Sunday, January 1, 2012

Treat the Patient

It happened again. A phone call from an Emergency Center at two am requesting that a patient be admitted to my service. The ER physician explained that the patient had a small bowel obstruction, a problem commonly managed by general surgeons. I pressed the ER doctor for more history.

The patient was thirty on years old, had been sick for about twelve hours with abdominal pain, nausea, vomiting and diarrhea. The obligatory abdominal and pelvic CT Scan had been performed and the reading was “small bowel obstruction”. I asked for more details, which was almost like pulling teeth. The patient had not had previous surgery, there were no apparent hernias on exam, but the CT report was unequivocal: “dilated proximal small bowel with collapsed ileum and normal appearing colon”, the classic radiologic appearance of a small bowel obstruction.

I explained to the calling physician that, almost certainly, this patient did not have a small bowel obstruction; most likely it was acute gastroenteritis and it would likely resolve spontaneously within twenty four hours. The ER doc persisted, however, stating that the patient had an elevated white blood cell count at 21,000, there were ketones in his urine and the BUN was elevated at 28. I did agree with his diagnosis of dehydration and that the patient would benefit from admission, so that IV fluids could be administered. I saw the patient in the morning. His pain was gone, his nausea and vomiting had resolved, he still had some diarrhea, the WBC had decreased to 12,000 and the BUN was normal. I started him on a liquid diet, which he tolerated without problem and he was discharged that day without any significant sequelae. In retrospect, the patient could just as easily have been managed in the ER with an infusion of IV fluids and discharged home with medication to address his symptoms; admission being reserved only if he did not improve with such measures.

The scenario above is played out on an almost daily basis around the country. A patient is admitted to the hospital because an X-Ray or lab test suggests a certain diagnosis, even if a patient’s clinical presentation suggests something completely different. The patient above gave a pretty good history for acute gastroenteritis. It is unusual for patients without hernias or previous surgery to develop small bowel obstruction, certainly not impossible, but definitely out of the ordinary. But, the hallmark of diagnosing intestinal obstruction is the X-Ray findings. The CT Scan clearly demonstrated the classic appearance of small bowel obstruction. Sometimes, I wonder.

The clinical presentation of acute gastroenteritis is, typically, sudden onset of abdominal pain, often crampy, nausea, vomiting, malaise, fever and diarrhea. But, what happens to the bowel in such a situation. Does it become hyperactive, trying to expel some offending agent, does it stop altogether and dilate, as our body’s defenses are mobilized to attack the noxious invader causing the illness? Does the bowel contract, dilate, or does it do both; perhaps the stomach dilates, while the small bowel contracts or vice versa. I don’t know.

Common teaching about acute gastroenteritis is that it is an exclusionary diagnosis based on clinical presentation and the absence any other discernible underlying cause of the associated symptoms. General consensus is that viral infection is the etiology and it is a self limited disease, usually resolving in 2-3 days. There have not been any good studies, at least to my knowledge, that document the CT scan findings of a patient suffering from acute gastroenteritis.

These days it seems to be common practice, by some physicians at least, to treat patients solely on the X-Ray and lab findings, often ignoring the fact that there is a patient attached to those images and numbers. These doctors are guilty of ignoring clinical judgment, treating the X-Ray and not treating patients. In my mind, it is one of the cardinal sins of modern medicine.

Diagnosis and therapeutic management of a patient requires that every aspect of the patient be included in the evaluation; history, physical exam, laboratory data and imaging. Each factor is weighed against a variety of possibilities and a diagnosis is made. As I’ve written previously, (See Talking to Patients, July 10, 2010), the majority of patients will tell you what is wrong within the context of a 5-10 minute interview. All the testing that follows confirms or rules out the various conditions that appear within the differential diagnosis. The knowledge necessary to ask the proper, probing question is taught in medical school and the skill is refined during residency and post residency practice. In our modern, harried, defensive, get ‘em in and get ‘em out quick, medical world, taking the few minutes necessary to properly interview the patient may not be seen as cost effective as ordering a CT Scan.

And, if the patient winds up being treated for the wrong condition, well, the CT Scan said they had it and that’s documentation enough to provide proper coverage of one’s derriere.

The only problem with this approach is that the patient suffers. Far too often, patients are sent home because the White Blood Cell count or CT Scan is normal, or admitted to the hospital because one or another exam is abnormal. The history and physical exam may suggest a serious condition, but the imaging and lab were unremarkable. Would it be better to forego such testing and base everything on clinical impression? Certainly not. As I’ve stated previously, it is best to approach patient care utilizing all the tools available. CT scans provide a great deal of information; detailed images that help clarify a murky clinical situation and allow physicians to say it’s OK to defer surgery or, conversely, to say that surgery is absolutely necessary.

For example, a 20 year old male is minding his own business, sitting on his porch reading his Bible when “two dudes” come out of nowhere and shoot this poor unfortunate soul in the right flank. He walks into the ER complaining of pain at the site of the wounds. There are entry and exit wounds, one just medial to the right anterior axillary line and the other posterior and a bit more lateral. The physical exam is equivocal and the chest X-Ray is normal. What should be done? In this case the CT Scan provides a wealth of information. Very often the latest model scanners will provide images that demonstrate the path of the bullet and provide information regarding damage to organs in that path.

I cared for a patient with this exact scenario recently. The path of the bullet was obvious, there was an injury to the right lateral aspect of the liver and the bullet appeared to have nicked the right kidney. The only thing I couldn’t be sure about was the hepatic flexure of the colon, a devastating injury if left untreated. I decided it would be best to operate on this patient. At surgery, the findings correlated perfectly with the scan. The bullet had travelled through the liver, just missed the colon and nicked the upper pole of the right kidney. The injuries required no special repair, just leaving a drain in the area of injury, and the patient recovered uneventfully.

What about a much different, but very common presentation. A few weeks ago I was asked to admit a ten year old boy who presented with complaints of right lower quadrant abdominal pain, present for twelve hours. CT scan was done and reported as acute appendicitis. Specifically, the appendix was described as having enhancement of its wall, a sign of inflammation, and was minimally dilated to 7 mm with inflammatory changes surrounding it. The boy was admitted to the hospital and seen by me about four hours later. When I evaluated him he reported that the pain had disappeared. His exam was perfectly normal; by normal I mean I could push on his abdomen through to his back and all he did was smile at me. What to do? In this case, nothing. I observed the patient in the hospital for about 8 hours more and then sent him home with instructions to his mother to call if any symptoms recur. Most likely, he had a self limiting stomach bug that had caused the CT Scan changes.

I suppose there are some surgeons who would have operated on that patient and, perhaps the appendix even would have been abnormal when examined by the pathologist. I have to believe, however, that it is always best to remember that radiologic images are only shadows, lab results are mere numbers and there is a live patient that comes with both.