This was the fourth time Gareth had suffered from stomach ache over the past six months. “I’ve put it down to constipation before,” he said. There was a lull, during which I imagined him questioning how cast-iron this self-diagnosis had been. “It certainly went away after a couple of days if I took some laxatives.”
“So, what’s different this time?”
“This is the third day, and it’s getting worse.”
The pain was low down on the right. He’d felt cold and sweaty the previous night. At the age of 58, he was still the proud owner of an appendix. I said he ought to come in.
Initially, I thought I’d over-reacted. He strode across the waiting room, looking the picture of good health. His pulse rate was unremarkable, but there was a subtle fever, and a urine test revealed inflammatory cells. When I examined him, his abdominal wall was tense over the appendix area – a phenomenon known as guarding – and the pain briefly worsened when I pulled my hand away – a sign called rebound. The rest of his stomach was non-tender, other than that pressure low down on the left provoked pain on the right.
“I think you’d better go and see the surgeons,” I told him. “This could be appendicitis.”
He looked doubtful. “Do you think so?”
“The fact you’ve had previous bouts is a bit odd. There are other things that could be going on – there’s a condition called diverticulitis, but that usually causes pain on the left. But they’ll sort it out at the hospital; they’ve got tests and scans that I don’t have out here.”
The admitting surgeon also suspected appendicitis, and blood tests appeared to support the diagnosis. Back when I was a surgical house officer, that would have been enough to get Gareth listed for an appendectomy. We expected an error rate, though: cases where, at operation, some other pathology would be found to have been masquerading as appendicitis. Today, patients undergo a CT scan before getting anywhere near theatre.
Gareth’s turned up a surprise; his appendix was blameless. Despite the unusual location, he did indeed have diverticulitis – an infection in a pouch coming off the intestinal wall. And there was free gas seen on the scan, indicating that the diverticulum had perforated. This can lead to peritonitis, a potentially fatal complication where faecal material leaks into the abdominal cavity causing disseminated infection. Had that been discovered at operation, it is likely Gareth would have had the diseased section of bowel removed, a substantial undertaking. But the CT images also showed that the perforation had been completely contained by an organ that few outside the medical world will have heard of.
The greater omentum is a broad apron of fibro-fatty tissue that lies like a blanket over the intestines. It was once thought to be a passive structure, nothing more than a layer of insulation at the front of the abdomen. As surgical practices advanced, surgeons noticed how often they would find the greater omentum tightly adherent to damaged bowel. It became clear that the omentum “patrols” the abdomen and pelvis; at the first sign of trouble, it seals off the area, helping to prevent the development of peritonitis. Describing this extraordinary capacity in 1906, a surgeon named James Rutherford Morison dubbed the greater omentum the “abdominal policeman”, a soubriquet that persists to this day.
The omentum is far more than a biological puncture repair kit. Richly endowed with immune tissue, it also serves as a conduit to bring hordes of white blood cells to attack infecting bacteria, and it stimulates wound healing, accelerating repair of damaged tissue. Gareth’s had served him well. A couple of days’ worth of intravenous antibiotics and he was deemed fit for discharge. He made a full recovery without anyone going anywhere near him with a scalpel.
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