I was almost done dressing up when the text message alert went.
‘Good morning doc. We had two general surgery admissions last night.’
It was my intern on duty alerting me to the new patients in the unit. My interns know I do not mind text messages. They exploit it, even when the detail would have been better given via a phone call. It is an arrangement we are ok with. For non-emergency patients admitted at night, they will text me early in the morning to see them before start of the day’s schedule.
‘Morning. Let’s see them at 7.40am before I start the operations.’
I drove out and met him waiting for me at the doctors’ duty room. We walked together to the patient’s bedside.
There lay a man in his early sixties. He had travelled from Meru county. He suffered throat discomfort and had difficult swallowing for a year. Sometimes he would belch and feel the burning of his stomach contents up his gullet, with an acrid smell up his nostrils. He had lost some weight, and confessed to having been a smoker in the past.
I examined him, struggling to keep my palms warm in the biting cold Nyeri morning weather. I noticed that he was wasted. There was nothing to find on examining his abdomen or chest.
We turned to the folder bearing his eclectic array of investigations. He had cancer of the food pipe; at its junction with the stomach. I signalled to my intern to appreciate the ugly looking ulcer on the endoscopy picture. The biopsy report was still pending.
After agreeing to the list of investigations needed to assess the extent of his cancer, we moved to the next bed.
There lay Solomon*. He looked wasted and dry. He could barely speak. He opted to whisper instead. He had been admitted with a deficit in his body water levels (called dehydration in medical parlance) from vomiting. He had been commenced on fluid drips and felt a little better that morning.
Solomon* had presented to our hospital three months earlier. Our series of tests had showed cancer in his stomach. Scans had revealed that it was not spread beyond the stomach wall. But he had lost weight significantly, and his biopsy had showed an aggressive type of stomach cancer. We planned for surgery, hoping to remove the whole tumour. But knowing that CT scan may miss out on up to 3 in 10 patients in whom seedlings of stomach cancer have spread to the rest of the belly, I was cautious in my optimism.
After anaesthesia, I had opened up his belly starting just below the breastbone to the navel. I had quickly run my hands over the liver and the rest of the viscera. There was a lump of tumour blocking the lower part of his stomach. Additionally, I found pellets of tumour scattered behind his bladder!
We were too late! The cancer had already spread.
We opted to give him a bypass procedure by creating a canal between the upper stomach and a loop of his small intestines below the tumour. In three months, the tumour had grown to block this canal, built eight centimetres upstream. Now here he was, vomiting anything that went into his mouth. I felt pity for him.
What’s worse about this case is that he had spent months hopping from one peripheral lower level health facility to another. His refrain was the same: “I suffer from gastritis and here is the medication I am using”.
And seemingly one healthcare worker after another would buy that line and offer a refill of the Omeprazole.
It had taken me time to convince him that I would not refill his omeprazole unless and until he agreed to an endoscopy. I wish I had been as successful in convincing him to consent to insertion of an aboral feeding tube instead of, or besides, the bypass.
But then, patient autonomy reigns supreme ( see my next blog). And we still had some hope.
Have you suffered from a burning pain that troubles your upper belly and sometimes moves into your chest just behind the breastbone ?
In penning down the award-winning non-fiction work, The Emperor of All Maladies: A Biography of Cancer, Siddhartha Mukherjee might have been inspired by stomach cancer.
It creeps on a patient without them noticing. And unlike other areas that can easily swell up, we often do not find much when we examine the patients.
I have recently noticed that we waste too much time treating patients for hyperacidity that the tell-tale symptoms of early gullet or stomach cancer may slip through our fingers.
So, if aged 50 years and over and suffering from acidity, remind your doctor to send you for endoscopy. Especially if you think you have lost some weight, or blood, or if you have a relative who has suffered from cancer. It would be life-saving.
*Not his real name