Things Abdominal/Chronic Illness

        Things abdominal.  Now you talk about hard to figure chronic illness, these can be a beast.

        First of all, let’s define our terms.  We are not talking about acute here.  If you have severe pain of sudden onset, vomiting, (they call it vomiking around here) fever, blood, etc., follow the standard Internet protocol disclaimer and GO SEE YOUR DOCTOR!  Just as in chest pain, think of the things that can kill you first, then work your way down the list.  As a matter of fact, especially in the elderly, I am just as nervous about abdominal pain as I am chest pain, and I’ve already told you how that gets my attention!

        If it has been going on a long time, and been difficult to track down, today’s story might help some.  At the very least, it will give you some idea of the dilemmas and uncertainties doctors face when they try to figure things abdominal.  As someone said, “Golf is not a game of perfect.” Neither is medicine.  The trick is to go ahead and admit it and try to get to the bottom of things in spite of the fact that all us humans are by definition flawed.

        A few years back I had a close to elderly (around 75 years old) patient with intermittent abdominal discomfort and sporadic diarrhea.   Oh my, I put her through the full court press.  Of course, at her age I feared malignancy, but a colonoscopy by our local GI guy was normal.  I thought of everything you can imagine- celiac disease, parasites, lactose intolerance, intermittent ischemia- you name it I considered it. 

        The local G.I. man thought she probably had I.B.S. (irritable bowel syndrome)  I guess that would be O.K. to assume if she were several decades younger, but it seemed to me it had started a little too late in life.  I was sure her history was accurate, and she had not been plagued with the problem until the last six months or so.  I had her for Biology in High School, and she wouldn’t excuse us to go to the bathroom, much less leave the class herself.  (I’m telling you that woman could spot a lame excuse every time.)       

        The diagnosis didn’t ring true, and I put her through a few more paces.  After a negative upper G.I and small bowel follow through, there was some serious head scratching going on. Once your family doc gets down to a SBFT in a diarrhea workup, you can figure he’s about gone fishing at that point.

        The family was nice about it, but they too were unconvinced their mom had IBS.  The daughter was a nutritionist on the staff at a famous institution in Tennessee, and called to ask about second opinion. 

        “Doctor Bibey, what do you think about a carcinoid tumor?  I’ve looked it up on the Internet, and mom has the exact symptoms.”

        I had to agree with her.  It did sound like a bit like that.  The only problem was all of our tests failed to showed anything.  I wasn’t an expert on carcinoid, but one would think a CT or the SBFT would have picked it up.  “Well, ma’am.  I tell you what.  I don’t hardly see how, but I gotta admit you are right that she has some of the symptoms.  What do you think about a med center opinion?  You want her to come out to Tennessee or have me pick out a doc at Sandhills?”

        I guess all doctors are different, but a request for a second, or even third opinion never offends me.  In fact, I have found through the years the willingness to be open about uncertainty has helped more than it has hurt when dealing with chronic problems.  (Now when you get down to three or four good docs telling you the same thing, sometimes we have to accept what is and learn how to deal with it.)

       The family and the patient talked it over, and opted for Sandhills.  Back in those days they were just beginning to use this fancy new camera test.  It was the only thing we hadn’t done.  I knew little about it, but I had no diagnosis, and my patient was not improving.  It at least seemed like something to consider.  If she flunked that, I reckon we were gonna have to find some way to live with it.  (Keep in mind we cure very little in this business, most of what we do is help manage the reality of what folks have to live with.)

        Mrs. Andrews went to Sandhills, had another exhaustive work-up, and came home with no definitive answers.  She was there several days, and at the end the docs did opt for the camera study.  She came home and waited with instructions to retrieve the camera when it passed and send it back to Sandhills.

        Well days passed, but the camera didn’t do so.  We waited.  One Tuesday her son called.  Robert was an accountant in town and a old time fiddle man I knew well.

        “Hey Tommy.  Mom’s got the belly ache again.  They gave her something new to try at Sandhills, and I wonder if it is going against her.  Can you think of anything you could call in?”  

        Folks here is the fork in the road.  Pitfall city.  You can go wrong before you know what hit ya.  Not that the family was being unreasonable- not at all.  After all, they had followed every piece of advice and so far were no better off than the day I began to sort the thing out.  I wouldn’t blame ’em if they were irritated and had about enough of docs and tests.  Here’s where the old doctor/patient relationship can sometimes save the day.

        “I dunno Robert, are you sure it the the same pain?”  (Remember abdominal pain pain the elderly gets Doc Bibey’s attention.)

        “Hmn, I think so.  Well, I guess,… uh well, you know I’m not sure.”

        “Tell you what Rob,  I know you guys are sick of coming over here, but why don’t you bring her by and let me take another look.  I’m not sure what is wrong.  Who knows, it might be something new.”  (No rule says a patient can’t develop a second problem.) 

        Mrs. Andrews came to the phone.  She was reluctant.  I can understand that.  After all, we hadn’t helped her yet, why should today be any different? 

        I’d known them a long time, and that helps.  “Ms. Andrews, I wanta help you, but I’m telling you the truth.  I don’t know what we should do without another look.”  It took some persuasion, but she agreed to come in.

        When I took her history and examined her, I wasn’t much better off.  However, something about the pain sounded more acute, and the exam confirmed some tenderness in the right side (right lower quadrant to be exact) that had not been present before.  Hm.  Appendicitis was possible.  She seemed a bit distended compared to before, but had bowel sounds and didn’t seem obstructed.  Could acute be superimposed on chronic?

        “Jeez Mrs. Andrews.  I just don’t know.  I kinda wonder about your appendix.  Lets go over to radiology and get a flat plate (abdominal x-ray) and a CBC. (complete blood count)  We might need another CT scan.”

        She was weary.  “Now Tommy, I’ve had two of those scans- I’m getting worried about all this radiation.”

       “Yes ma’am.  Lets look at the plain films first, and then the blood count.  Maybe then we’ll have a better idea.”  I wasn’t hopeful, but I wanted to try an keep her spirits up.

        When the x-rays and the CBC came back, I had my first good clue.  Lord why didn’t I think of it?  Hot dang, I knew now I was gonna be home free. 

        I’ve had a number of days like that in my life.  The day I met my wife I put up all my rock n roll gear, ’cause the only reason I played that music was to meet girls, and I had no further need for the electric guitar after that.  At my med school interview at Sandhills U. I fell in love there too, and knew where I was going to medical school.  You know how those moments are, and this was one of those days, ’cause I had a notion my patient was gonna have a diagnosis.  I just hoped it wasn’t going to be a bad one.

        Y’all it is a beautiful Saturday in N.C.- so nice I promised my Marfar a convertible car countryside ride.  I hate to make my northern friends too envious, but it might get warm enough to put the top down.  (Remind me of that when the heat and humidity are both 95 this summer.) 

        I’m gonna have to tell you the diagnosis Wednesday.  I apologize I’ve left you hanging, but I have run outta time.  Just so you don’t worry over Ms. Andrews (that’s my job, I’ve done some powerful worrying over the years) I will tell you all this was several years ago, and she sent me a pound cake at Christmas so y’all can rest easy and enjoy the weekend.  Thanks to the Good Lord and some luck, she’s O.K.

        In the meantime, y’all guess about her diagnosis if you want to.  As we say from the bluegrass stage at our shows the winner can get a free tetanus shot at Dr. Bibey’s office if you’re ever in N.C.  (Sorry Dr. Bob, pros are excluded from the competition, but I would give yours professional courtesy anyway.)  And to Irene and The English Professor, mrs chili, Pande, Ms. Susan the romance writer, and all the rest of the gang, don’t feel too bad if you don’t get it- I couldn’t possibly do y’alls job-  ain’t that right mrschili?!  And, if it wasn’t for the grace of the Good Lord leading me out of trouble every day, I couldn’t do mine either to tell you the truth. 

        Ms. Marfar is a calling and it sure is a pretty day.  I don’t know any rock n roll any more and I don’t want to learn, so if the girl wants to ride through the country, then by golly that’s what we’re gonna do.  Like I say, my advice is if you find a wife who plays music you better hang on to her, so I’ll catch up with you guys Wednesday.  See you then.   

Dr. B        

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