Once in a while I encounter a case so bizarre and unusual that it begs to be written.
Though much time has elapsed, the details of the case are as fresh in my mind as if it occurred yesterday. It is extremely unlikely that I should encounter a similar case for the rest of my professional career.
One day, many years ago when I was on call a young man in his twenties was admitted with lower right sided abdominal pain for a few days. His GP suspected acute appendicitis.
Right sided lower abdominal pain has a multitude of causes, especially in female patients.
Common Causes of Lower Right Abdominal Pain (male)
- appendicitis
- gastroenteritis
- diverticulitis
- urinary tract infection
- kidney stones
Common Causes of Lower Right Abdominal Pain (female)
- appendicitis
- gastroenteritis
- diverticulitis
- urinary tract infection
- kidney stones
- period pains
- ruptured cysts of ovary
- endometriosis
- pelvic inflammatory disease
- ectopic pregnancy
- torsion of ovarian cyst
In males, the list is shorter and acute appendicitis is definitely high on the lists in textbooks.
These days, I order a CT scan to see if the patient has appendicitis but back then, we did ultrasound scans. Though ultrasound scans are less accurate than a CT scan when it comes to appendicitis, it is much cheaper, quick and does not involve exposure to X-Rays.
This man’s ultrasound scan was reported to be normal.
However, I was mindful that ultrasound scans were sometimes normal in early appendicitis. Moreover, he had a fever so I recommended laparoscopy with a view to removing the appendix should appendicitis be confirmed at laparoscopy. In any case, diagnostic laparoscopy is more accurate than even a CT scan when it comes to such cases.
Well what did I find?
Ah, you will say.
It cannot be appendicitis otherwise why would I bother writing this story?
THE PULSATILE MASS
Quite right – the appendix was entirely normal.
But next to the appendix was this mass. And it was pulsatile.
When a mass is pulsatile, it has something to do with blood vessels, specifically large arteries. And there is a large artery called the External Iliac Artery just there. Right where the mass was.
Hurriedly I closed up, judging it unsafe to proceed without knowing what the mass was.
Exploring such masses without adequate control of the artery can result in catastrophic bleeding. In any case, I did not have the patient’s consent to do all that.
The next day, I explained to him what I had found. More scans were required – CT scan and an MRI scan.
The scans showed a pseudoaneurysm of the external iliac artery.
Within the pseudoaneurysm, there was a long slender opaque object or structure with it’s tip resting against the external iliac artery.
Aneurysms and Pseudoaneurysms
An aneurysm occurs when an artery (usually a big one) develops weakening of the wall. The wall starts to bulge out, like a balloon being blown up.
A pseudoaneurysm occurs when there is injury to a previously normal artery. Some blood escapes and forms a clot around the hole in the artery. Such a clot is usually contained within a capsule made up of the surrounding tissue.
Both aneurysms and pseudoaneurysms can enlarge and eventually rupture with catastrophic bleeding. They present as pulsatile tender masses and should always be approached with caution by the surgeon.
THE MYSTERY OBJECT…
We debated endlessly. The X-Ray doctor thought it was a “bone spike” but no one had ever encountered such a structure. The rest of us thought it might be a foreign body of some sorts.
But what kind of foreign body and how did it get there?
I returned to the patient who staunchly denied any penetrating injury or trauma. He also denied self-administered injections of any sort. Indeed, there was no visible scars or wounds in the region.
There was no other way but to explore the mass.
Precautions had to be taken as well as cautious preparation. I had some blood on standby should I encounter massive bleeding.
I also had to carefully secure the external iliac artery proximal and distal to the mass with special clamps. I then gingerly explored the mass.
Inside, there was the expected blood clot. The artery was intact and not actively bleeding.
Lying next to the artery was a strange hard object with the sharp point resting against the artery.
It was a 5cm long glass splinter.
GLASS FROM THE PAST
How on earth had it got there?
The next day I was bursting with questions for him.
Equally bemused, he had no idea at all.
It was finally his mother who shed some light.
She recalled that he had fallen backwards 17 years ago as a child. His back hit some glass which broke.
Somehow, the glass splinter must have been missed and over time, it had worked its way right through the back muscles and downwards to rest against the External Iliac Artery thereby causing the pseudoaneurysm!
He went home well and I have since lost contact with him.
But I shall never forget this most extraordinary case.