By Tedler D. Depaynos, MD
The 68 years old male patient is from a northern native province but he settled down in the lowlands where his daughter got married. He was helping full time in the farm and taking care of his “apos” so their parents could work with lessened family obligations. He never had any health problems and he considered his farming a very good exercise that kept him constantly active and strong.
It was a surprise when one morning he could not pass out his stools and his abdomen gradually became “bloated”. He kept on trying to pass out flatus to relieve his uncomfortable abdominal distension but was unsuccessful. With the progressive discomfort of his abdomen, he was then brought to their municipal clinic where he was given intravenous fluids (IVFs) with electrolytes hoping that the distension was due to electrolyte imbalance. A nasogastric tube (NGT) was also inserted hoping to relieve the distension. Meanwhile an abdominal x-ray (flat plate) was done and the impression was “partial intestinal obstruction”. After a few days because of non-relief, he was transferred to the provincial hospital for further work-up.
The impression was likewise the same but suddenly he passed out stools and flatus and was relieved of his ‘bloated abdomen”. The MDs could not point out the precise etiology and just entertained likewise “electrolyte imbalance” as the cause because the patient refused further work-up and insisted to be discharged. He was warned, however, that it may again recur.
The “electrolyte” potassium (K+) when depleted may cause paralysis of the intestines so that stools and flatus could not be passed out resulting in abdominal bloating. This is usually due to severe diarrhea which the patient however denied having.
It was a few days later when he returned to his usual farming routine that he experienced the same problem and he was forced to return to the provincial hospital. He was referred to a more equipped hospital, however, for a more detailed work up.
Although he again recovered from his “partial intestinal obstruction”, a CT Scan was done on his abdomen. They were able to appreciate “swelling on his distal ileum” which is the distal part of the small intestine or where the small intestine connects with the large one. The cause was just labeled “infectious or inflammatory” because probably no signs of malignancy was noted by the specialists in this medical field. Besides, the incidence of malignancy in the small intestines compared to that of the colon is minimal. Considering the age of the patient however, the probability of a malignant lesion cannot easily be ruled out because of the higher incidence in the patient’s age group. Nevertheless, massive antibiotics were given hoping to control the “infectious or inflammatory” etiology.
For a more definite etiology, a young Gastroenterologist was called to do the gastro-endoscopy and colonoscopy and probable biopsy of the lesions.
The relatives were amazed when the procedure was done because they were called to view the insides of the stomach and intestines of the patient on a TV screen. Together with the scope was a camera which sent the video pictures to the adjacent huge screen. Explanations of the young Gastroenterologist was very detailed as they were shown the normal tissues and the pathology. There were “polyps” seen at the colon but at the entrance of the ileum, it was noted to be swollen so that it cannot obviously distend and the lumen became smaller. This was obviously the site of the “partial obstruction”. All the polyps were biopsied and likewise tissues from the inflamed ileum were taken.
When the biopsy results were released, the joy of the patient could easily be appreciated with his wide smile. Although there was no definite reason why it got “swollen” or “infected” the family were happy that the biopsy results were “negative for malignancy”. The antibiotics were then continued and despite the apparently significant weight loss, he was discharged symptomless.
Before returning to the lowlands, the patient expressed his desire to go home first to their native town to see his neighbor so that they could give thanks thru their native rites. **
