Odysseys of George

Grandrounds is up at The Blog That Ate Manhattan

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As I did my rounds, I came across an elderly lady who presented to us with fresh per rectal bleed(bleeding fresh blood from her anus). The medical officer who saw her after taking the history, proceeded to do a digital examination of the anus. She felt some soft bulge for which she assumed that it was haemorrhoids. As it was not bleeding anymore, she admitted the frail lady, for observation.

Suspicious, I decided to examine this cachetic lady myself and to my horror she had a mass in the rectum. I ordered for an urgent colonoscopy and this was the image I saw.

That was cancer of the lower rectum.

Didn’t the famous Norman Browse(editor of a famous surgical textbook) say that you cannot diagnose haemorrhoids with digital examination.

The dangers of assumption!!

An endoscopy is a procedure which is performed by a specialist (Surgeon or Gastroenterologist) to visualize the internal aspect of a luminal organ with the aid of a scope. A scope can be rigid or flexible and is a tube-like instrument inserted through an orificce in the body. A basic flexible endoscope will have a light source, a eye-piece which is usually mounted with a camera to view images onto a TV, an air inflator and a suction channel and also a working channel for added procedures like taking biopsies and washings.

The two main scopes discussed here will be the OGDS (oesophago-gastric-duodeno-scopy) for the upper gastrointestinal tract from the start of esopohagus all the way to the duodenum, and the colonoscopy for the large intestine beginning at the anus all the way to the caecum or terminal ileum.

This article would be about OGDS. I will cover the colonoscopy later.

How is it done, the OGDS?

This procedure is done as an outpatient.

One cannot eat or drink for about 8 hours before the test so that your stomach and duodenum are empty.

Most people have a choice between having the procedure while they are awake, or after having a medicine to make them drowsy (a sedative).

One will have a spray to numb the back of your throat and make it easier for you to swallow the endoscopy tube.

You will be instructed to lie on your left side.

Doctor will pass the endoscope tube down your throat to the area being investigated.

The test lasts about 5 to 20 minutes.

If there are any abnormalities, the doctor will take pieces of tissue from the abnormal looking area to send to the laboratory for closer inspection under a microscope. These tissue samples are called biopsies.

There may be a sensation of gas, and the movement of the scope may be felt in the abdomen. Biopsies cannot be felt.

The test lasts about 5 to 20 minutes.

If one was given sedation, you will need to take someone with you to the hospital appointment. You won’t be able to drive for the rest of the day and should have someone to go home with you.

Who should have the test done?

People who are at low risk for cancer, or even have no symptoms, should schedule a scope every 3-5 years after age 50 years. Those who are high-risk should begin regular screening prior to age 40 years.

Those below 50years old would require an OGDS if there are the alarm symptoms as below:

Complications

Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. The overall risk is less than 1 out of 1,000 people. Most people will probably have nothing more than a mild sore throat after the procedure.

Is endoscopy always necessary?

Well, actually apart from the indications I mentioned above, where one is less than <50years old or without any alarm symptoms, can be treated with medications first and reassessed for persistence or improvements. Persistence or failure of treatment would require this procedure to be done.

I operated on a 67year old lady yesterday. She is a very nice and friendly lady with very caring children. She had upper abdominal pain which started 2 years ago. She saw a general practitioner who did some blood test, told her she had gastritis ( everybody’s favourite diagnosis for any upper abdominal pain or discomfort), and this was because of H.pylori infection detected in her blood. He started her on medications. She was the same medications for two years despite her symptoms not resolving and being persistently worse.. He only decided to refer her to us when she started complaining of difficulty in swallowing and feels that her solid food gets stuck at the upper abdomen(epigastrium).

This was what we saw on endoscopy:

It was a large growth arising from the junction of the esophagus and stomach and extending down into the stomach for at least 10cm. It was what we call as Cancer of the Cardia or simply Stomach Cancer.

Her CT scan did not show any distant spread but CTscan in stomach and esophageal cancers are not accurate.

Upon surgery, the tumour was found to be advanced with many lymph nodes involved and also seedling along the small bowel and peritoneum(layer around inside of the abdomen). This was no more a curative surgery but mainly just palliative.

Was she late? Well, either she refused to have a scope done and took her symptoms lightly or she was not been appropriately counselled and adviced to get a scope done. She claims that the general practitioner never suggested anything as such!!!

I am speechless.

Wow leave it to three shrinks and this is what they come up with:

— a clickable brain for grandrounds —

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It was December 2005, I was on call that very day. I received a call from both the Emergency doctor and my Surgical medical officer to see a case in the Resus bay of the Emergency Department. As I approached the cubicle, I get the feel that all is not to good for the patient. There was a rush, blood spills probably the patient were forming tracks on the floor. I could hear the wailing of the patient’s loved ones from far. There lying motionless was a young girl who was involved in a motor vehicle accident. She was intubated and ventilated, she was bleeding from her ears and nose. Her upper arm was deformed and had multiple facial bone fractures. A CT scan of her brain revealed that she had some bleeding in the brain which were not for any surgical intervention. She was pale and a FAST(focused abdominal sonography in trauma) scan of the abdomen revealed blood in the abdomen. Her abdomen was distended and hard. After a quick resuscitation, we rushed her to the OR(operating theatre). Her spleen was macerated and thus it was removed. She was nursed in ICU with cerebral protection. The repeat CTscan of the brain was getting more oedematous but the neurosurgical team continued to treat conservatively. A week or two later, as all sedations and respiratory support was weaned off, we realised that the injury to her brain has caused her a diability. She was unable to move one side of her body. She was transferred to my ward and her mother dedicated herself to taking care of her daughter. She survived a couple episodes of sepsis. She was discharged with active physiotheraphy as she was still unable to move her limbs. Thereafter, she was lost to our follow-up and the months passed by without any news.

I saw her today. She walked to my room with a smile. She had scars but she has completely recovered physically and the way she spoke told me she is doing well mentally too. Her presence made my day. Above all, I admire her mothers dedication and her will to survive.