0:01

So, another patient presenting with right

0:02

lower quadrant pain that's not necessarily

0:04

an appendicitis in this particular case.

0:07

Again, following that colon

0:08

down till we reach the cecum.

0:10

You can already spot it over here that

0:12

there's an inflamed, thickened, fluid-

0:14

filled tubular structure with lots of

0:16

inflammation and lymph nodes around it.

0:19

But always keep things in order if you can.

0:21

And so I continue to follow that cecum down

0:26

and now we see where the

0:26

structure is arising from.

0:28

This is the appendix.

0:30

But it does look a little bit different

0:31

than all the other cases that I showed you.

0:33

If you put a measurement on it, this is easily

0:35

going to be, you know, 16 to 20 millimeters.

0:38

This is way larger than that 6-

0:40

millimeter cutoff that we usually use.

0:42

There's a lot of inflammation and there's a

0:43

whole lot of lymph nodes, which we generally

0:45

don't see with an acute appendicitis

0:47

because it's happening so quickly.

0:49

So in a case like this, when it's this dilated

0:52

and this fluid-filled, you want to stop and

0:54

take a second to think, could this be something

0:56

else that's causing an acute appendicitis?

0:59

So I would agree, we do have an

1:00

acute appendicitis here, that-

1:02

appendix is absolutely wildly abnormal.

1:04

It is inflamed, it's thickened, it's enhancing.

1:07

But we're looking for an obstructed

1:09

region right here, reason right here.

1:12

And you can see here in the cecum, the

1:13

cecum itself is thick-walled and enhancing.

1:16

And this to me is more than

1:17

just reactive cecal thickening.

1:20

Reacting to that acute appendicitis.

1:21

This itself is the abnormality.

1:24

And that would also explain

1:25

why we have lymph nodes here.

1:26

So you could say, is this an

1:28

inflammatory process of the cecum?

1:30

And I would argue that it's not because the

1:31

inflammation is centered around the appendix.

1:34

It is not centered around the cecum.

1:35

So we do not have, you know, focal colitis

1:37

that's also causing an acute appendicitis,

1:40

but we do have lymph nodes and lymph nodes

1:42

imply something more chronic is going on here.

1:45

So in a case like this, I would be most

1:47

concerned for a cecal cancer that's

1:50

obstructing and causing acute appendicitis.

1:53

And in particular, in my experience

1:54

with cases like these, the cecal cancer

1:56

is not an acute obstructive process.

1:58

It's more of a chronic, ongoing thing.

2:00

So it obstructs it very slowly,

2:02

which allows that cecum to dilate.

2:04

much more than you would see in a

2:06

normal acute appendicitis, which

2:08

is a relatively acute obstruction.

2:10

And so in these cases, that appendix

2:12

will be allowed to get way, way, way

2:14

bigger until it finally becomes an

2:15

inflamed, um, potentially perforates.

2:18

So in this case, the operation is the same.

2:20

They need an operation immediately.

2:22

But it's really good for the surgeon to

2:24

have an idea ahead of time that they may

2:26

be doing a partial colectomy in this case,

2:28

maybe they would get a different surgeon,

2:30

you know, colorectal surgeon to come in,

2:32

but it's good to know that ahead of time.

2:34

So potentially have the patient have

2:35

one operation instead of one for the

2:37

acute appendicitis and a second to

2:39

come back and do a hemicolectomy.

2:41

So it is really useful to the surgeon

2:42

to know that you might suspect that

2:44

there's an underlying cecal mass

2:46

causing this acute appendicitis.

2:48

So again, just to recap.

2:50

The, the salient findings in a

2:52

case like this, you'll see abnormal

2:53

cecal thickening enhancement.

2:55

You may see lymph nodes that may be

2:57

from the cancer itself because this

2:58

is a more chronic process that's

3:00

resulting in this acute appendicitis.

3:03

And then finally, the appendix

3:04

itself will be more dilated than it

3:06

normally is in acute appendicitis.

3:08

Those, again, will be greater than six

3:10

millimeters, but they're usually, you

3:11

know, up to maybe 12 millimeters or so.

3:13

This one is much more dilated

3:15

than that, much more fluid-filled.

3:17

And that is again because

3:18

as they chronically slowly

3:20

process because of this cecal cancer.