 4 x 5 cm, with an air-fluid interface. The appendix cannot be visualized.


8

You realise that surgery is not indicated immediately. As you sit contemplating your next step, a nurse walks in to inform you that Jason is running a high fever, while the pain has also worsened.


10

Ten hours later, the on-call nurse calls you to inform that the fever and abdominal pain have worsened, and that the abdominal mass appears to have increased in size. You say goodbye to your half-finished breakfast and head over to the ward. Upon examination, you realize that her clinical findings are accurate.


12

The morning ward rounds are over, and you gradually relax as you contemplate going home for a well-earned rest. Your musings are rudely interrupted by the head of the surgery department, who storms in and demands to see Jason's records. As he skims through your notes, his face turns more and more grave. He finally gives you a look of utter disbelief. "This mass needs to be drained under radiological guidance. Please arrange this immediately, and meet me in my office afterwards" You realize that you're in big trouble .....


13

CT imaging confirms the presence of an intra-abdominal abscess, which the radiologist drains successfully. Empirical antibiotics are commenced as ordered. Over the next few days, Jason begins to feel better. His fever settles, his appetite improves and the abdominal mass reduces in size. His parents enquire if he may be discharged.


15

Jason's parents are not happy with your answer. They demand a second opinion. Subsequently, the head of the surgery department declares that Jason is fit to be discharged soon after the course of IV antibiotics is complete. Meanwhile, you are being paged by the director ....


16

Jason's parents are pleased with your response, and thank you for all your help. They ask you whether he might require an operation in the future.


18

Jason's parents thank you and take their leave.


19

Later that day, over lunch, you discuss Jason's case with a colleague, and mention how you managed him. Your colleague replies, "So, I guess that you'll be seeing the kid again, when he comes in for surgery?" You take a big gulp from your mocha latte, as you realize the magnitude of your mistake.


20

Jason's parents seem content with your answer, and thank you once more for saving their son. Well done!