Tuesday, October 16, 2007

What took so long?



I saw this poor guy last week who'd been admitted for complaints of nausea/vomiting and abdominal pain. He was a frail, emaciated 83 year old guy who had the usual medical issues of that demographic (hypertension, CAD, urinary retention, etc). Interestingly, he had had a laparoscopic cholecystectomy done three weeks prior to this admission. He looked like a refugee from some war torn country. Weighed about 85 pounds. Clavicles and cheekbones protruding, hunched over in bed with an enormous nasogastric tube exiting his nose. He was putting out 500 cc a shift of pure green bile and his labs were consistent with advanced dehydration. He wasn't tender though, and seemed comfortable enough. Other than the lap chole, no previous abdominal surgeries. Then I started asking questions. A daughter arrived and more information started to flow. Apparently he'd been plagued by weight loss (50lbs) and intermittent vomiting for over a year. And the worst part, he'd been in and out of hospitals several times over the past few months. Huge work-ups had been done including EGD's, CAT scans, and ultrasounds. He kept getting diagnosed with "gastroenteritis" and sent home. I asked why the gallbladder surgery was done and the daughter explained that the "other doctors" felt it might do some good since they had no other explanation of his symptoms. My God. I love the old "take out the gallbladder because it might magically make the patient feel better" indication. So we got a CT scan. (see pics) It suggested a high grade bowel obstruction with an abrupt transition point in the proximal jejunum. GI decided to do a push enteroscopy rather than an UGI and he encountered a completely obstructing mass in the jejunum, which biopsies confirmed to be adenocarcinoma. So I took him for a laparoscopic small bowel resection yesterday. The mesentery was thickened and foreshortened, and the enlarged nodes appeared grossly positive. But we got it out. Hopefully he'll start to eat in a few days. But why the delay? A barium swallow evaluation months ago would have identified the problem. This wasn't rocket science figuring out what was going on. The poor guy wasted away to nothing while everyone dicked around. At least his gallbladder won't be causing him any more problems.

4 comments:

Sid Schwab said...

Yeah, the organ-elimination approach to the diagnosis of abdominal pain...

I'm guessing you had diplomatically to let the GI guy do his scope, knowing it wasn't going to change a thing...

rlbates said...

Has it been that long since I was a general surgery resident (or medical student)--don't they do Barium swallows for the complaints and weight loss this patient had anymore?

tom said...

This sounds like a "reverse r/o" approach-Start with something risky/invasive/expensive and proceed to something not so risky/not so invasive/not that expensive and -Oh my God, something of value!! Yikes, what a concept.

I am sure that if elected Hillary will put a stop to this nonsense!

Bongi said...

gastro guy at meeting presents a clear operative case. he then says he did a ct. trying to catch us surgeons out, he asks 'why do you think i asked for a ct?' not missing a beat, i pipe up, 'because you can't operate!'

even the profs were laughing.