The patient’s symptoms had sent him to the emergency room 22 times in the past year.
As soon as Dr. Benjamin Day entered the room, he could see that the 67-year-old patient was in pain. The man sat with his arms crossed, his head and shoulders bent over as if he was protecting his midsection. “I’ve got pain right here,” he told the doctor, placing his hands gently on his belly, just below the rib cage. It had been hurting off and on for more than a year, he reported, but for the last two weeks the pain had been constant. He had no appetite, and when he forced himself to eat, he would often vomit.
Day, an intern at the V.A. Medical Center in Birmingham, Ala., knew that the man had been to that emergency room at least once a week for the past month, and 22 times over the past year. Most of those visits were for the same terrible pain.
The man had kidney failure and started dialysis three days a week around the time his pain began. He was sure the dialysis was the cause. If he couldn’t get rid of this pain, he told Day, he was going to stop getting dialysis, even though he knew that without it he would die.
He had already had an extensive work-up. An endoscopy indicated mild inflammation in his stomach, for which he was prescribed powerful antacids. They didn’t help. A colonoscopy had shown a few polyps, which were removed. They weren’t cancerous, and he felt no better after. His gastric motility — a measurement of how quickly food moved through his system — was normal. Five CT scans from the past year were unrevealing.
Day felt anxious. The patient had been seen by so many doctors that he worried he wouldn’t have much to offer. He was just an intern, not even halfway through his medical training. He knew that nausea and vomiting are common in patients getting dialysis. Why that happens isn’t fully understood. Still, this man seemed to be in far worse shape than most dialysis patients. And his chart confirmed that he’d recently lost over 10 pounds.
Day examined the patient’s abdomen carefully. He pushed down firmly, applying as much pressure as he could, then lifted his hand rapidly. In patients with an infection or severe inflammation outside the gastrointestinal tract, releasing pressure quickly like that would cause excruciating pain. The man continued to look uncomfortable but no worse than before. The rest of his exam was unremarkable.