35. The Weight
'Morning, Jane! How's the family?'
‘Great, Dr. Diaz. What about yours?’
‘Everyone alive and well, thank God.’ I was getting the charts she was handing me. ‘Have you lost some weight?’ I asked her, she looked so thin.
‘Yes! And thank you for noticing.’ She burst with laughter. ‘I just love to hear I’m thinner.’
‘Who doesn’t?’ I started laughing too.
That day I had a few admissions, but the one I want to tell you about is Lisa Jenner - yes, we had the same name. Weird how we feel connected to someone when we share a name, right? Anyway, she was 21 years old and was admitted the night before with vague abdominal pain and vomiting for 12 hours.
Truth be told nobody wanted to miss appendicitis. So they decided to admit her for observation and see if her pain would localize to the right lower quadrant. They ordered some labs and they were normal. But when I went to talk to her, things changed.
‘Morning, Lisa! My name is Lisa Diaz and I will be taking care of you today.’
‘Nice name.’ She said with a smile.
‘It is, isn’t it?’ I acted surprised and she laughed.
I asked how she was doing and she said the pain was still in her epigastric area and the vomiting got worse.
‘How much worse?’
‘Like, tripled.’
Weird. That was ringing me another alarm, just as bad, or even worse than appendicitis. Obstruction alarm.
‘Is the vomiting related to eating?’
‘Maybe. I have been feeling full very fast these last weeks, a few bites and I’m done. But I hadn’t vomit until yesterday.’
‘What does your vomit look like?’
‘It’s pretty green.’
Bile, I thought. Obstruction was winning.
On her physical exam, her abdomen was a little distended and she had hyperactive bowel sounds. No signs of peritonitis or masses, though. I couldn’t help noticing the patient was also very thin, which funnily reminded me of my conversation with Jane that day.
I went to find Peter in the cafeteria, and we small talked a bit. He was excited about this new dog he had adopted. Said it would make him exercise.
‘How could a dog make you exercise?’ I laughed.
‘Dog’s need to walk.’
‘Oh, so that’s what you call exercise?’
‘Well, better than watching sports from a couch, isn’t it?’
I shrugged. He was teasing me because he knew I followed sports.
‘Don’t mess with my sports, Allen.’ I warned him. ‘We should go, Dr. Collins is probably waiting for us.’
As we were walking in the hallway, it hit me that I hadn’t thought of a good hypothesis for Lisa yet. Yes, I’d figured out she was probably obstructed. But why? I was so taken up by the other admissions that I completely spaced on her case.
She had no history of abdominal surgeries, which ruled out adhesion. She didn’t have visible hernias on her physical, which is also a common cause of obstruction. No history of abnormal bowel movements, which if present could point to inflammatory bowel disease. The only other thing I could think of was a big ass tumor.
While I thought of that, I waved at Jane. I was still a little shocked at how much weight she had lost. That reminded me of Lisa Jenner and how thin she was.
‘Damn it, her weight!’ I accidentally said this out loud.
‘What?’ Peter asked.
‘Nothing.’ Lucy was coming towards us. ‘Start discussing your cases with Lucy. I’ll be back in a moment.’
I went to Lisa’s room and she was sitting on her bed watching TV. Thinking about her thinness made me think even more of neoplasia, even though she was so young.
‘Hi Doctor, I didn’t expect to see you again so soon!’ She greeted me with a smile.’
‘Me neither, but I remembered something I forgot to ask you. Have you lost some weight recently?’
‘Actually, yes!’ I started to worry for her. ‘I recently got into the gymnastics team at college and I had to change my diet completely.’
‘Really?’ Neoplasia was losing points. ‘Congratulations for making the team! How much weight do you think you lost?’
She thought about it for a moment.
‘I am not sure. But enough to make me need a new wardrobe.’
I asked her about fever and other ‘I’m sick’ symptoms but she fortunately didn’t have any. And I fortunately had a more benign hypothesis than cancer.
I thanked her and rushed to find Peter and Lucy. When I got there, I started with Lisa Jenner.
'It is a rare disease and maybe a wild guess, but her weight loss could be the very cause of the obstruction.' I said after my presentation.
‘So you’re thinking Superior Mesenteric Artery Syndrome?’ Lucy asked me and I nodded. ‘So you know what to do.’
And I did, I ordered a CT scan to confirm it and it was true, her weight loss affected her retroperitoneal fat, which made her superior mesenteric artery close up her duodenum. We managed it conservatively with a nasogastric tube and we encouraged her to gain weight, which ultimately resolved her obstruction.
‘So too much weight loss is not as great as it sounds.’ Lisa Jenner said to me.
‘It can hurt quite a bit, right?’ I smiled.
‘You have no idea.’
…
Want to read more about Superior Mesenteric Artery Syndrome?
Want to read a real case of Superior Mesenteric Artery Syndrome?
https://www.scielo.br/scielo.php?script=sci_arttext&pid=S2237-93632011000400015&lang=pt
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