Missing House M.D- Part I

Making a diagnosis in surgery is usually easy. Most of the time we worry about what happens after the diagnosis- how will we approach the problem? What kind of surgery will we do? should we even operate? what if something goes wrong during the operation or afterwards? Oh yes, I thought diagnosis was easy. Until I met this one patient that presented to us at night in our emergency.

 She was a 50 year old woman who came to us with classical symptoms of intestinal obstruction. This is an obstruction of the gut or food pipe. If something obstructs it and food cant pass through, the stomach (abdomen) starts expanding due to the block. The patient obviously doesn't pass any stool or gas, and usually there's bouts of vomiting. She had all these features, so we started to give her initial management and didn't worry about her too much. As we expected, by morning she had passed gas, there had been no more vomiting and her abdomen had flattened. The only problem she had was that she hadn't passed much urine (there was a pipe placed in her bladder so we could monitor how much her fluid input and output was).

 Her Hemoglobin was 4.5 when she came to us. Hemoglobin is the red pigment in blood that helps take oxygen to our cells. The normal for her would've been above ten. We had given her two units of blood overnight. My Senior Resident thought that this was the reason for her dehydration. She had been asked not to take any food or water from her mouth to prevent loading her blocked food pipes, and since blood is thick and takes a few hours to be transfused, she just hadn't gotten enough fluids. Obviously her urine output was low. So we upped her fluid intake for the day. But by that evening, her urine output was even less that earlier.

 By the next morning, she had developed some swelling of her ankles and feet. This indicated to us that the fluid we were giving her was probably not removed by her kidneys. That's why it wasn't coming in her urine. The fluid had to go somewhere so it came out of her blood vessels and into the tissues of her ankles and feet. We sent her to the kidney specialists for an opinion. They asked us to start her on Lasix.

 Lasix is a medicine that forces fluid to draw itself into the kidneys and would help decrease the swelling in her ankles. Meanwhile, her general condition would improve and her kidneys would start functioning well again. So we gave her Lasix- it didn't work. We increased the dose and gave her more Lasix- it didn't work. To improve her general condition, we transfused her again to improve her Hemoglobin. We gave her protein through her veins to help draw in the water back into her blood vessels. We gave her only water and juices by mouth, fearing that the gut would get blocked again if we gave her solid food. It didn't work.

 By the next day we could see swelling of her stomach, her hands and her thighs. She was still not passing much urine. Something had to be wrong with her Kidneys. The kidney specialists (Nephrologists) differed with us on that. You see, in her Kidney function tests, he Urea was grossly elevated, but her creatinine was normal. What this meant was that the problem was arising before the blood got to her Kidneys (Pre-Renal). The Kidney was doing its job, it was something else that was wrong. A kidney wouldn't remove something that couldn't get to it to be removed. They asked us to investigate her Heart. Meanwhile, fluid kept accumulating in her tissues. Her hands had swollen to her elbows, her stomach was filled with fluid, and the swelling of her legs had gone upto and above her knees. If we gave her less fluid, she'd feel extremely thirsty, if we gave her more, it would just fill up her tissues. It seemed to me as if she was drowning, from the inside......to be continued.