29. The Shoes


‘So, did the Giants win last night?’ I asked when he entered the room.

‘You know I’m not a Giants fan.’ Mr. Manning laughed. I always teased him about it cause, well, his last name was the same as their famous quarterback. But he was a New York Jets fan.

‘Well, too bad. I would ask you how the Jets are, but I bet they are still losing.’

We both laughed. I loved talking sports with patients, It was fun for me and they liked talking about something else besides being sick.

‘So, how have you been?’

His shoes weren't fitting anymore. That was his chief complaint.

He was in his fifties but had almost no hair left in his head. He was already my patient at the clinic, I’d seen him a couple of times by then. He was a healthy guy, but had the bad habit of smoking like Jax. Either way, that was the first time he came in with a complaint.

‘Since when, Mr. Manning?’

‘I don’t know, dear. But not that long ago. I can only wear slippers now, and I hate slippers.’ He laughed.

It was nice to hear him laughing that day. Despite being young, he was already a widower. He had lost his wife to cancer not that long ago, and he was grieving a lot. In fact, he had lost so much weight since the first time I met him that I decided to ask him about it.

‘How is your appetite?’

‘Not great, I think I lost a few pounds these last months.’

We chatted for a while, he seemed like he needed to talk. Despite that, he didn’t seem depressed, he just missed his wife. He showed me some blood tests I had ordered him at his last visit and they were all good.

I examined him and in fact, his feet were really swollen, both of them. Not just his feet actually. Even though he was skinny, his hands also seemed a little swollen. Weird.

While I talked to him I started thinking about what could be going on. His kidney and liver were good, I had just seen his lab results. The heart was the one missing but his jugular veins were flat and no hepatomegaly; cardiomyopathy didn’t seem to be the cause either.

I decided to order him a test to check for albumin and proteinuria. Who knows, maybe he was having a nephrotic syndrome or something like that.

I didn’t see Mr. Manning again until the following week. He was still swollen like the first time but seemed even skinnier.

‘Morning, Mr. Manning! How have you been?’

  ‘Not great, doctor. I haven’t felt like eating this past week.’

I was starting to worry about him. He was looking so weak. By then I hadn’t realized yet that I was wrong to think that his poor eating was due to grief.

He handed me the labs and it was a little disappointing and surprising. No proteins in his urine, but his albumin was very low. Was he eating this badly? I don’t know, I didn’t buy it. For his albumin to be that low he had to be extremely malnourished for a while.

Anyway, not kidney, not liver, not heart. I was reaching a dead end with this edema. I decided to remember what other symptoms he was having. The only other thing was that he wasn’t eating. I decided to ask him more specifically about it.

‘I just don’t feel hungry, you know?’

‘I understand, Mr. Manning, I’m sorry to hear that. But why exactly? Do you feel something like nausea or pain?’

‘I feel like I ate a truck after just a few bites.’ He laughed. ‘And if I eat too much after that, my stomach hurts.’

‘Has that feeling ever made you vomit?’

He thought about it. ‘Maybe a couple of times.’

So that’s when I found out where he was losing all this protein. Feeling of fullness, abdominal pain, and vomiting strongly suggested some sort of obstruction. And what obstruction could cause so much protein to be lost that he couldn't fit in his shoes anymore?

The answer is Menetrier disease, a protein-losing gastropathy that is caused by hyperplasia of mucous glands. They get so thickened they occupy almost all of the stomach cavity, causing the obstruction. And they produce so much mucus it drains the body's proteins.

I explained to Mr. Manning what I thought he might have and ordered him an endoscopy along with a TGF-α in the serum. They both confirmed my hypothesis: his stomach was filled with giant rugal folds and his TGF-α was high. I started him on anticholinergics, steroids, and cetuximab. Fortunately, he responded well to these medications and didn’t need a gastrectomy after all.

‘The Jets are out of the season again. Maybe you should switch teams.' I told him in one of his last visits with me that year.

‘Yeah, we’ll get them next year.’ He smiled. ‘This year I’m just grateful that my shoes fit again.’

Want to read more about Menetrier Disease?


Want to read a real case of Menetrier Disease?


Clinical Board
SS: signs and symptoms; EGD: esophagogastroduodenoscopy; AdenoCa: adenocarcinoma.

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