It’s just another day in the neighborhood. Night shift, actually. Things are just beginning to heat up around 2 am, and the ambulances are starting to roll in. A phone call from the triage nurse interrupts me. “I’ve got an appendix here. Young woman. Been sick for a few hours. I going to put her back in the psych room for a few minutes so you can look at her, then she’s going to Hallway 3.” We are in our usual state of “no-beds-in-the-ER-itis.” But I’m in luck. Triage thinks she is sick enough to justify one of our few empty rooms.
I finish the orders I am working on, and bop over to the psych room. A healthy-appearing twenty-something woman is lying on the bed, nursing her lower abdomen with her hand. She manages a weak smile. I introduce myself, manage a similar smile in return, and sit on the end of the bed. She tells me that she has had lower stomach pain since early evening, starting very abruptly. Since then she has had persistent pain, and two episodes of vomiting. Her vitals are normal except for tachycardia of 110/min. She has RLQ and R pelvic pain with guarding. A dip pregnancy test is negative. There is no chaperone available for a pelvic exam—hopefully I can get to it later. I give her the plan (“you may have appendicitis, we’ll start an IV, give you pain meds, I will call the surgeon, draw labs, yada yada”).
I step out and call the surgeon, then move on to check on my most recent ambulance patient. “Doesn’t really sound like an appendix. Its probably an ovarian cyst,” the surgeon says about fifteen minutes later. “Get a CAT scan and call me back.” All right, I think to myself, this patient is probably OK to wait a little while to get sorted out. No sense starting a war with the surgeon. I put in for the CAT scan (non-contrast renal-stone protocol-- who says I can’t cut a few corners).
The bedraggled CT tech shows up a few minutes later. “This had better be good for 3 am,” she says. “Appendix,” I return with a short glance, distracted by another problem. “Umpgh,” she tosses back. A short time later, CT calls up. “You might want to come look at this scan.” I review the plain X-ray and CT slices (shown below), and quickly go grab the ultrasound and hustle back to the psych room. The nurse is just getting the pain meds on board. “I just saw your CT, and want a peek myself with the ultrasound,” I say, making conversation. The patient is still not a happy camper, but is putting a good face on the situation. I finish my ultrasound peek (shown also), and call the surgeon back. Labs show a WBC of 12.4 and Hct of 32mg/dl. Forget the pelvic at this point.
This is a nice example of CT and ultrasound showing the unexpected, and leading the clinicians to the correct diagnosis. This was an atypical appendix story, and sounded very much like an ovarian cyst case. These often show minimal findings on CT, and ultrasound (hard to get at night in many hospitals) doesn’t usually add much to the clinical picture. In this case, however, the CT scan shows very nicely the presence of free fluid, presumably blood, surrounding the liver (see labeled picture). This was also confirmed by ultrasound, which showed pelvic free fluid between the uterus & bladder (FF). The Hct of 32 might be chronic anemia in a young woman, but might also after 6+ hours reflect more acute intraperitoneal blood loss.
We still did not know enough to confirm a diagnosis, but had enough clinical information to justify a emergent trip to the OR at about 5 am. This case turned out to be a ruptured hemorrhagic cyst, and the free fluid was about 750 cc of blood. Not bad for a night’s work. And I was sure glad we opted for the non-contrasted CT scan, which can be done quickly, as opposed to the typical abdominal or appendix-protocol CT scan, which burns up several hours. In retrospect, going straight to the FAST ultrasound exam (maybe on a less busy night) would have likely shown the free fluid right away. This large amount of free fluid on ultrasound, coupled with a low hematocrit, would have probably bought the patient a ticket to the OR a little earlier.
John Dallara, MD, practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course. www emprepcourse.com