I saw a 28 year old guy about a week and a half ago who presented septic with three to four weeks of crampy abdominal pain and malaise. Initial CT scan in the ER suggested an inflammatory phlegmon in the RLQ consistent with perforated appendicitis. I admitted him, started Zosyn and had interventional radiology place a pigtail catheter in the fluid collection. He quickly got better; pain resolved, WBC normalized, hemodynamic paramters back to baseline. The working diagnosis was appendicitis. The plan was to potentially bring him back for an elective interval appendectomy in 6-8 weeks. Well, he returned to the ER 3 days after his discharge with tachycardia, worsening pain and a leukocytosis. CT scan this time showed a peristent fluid collection in the RLQ and a distal small bowel obstruction. It was obvious he had failed conservative management and I prepared him for the OR. I anticipated finding a bunch of muck in the ileocecal area; ileocecectomy was the likely procedure. Upon entering the peritoneal cavity, everything was stuck in the RLQ. I gently teased the omentum and small bowel away, and immediately broke into a large cavity of pure stool. Further mobilization of the right colon revealed that the posterior (retroperitoneal) wall of the cecum was completely blown out. I'd never seen anything like it. I ended up doing a formal right hemicolectomy just to ensure that healthy bowel would be involved in the anastomosis. He did reasonably well post-operatively. After all, he is only 28 years old. Young healthy males can withstand just about anything. But then I received a phone call from the pathologist on Friday (day after Thanksgiving).
-Your patient appears to have a mucinous adenocarcinoma arising out of a villous adenoma. Eleven of twenty five lymph nodes are involved with the cancer.
-Excuse me? I asked. Are we talking about the right patient? You better double check that specimen. My guy is only 28 years old.
- Sorry... This is the real deal. Any family history?
I told him the next day. His voice wavered as he struggled to ask questions, to process what he was hearing. Cancer. Chemotherapy. Prognosis. Words he was too young to have to comprehend. Hell, he didn't know what to ask. Why would he? No one prepares you for a moment like that. He has a fiancee'. He works in the health care business. He has a loving, dedicated immediate family. He woke that morning thinking about life as an open field extending as far as the eye could see, into the horizon, limitless. And now there are limits. Boundaries have been drawn. What do you say to him? What is there to say? What comfort can be elicited?