Sunday, December 31, 2006

You Are What You Eat



One of the most dramatic changes from the time of my training to the present is the nearly complete disappearance of elective ulcer surgery (reminder: as I've said before, "elective" means non-emergent, as opposed to unnecessary.) The revolution began with the advent of drugs which effectively reduce gastric acid production, and settled in for real when the relationship between ulcer formation and the bacterium known as h. pylori was worked out. I have to admit I lament the passing. Given time to plan it and give some thought to the available surgical choices, operating on the stomach for ulcer is technically interesting and therapeutically rewarding. Limiting the experience to emergencies, while setting the stage for drama, means narrowing the field to one of a certain untidiness.

I've always liked fresh corn and peas. Each brightly colored, with a crisp sweetness, and both best when cooked very gently. Sit those kernels on a plate, they make a nice visual statement as well. Slopped between loops of intestine, stuck above the liver, soiling the hidden spaces around the pancreas and duodenum, filling the pelvis, some of the sensual pleasure of what may have been a nice meal gets lost, and dealing with it puts me off the feed for a while. Doesn't smell all that great, either. If it's embarrassing to get a drop of soup on your tie, imagine how it'd feel to see your omentum harboring a whole salad. Hanging down from the transverse colon like a wet apron, it can hide lots of cranberries in its crannies; getting them loose requires individual plucking, and can take a while. The upside is that a person with a perforated ulcer is generally in a lot of pain, and sewing up the hole, cleaning out the food, and copiously irrigating away the acids means s/he is likely to wake up with a smile. I can put up with a little personal unpleasantness when it produces results like that.

Stab wounds don't seem to happen on an empty stomach. Maybe it's because victims of such things are not always entirely innocent. Drinking all night in a bar, washing down peanuts and chicken wings appears to be a necessary precursor to picking a fight, and losing it. Knife holes in the stomach are generally much larger than ulcer holes, and can empty prodigious amounts of stomach content into the abdominal cavity. The odor of alcohol and partially digested food in the belly is not much different from when it appears on a fraternity floor; sticks with you a while. But once again, a few well-placed sutures and some high-class janitorial work predictably results in a happy patient. The process can require an amazing amount of saline wash before the irrigating fluid looks clear enough to drink.

Of all the new words I learned in medical school, "bezoar" (pronounced BEE-zor) is among my favorites, just for the way it sounds. It means an aggregated lump of stuff that can clog the stomach, or the intestines, and can look quite impressive. They come in two main varieties: trichobezoars, meaning those containing hair, and phytobezoars, referring to those resulting from undigested vegetable matter. A feline furball is a trichobezoar, as is one occurring in a human who chews hair. Where I learned to be a surgeon, springtime often produced a victim or two of over-indulgence in a not-yet ripe local fruit: persimmon bezoar was on the list of possible diagnoses of abdominal pain. I've opened a few stomachs to extract bezoars, typically in pieces. The usual word sequence, spoken to the scrub nurse, goes something like "stay stitch... one more.... cautery.... suction.... ring-forceps.... eww gross...."

I must have dozed a bit during the lecture on bezoars in med school: not at all unusual, I confess. Hearing vaguely through my daze about eating hair, fur-balls, undigested organic matter, tricho- and phytobezoars, for a while I thought I'd heard that a hair-ball was called a Fido-bezoar, as in the generic doggie, good ol' Fido. When I was corrected by a classmate, I was less embarrassed than disappointed.

16 comments:

Empress Bee (of the High Sea) said...

well doc i really try hard not to hack up hairballs, but i thought eating veggies was good for you!! sigh.... bee

origin said...

What a great post! The visual imagery of the corn and peas stuck in the omentum is quite vivid! When we're sick and in pain, all the niceties get thrown out the window and all of us just want to get better - regardless.

happyj said...

This is so interesting! Is this a reason why doctors don't want gall bladder patients to eat for two weeks before removing the gall bladder?

kïrstin said...

'eww gross', ya i say that a lot. i have a long haired cat who tosses trichobezoars frequently. and an older cat who has a taste for the fur on other cats, ie she pulls the fur and eyebrows off the head of the submissive feline. dont ask, i dont know.

this was a very interesting post. although, the visuals i have now, i may be fasting more ...

A Bohemian Road Nurse said...

That's a cool word: "bezoar".

Greg P said...

In my medical fraternity one of the members was nicknamed Trichobezoar, Bezoar, or Beez for short. It seemed to have come about from the way his hair kind of stuck out in various directions; this was a time when many of us had long hair, even those who shouldn't have.
His brother was going to dental school and immediately got the nickname (what else?) Phytobezoar.

Anonymous said...

How ironic - I was thinking deep thoughts of bezoars the day before you posted this treatise.

I love the transformation of "phyto" to "fido" in the wandering mind. It is humourous images like this that our mind creates that makes keeping esoteric knowledge accessible. That is why I am a fan of mnemonics, no matter how much of a crutch the hard core "pure" thinkers think it is.

Reminds me of the time that we had a lecture on gout but the accent of the professor made the word out as goat. I think it was almost at the end of the hour class that we finally figured out the disorder he was lecturing on was the metabolic disorder that results in crystal disease in the joint space and soft tissues. But because of the humour that is associated with that lecture, I have never forgotten the biochemistry / pathology of Gout and in fact, went to make a career out of it! Funny how the littlest things influence life's choices.

Judy said...

Once in my umpty-zillion years as a NICU nurse, I saw a baby who developed a lacto-bezoar. The neonatologist who figured it out was quite pleased with herself. It resolved with conservative (ie non-surgical) therapy and the baby received lower calorie feedings once oral feedings resumed.

I didn't realize that people could get hairballs or that certain types of produce could cause problems as well. Very interesting post.

Surgeon in my dreams said...

uxhwtfvThat one little haiary one looked like a very small hairy penis to me. Course, it's been a long day too!

So, what do you know about pilonidol cysts? I had one several years ago that would get so big you could see it making my jeans poof up over it. Horrible painful. I was terrified to go to the doctor and suffered with it flaring up for over a year, but finally did go and then it was so wonderful the day he drained it I felt totally stupid for suffering.

Once the infection cleared, my surgeon took good care of that thing. Never had a problem with it again.

Sid Schwab said...

think I'll post something about pilonidal cysts sometime. Hardly glamorous; but draining one makes the owner happy indeed.

DisappearingJohn said...

Actually heard about one in a post-gastric pypass patient that I thought was amazing that this post reminds me of. This guy was having trouble eating, so they thought he might have a stricture. The did an EGD and found something amazing. One of the things we have to do is eat a lot of supplements, and when they got to this guy's tomach they found a huge ball of ascorbic acid. Vitamin C suppliments he h ad been chewing had been building up in his stomach, not going down. I'm not sure which class that would fall in, but I guess it qualifies..

athenivanidx said...

those bezoars looked like shits........

eww gross is right. When you were just starting out as a trainee surgeon, did you ever vomit from seeing or smelling something particularly narsty?

seeing blood doesn't bother me.........even seeing or smelling poo I can deal with...........urine not a problem.....and the feminine crud......ugh I hate it.......

but something like the taste in my mouth in the morning makes me extremely queasy.

Do surgical residents have any kind of "olfactory desensitization training" or something like that so they don't react to smells.......or it is just some kind of behavior therapy.......mind tricks.......brain signals.........I can't think of a better phrase for it

The Integral

Sid Schwab said...

Integral: there's not "desensitization" as such; I think it's sort of self-selecting. People who are sensitive to such things find out somehow and don't go into surgery. I think there are things that disgust even the seasoned pros, though. Like the rotting feet of some poor derelict, with maggots... Or the smell when draining some abscesses. People will put benzoin or some other such thing on their masks to blot out the smell...

Aloha said...

30 yrs ago my mother had surgery and 2 phydobezoars were taken from her stomach!!! We were asked if we wanted to see these "rare" things...and we did...they were 'yukky' looking, were 'clay-like' in matter for about 1/4 inch - then they were "calcified" ... one kidney shaped, the other like a hot dog bun...some pills recently given to her in hospital were 'stuck' to them....were NOT attached, just 'floated' around her stomach causing her "stomach issues" her entire life...getting worse with time, as they 'grew' - until discovered when she was 60 yrs old! A team of Dr's "interviewed" her afterwards and an 'odd' question was asked.."if she had ever "eaten persimmons"?!? She said she HAD...when she was a little girl walking home from school they would pick and eat them!!!!! She is now 92 years old, still golfs and eats anything she likes without any issues! She has an amazing 'bezore' story and she is an amazing woman!!!!

Sid Schwab said...

Great story, Aloha. Thanks!

Txtraveler79 said...

Funny seeing the word "bezoar" again. I first saw it in a Harry Potter novel, of all places. I thought Ms. Rowling had made it up until I looked it up later.

When DID we finally figure out the relationship between h. pylori and ulcers? James Herriot ("All Creatures Great And Small")swore that vets knew about it ages ago - from dealing with pigs I think he said.