Medical Author: Jay W. Marks, M.D.
When a medical problem comes on quickly, or occurs periodically over a longer period, it is best to move quickly and make a diagnosis while the patient is still experiencing symptoms. The more serious the problem, the greater the urgency. Nevertheless, urgency should never replace careful and complete diagnostic testing, as is illustrated by a recent experience.
I was asked to see a patient, a young man in his late twenties, who for several years had been having episodes of abdominal pain. There was nothing very distinctive about the pain except that it would last from hours to one or two days and then disappear. During the episodes, he would not eat; he also noted some nausea. He had visited an emergency room once, but only limited testing had been done and no diagnosis was made. At a later time, he had been seen by a gastroenterologist who had performed an upper gastrointestinal endoscopy. No abnormalities were found by endoscopy.
The patient was healthy except for these bouts of abdominal pain. Despite discussing his medical history in detail and examining him, I could find no clues to the cause of his problem. Since the episodes always resolved completely, I thought the best course of action would be to see him during an flare-up. By examining the patient during an episode, I hoped to be able to decide on the best diagnostic course.
It took almost 12 months, but finally, early one morning I got a call at home from the patient. A typical episode of abdominal pain was beginning. I told him to have someone drive him to my office where I'd meet him. When we met, he was in severe pain, and his abdomen was very tender to the touch. I had not expected such severity and was a bit puzzled. Fortunately, I shared the office with a general surgeon who was used to dealing with abdominal emergencies. He also was impressed by the severity of the episode and recommended that the patient be sent to the emergency room. He was concerned that surgery might be required and also felt that diagnostic testing could be expedited from the emergency room.
In the emergency room, routine blood and urine testing were normal. There was no fever. Because of the severity of the symptoms, a CT scan was chosen as the first test. The scan was obtained quickly. It showed an area of swelling within the abdomen that was interpreted by a radiologist as a segment of the small intestine.
Several hours passed and the patient was feeling more comfortable, having been given potent medication for the pain. His abdomen was less tender. Our recommendation to the patient was that he should be admitted to the hospital for observation and further testing. The patient was very reluctant because all prior episodes, even those of equal severity, had resolved completely within a day or two. I finally struck a deal with the patient. I would agree with his going home if he promised to return early the next morning for a barium x-ray of the small intestine. (We still did not know the cause of the intestinal swelling and I hoped the x-ray would identify the cause.) I took the CT scan to the gastrointestinal radiologist who would be performing the x-ray the following day and reviewed it with him in preparation for the x-ray. (He agreed with the prior interpretation of the scan.)
The following morning, the small intestinal x-ray was performed. It was normal! The astute radiologist, however, not having found an abnormal segment of the small intestine, followed the barium as it left the small intestine and entered the large intestine (colon) - something that is not part of a small intestinal x-ray examination. By doing so, he identified a narrowing in the middle of the colon. Clearly, the CT scan had been interpreted incorrectly.
The patient now needed a colonoscopy so that the abnormal area could be examined and biopsied. By this time, however, the patient was feeling much better and refused to return during the next day or two for a colonoscopy. I was disappointed because the opportunity to define the exact cause of the problem would be missed (as well as the chance to determine the most appropriate treatment). However, we had at least defined the exact location of the problem. This might be useful if surgery was required in the future. It also might expedite the diagnostic approach to further episodes, i.e., a prompt colonoscopy.
The most important lesson from this experience was the importance of timely, expeditious, and complete diagnostic testing. The secondary lesson was that no test (e.g., CT scan) is infallible, particularly when human interpretation is involved. The final lesson--discussed in a prior perspective--was the importance of a skilled and prepared radiologist who is able to go beyond the limits of a standard x-ray examination