Wednesday, September 19, 2007
This case drove me crazy. She was a mild mannered, soft spoken 38 year old African American woman who presented with nausea/emesis and abdominal pain. On exam her abdomen was distended and she was pretty tender in the periumbilical area. This was her third admission to a hospital over the past 12 months with such symptoms. She carried a past medical history of scleroderma, but no previous abdominal surgeries. Bowel obstruction in a young woman without previous surgeries sets off the alarm in my mind. On exam, she was actually pretty tender diffusely, arguably with rebound in the lower quadrants. Then I looked at the CT. The radiologist actually called me, and said I better hustle to see this lady because she had one of the worst examples of pneumatosis intestinalis he'd ever seen. Then i started reading up on scleroderma and its GI manifestations. There is an entity called Intestinal Pseudo-obstruction that has been described for patients with scleroderma. It's a chronic motility dysfunction attributed to the effect of the scleroderma on small bowel musculature. I dug a little deeper. Pneumatosis intestinalis has also been described in this clinical picture. The theory is that chronic stasis/dysmotility leads to build of of nitrogenous waste from intestinal bacteria that can track transmurally through the bowel. Well, that's all good and fine. But look at that image from the CT! And her bicarb on the BMP was 18. And she was tender. And..... I wasn't sure what the right move was. The literature suggests that bowel rest, NG decompression, and TPN invariably leads to resolution of symptoms. But, for whatever reason (arrogance, inexperience, anal rentive disorder), I didn't trust the data. The clinical picture was too troubling. So I took her to surgery. And I found nothing. Diffusely dilated bowel from Trietz to cecum; no transition points, no adhesions, nothing no suggest a mechanical obstruction. Moreover, the bowel looked perfectly pink and viable. No evidence of ischemia. By POD#2 the NG was out and she was tolerating clears. Went home the next day.
Humbling case. You learn to trust your instincts in surgery because so much of the diagnosis comes from recognizing signs and symptoms you've seen before. Peritonitis is universal. The history one sees with appendicitis is about as standard as a recipe. But everything was reversed in this case. I'd never seen it before. Not too many people have. But I had the clarifying information in front of me, and despite the medical literature, I did the opposite thing recommended. I certainly had an indication to operate but perhaps a cold, evidence based, algorithmic-programmed, decision making monkey would have made the better decision. The human factor always plays a role in medical care; usually it's to the benefit of the patient. In this case I would have been better off not looking at the CT, not examining her, not checking her labs. Then I might have been more likely to trust the literature.
Wednesday, September 5, 2007
This 84 year old lady presented to me last week with complaints of epigastric pain and reflux. She had actually been hospitalized several times over the past year for similar symptoms. In addition, she was hospitalized last summer for an episode of melena and anemia which, after an extensive work-up, was deemed to be secondary to gastritis. For an 84 yo lady, she was pretty sharp and pleasant. History of hypertension, controlled with lisinopril and atenolol. She also had a severe case of scoliosis, rendering her wheelchair-bound. Here's a couple cool CT slices:
Any ideas on diagnosis? Approach and kind of repair?
Any ideas on diagnosis? Approach and kind of repair?
Monday, September 3, 2007
Read Brideshead Revisted over the holiday. Besides the annoyance of constantly having to inform people that Evelyn Waugh was actually a man, I found the book fairly compelling. It was strange though. For an author often described as the greatest humorist, social-satirist of the twentieth century, the theme was very conservative and earnest. The story involves the relationship between Charles Ryder and the Flyte family. The Flytes are old money English aristocracy, while Charles comes from humbler origins. Charles and Sebastian Flyte meet while at Oxford and quickly become thick as thieves. Sebastian takes Charles back to Brideshead, the family manor, over holiday, and Charles is seduced by the Flyte mystique and lifestyle. Unfortunately, Sebastian falls into dissolution as an alcoholic holy fool and Charles moves on to the next Flyte. He falls in love a few years later with the distant Julia, the older sister, and they both obtain scandalous divorces to be together. Charles is an agnostic. The Flytes have always been Roman Cathloics, although lapsed, and, in the end, Julia renounces Charles as a gesture of respect to her faith. Ryder returns to Brideshead years later, during WWII as an army captain, the broken down manor serving as lodging for his company. The only thing untouched by the war years, the years of decay and despair, is the Brideshead Chapel. Charles kneels and murmurs "ancient words, newly learned" and rises a new man. Apparently, Waugh wrote this book after his conversion to Catholicism. It's a very Christian novel, without the least bit of irony or satire. Waugh means to say, I think, that the true significance of Brideshead, the attraction to agnostic Charles wasn't the wealth, the glamour, the aristocratic values, but, rather, the perpetual light burning deep in the heart of the chapel; it just took him twenty years to realize it. Interesting theme for a universally lauded novel, I thought. Not exactly what I was expecting, but c'est la vie.