The other day a woman presented to the hospital with vague abdominal pain. It had been nagging at her for about a month, and she just felt that something was wrong and wanted to get checked out. The emergency room scanned her over, and decided that there was something to her pain, and so she was admitted. The admitting medical team concurred, and consulted the gastroenterology group. Everyone was in agreement – her story, her looks…it all pointed to her gallbladder.
The only thing was that ultrasound – which is usually the best test for the gallbladder – was completely normal. But her blood-work indicated some sort of pathology- perhaps the gallstones had already been expelled from the gallbladder and were now stuck downstream? An MRI was ordered to confirm, but it, too, was normal. Her labs continued to worsen, and her pain persisted, so a nuclear medicine test was ordered. These are very good at picking up an occult cholecystitis, or attack of the gallbladder – sadly, it was negative.
I say sadly because patients like to know what’s wrong with them. Even when we hunt for a diagnosis and it comes back something scary, there is a certain relief in at least knowing what the problem is. There is a degree of comfort to at least giving your enemy a face, even if it is an ugly one. Most patients who have abdominal pain get a CT scan at some point during their hospital stay – in all honesty, it is often the first thing ordered. But in this woman’s case, the testing was more discretionary, and rightfully so. But now, with all roads turning up empty, worsening labs, and continued pain, a CT was justified.
When a CT scan is performed, it collects hundreds of images in just a few seconds to compile the pictures we see. Oral contrast is ingested to illuminate the bowel, and intravenous contrast is injected to illuminate the blood vessels and the highly vascular organs. When we ordered this particular CT, we asked the radiology tech to time the imaging to optimize our views of the liver and pancreas – the supposed region of interest – in the hopes that it might pick up any pathology. And it’s a good thing we did. The venous phase of the study showed the portal system was largely occluded. The liver actually has two systems of blood supply. It has an arterial supply (via the hepatic artery) which is analogous to every other organ in the body. But it also has what is known as the portal system. This is the network of veins which drain the bowels and bring their contents to the liver for processing. This is actually the major source of the liver’s blood. The clot within the portal system was so extensive that it had managed to kill the central portion of the right half of her liver. She wasn’t sick from a simple gallstone – she was sick because a major blood clot was killing off her liver.
She needs to have her blood thinned right away. And she’ll need that for about six months or until the clots dissolves. And we need to find out why this happened. There are really only two possibilities – either she has a disorder of her blood that causes her to make clots, or she has an occult malignancy, like lymphoma, that is causing her blood to behave this way. Either way, her life has been severely altered. It’s humbling to arrive at conclusions that are so far from where we start. Life’s messages are often hidden – we just need to keep searching to find them.
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