Page 20 - Volume 69 Number 2
P. 20

The Most Remarkable
Patient I Ever Met
By Richard E. Burney, MD
Walter was the most remarkable patient I ever met. One day, in November 1983, he called me from his hotel room in Las Vegas where he was attending a convention and said, “I think it’s happening again; what should I do?”
I told him to go to the emergency department, and once there, even if it wasn’t obvious he had an acute abdomen,he should insist on being seen by a surgeon. Have that surgeon call me before he makes any decisions,I told him.No one is going to believe your story. You need an operation,but I need to talk to the surgeon first.I knew what needed to be done.My worry was that no one would believe me or Walter,who wasn’t going to have time to get on a plane and fly home.
By 1983, I had been Walter’s surgeon for about six years and had operated on him four times for an idiopathic illness that caused small bowel inflammation, bleeding, obstruction, and perforations. We didn’t know what the disease process was, but had learned from experience how it presented and what we had to do when it flared. The prodromal symptoms were consis- tent: high fever and abdominal pain, which always presaged gastrointestinal ulceration that could lead to hemorrhage, or perforation, or both. After this had happened several times, the pattern had become clear both to him and to us and he knew when to call. These were the symptoms he was experiencing again when he called from his hotel room. He knew he was in trouble and also what needed to be done, but no one in Las Vegas would know, nor would they necessarily believe his unusual story if he tried to explain it to them. Although he might not look sick – and Walter always looked remarkably healthy, except when he had one of his major GI bleeds – he needed to be taken to the operating room sooner rather than later.
Walter was a perfectly healthy man until his early 60’s when he first developed fever and abdominal pain. In 1983, a hospital might or might not have a CT scanner, and no one with acute abdominal pain was whisked first through the scanner as the main diagnostic test. More often, the diagnostic test was exploratory laparotomy. The most likely cause of abdominal pain and fever being possible cholecystitis, he was taken to the operating room at a local hospital where a cholecystectomy was done (through a paramedian incision) and note was made, but nothing done about apparent inflammation involving the distal small bowel.
He was referred to University of Michigan for further evaluation, and in 1977 was admitted to Internal Medicine for evaluation of fever of unknown origin (FUO). Based on the history and early surgical findings, the presumptive diagnosis of Crohn’s Disease was made, for which there was no proven effective treatment at
the time. In November 1977, we returned to the hospital with lower gastrointestinal bleeding and an obstructing inflammatory mass in the distal ileum, for which he underwent resection of the distal ileum and a portion of ascending colon. The presentation was most con- sistent with Crohn’s Disease and pathology seemed to verify that.
One year later he was once again admitted, this time for lower GI bleeding. Colonoscopy found ulcerations
in the bowel. He was treated for presumed Crohn’s. In February 1980, after two more episodes of acute lower
GI bleeding, I did a right ileocolectomy once again, removing 31 cm of abnormal small bowel. Pathologic examination showed only ulcerations, no signs of inflammatory bowel disease. Over the next several months an intensive work-up was done looking for an etiology for his disease process. In May 1980, he had a six unit lower GI bleed. In June, after much testing, the diagnosis of Crohn’s was ruled out, as was vasculitis; ischemic colitis was postulated. In July, he returned
with another FUO episode. It was self-limited and things seemed to settle down after that. He resumed his normal, busy businessman’s life and career.
I didn’t see Walter for over two years, but in late
March 1983 his symptoms of fever and abdominal pain returned. His abdominal films showed bowel obstruction once again. When I operated on him, I found an inflammatory mass involving distal small bowel and colon. Another resection was required. An enteroenteric fistula was found in addition to non-specific inflamma- tion and ulceration (not Crohn’s). He made a remarkably rapid recovery from this operation, but by now had lost
a fair amount of small bowel. I would have to be careful about further small bowel resections to avoid short
gut syndrome.
Unfortunately, he was not well for long. A month later he called: I think it’s happening again. This time, even though he didn’t look sick, both he and I knew that something bad was about to happen. The pattern was becoming clear. I took him straight to the operating room where I found 3 jejunal perforations. At this point,
20 Washtenaw County Medical Society BULLETIN APRIL / MAY / JUNE 2017

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