I recently saw a patient with severe left-sided abdominal pain that was so bad, he said that he wanted to “kill himself to stop the pain”.
He had seen doctors in two hospitals for two weeks before his pain became unbearable and his parents brought him to the Emergency Department in the middle of the night to consult me.
It would take me another four days before I diagnosed him as having a rare condition involving inflammation of the blood vessels.
The patient’s family was upset with what they thought was misdiagnosis at the two previous hospitals. But as I will explain, there was not the case.
The episode highlights the challenges doctors face in diagnosing rare conditions and how they sometimes get rather unfairly blamed by patients.
First, let me share what happened to the patient in question.
K is 20 years old and has no past medical history. Two weeks before he came to see me, he had a fever and a sore throat. He went to Hospital A, where a chest X-ray did not find anything wrong and he was discharged with some medications.
A week later, while his fever had subsided, he started having severe abdominal pain and was admitted to Hospital B.
There, an endoscopy was done which showed ulcers in the duodenum, which is the first part of the small intestines. He was prescribed gastric medication. A computed tomography (CT) scan was said to have found nothing abnormal.
After discharge, his pain worsened and he finally came to see me.
K was in distress and begged for the strongest painkillers. K’s abdomen was tender. A CT scan showed nothing life-threatening or urgent, but his jejunum, which is part of his small intestines, was swollen at some part.
Laboratory tests showed elevated C-reactive protein (CRP) at about 100mg/L, which was way above the normal range of 10mg/L.
CRP is a marker for infection or inflammation. It signified that K’s condition was serious.
I treated K as a case of infective jejunitis (food poisoning) with antibiotics, hydration, and painkillers.
But K did not respond as expected. His pain remained severe, requiring regular doses of narcotics injection. His CRP dropped slightly to 73mgL, but it was still very high.
I was puzzled and asked K’s parents to show me his CT images and all laboratory reports from Hospital B for comparison.
At Hospital B, K’s CRP was also elevated at about 100mg/L. And his jejunum was already slightly swollen. This confirmed my suspicion that his serious condition had happened a week ago at Hospital B.
On the fourth day of his admission under my care, K developed a rash on both his lower limbs. This was a sign of an uncommon disease called vasculitis.
["Vasculitis" - I hear that a lot... on "House", the TV series with Hugh Laurie. :-) Maybe if the doctors at the first two hospital watch more "House", they would have made the correct diagnosis? :-) Related question: How much "House" did this doctor, Desmond Wai, watch? And still a related question, is there a need for a Diagnostic Unit like in "House" in Singapore?]
I asked a dermatologist friend of mine to review the patient, and she did a skin biopsy to confirm the diagnosis of vasculitis.
My rheumatologist colleague and I put K on intravenous steroids. He responded rapidly. After about two days, he had no more pain and the CRP dropped to a normal level.
Before discharging K, I spent some time explaining to him and his parents what vasculitis was and what treatment and follow-up would be needed.
While they were pleased at the outcome, they were very unhappy with Hospitals A and B.
They questioned why their doctors did not diagnose vasculitis, and why K’s CT scan at Hospital B was reported as normal, even though there were mild changes seen in his jejunum.
They were also puzzled why he was discharged from Hospital B despite his pain persisting.
These are common and valid questions that patients ask nowadays.
But these scenarios are common in medical practice, though they can be tricky for doctors.
I explained to K and his parents that vasculitis is an uncommon disease. In my 17 years as a gastroenterologist, among the thousands of patients with abdominal pain, I recall having seen less than 10 caused by vasculitis.
Instead, the most common causes of severe abdominal pain are appendicitis, peptic ulcers and gallstone diseases.
We cannot blame doctors at either Hospital A or B for not thinking about vasculitis when K was first presented with fever and abdominal pain.
I was able to make the correct diagnosis only when his rash appeared. His rash is called a purpuric rash, which is very typical of vasculitis. Without this rash and its biopsy, it would be almost impossible to make a diagnosis of vasculitis.
Indeed, I did not think of vasculitis as a possible cause of K’s pain during his first four days of hospitalisation.
His CT scan done on admission showed a swollen jejunum, so when I reviewed his previous scan at Hospital B, I knew where to look for the abnormality.
I explained to K’s parents that the changes in the jejunum in his first CT scan at Hospital B were so subtle that even my radiologist colleague at my hospital admitted he could have missed the findings.
Indeed, many abnormalities seen on imaging or laboratory studies are minor at the onset of diseases.
In addition, K was correctly diagnosed with duodenal ulcer at Hospital B and was prescribed the correct gastric medication.
Doctors often discharge patients before their presenting symptoms have completely subsided. This is because most symptoms take time to resolve and doctors can review the cases as outpatients subsequently.
K’s abdominal pain did not improve because besides duodenal ulcer, he also had jejunal swelling.
K’s parents thought of filing complaints against hospital A and B initially, but they aborted the idea after hearing my explanation. I am glad K’s parents are understanding.
We are now in an era of what I call “outcome-based medicine”. When the outcome is unsatisfactory, patients do not hesitate to change doctors. This is not wrong. But they also vent their grievances on social media, complaining about missed diagnosis and improper management from their previous doctors.
Some would even lodge official complaints to the hospital or the Singapore Medical Council, and even file civil suits against the doctors.
But patients need to understand that many diseases are complex, with a diverse range of presentation.
Upper abdominal pain can be the first presentation of H pylori infection, gastroesophageal reflux disease, or peptic ulcers. But it can also be the presenting symptoms of gallbladder infection, appendicitis, and even vasculitis, as in Mr K’s case.
To make a diagnosis of vasculitis when he had fever, a sore throat and abdominal pain would be extremely difficult.
Patients and the public should try to understand the full picture before complaining about their medical care. Many medical conditions change their presentation during the course of disease. The last doctor who see the patient would be the most likely doctor to be correct.
[Just like you always find the missing object in the last place you look... because you would be an idiot to keep looking after you have found the object you are looking for... But "the last doctor to see the patient would be most likely to be correct" - note that it is "most likely"... because the last doctor might also be the one to sign the "cause of death".]
The earlier doctors who do not make the right diagnosis are not necessary incompetent. The last doctor who gets the diagnosis right is not necessarily better.
If a patient’s condition does not improve as expected, the best thing the patient should do would be to sit down with his doctor to re-evaluate the whole course of illness, including any new sign or changing symptoms.
More often than not, making complaints against the medical team or the hospital would do very little to improve the situation.
There is a famous Chinese saying: Employ staff that you trust, and trust the staff whom you have employed. Similarly, select a doctor you trust, and trust the doctor you have selected.
ABOUT THE AUTHOR:
Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.