Part I can be found by clicking here: Stomach Pain: It Starts – Part I.

*****

We sat quietly waiting in the waiting room. Again, we found ourselves in an odd position of being on the patient end of things. Allison, my wife, is a registered nurse. At the time she was working as an RN on a cardiac unit and I was at the end of my second year of Internal Medicine residency. Also, before this GI appointment, Allison had made a 2nd visit to the LLUMC ED. On that second visit they had decided to admit her to the Family Medicine service since her primary doctor was from the Family Medicine service. They did what they could but in the end agreed that she would need to be followed by with GI and proceed with the EGD. They did offer her more medications to try and help control the pain.

After finally seeing the gastroenterologist and sharing the events of the last two years, he sat quietly typing on his computer. He explained that he doubted it was an ulcer and that her description sounded more like the pain was biliary¹ in origin.

Although he thought an ulcer was less likely to be the cause of the pain, he recommended proceeding with an esophagogastroduodenoscopy (EGD) to rule out peptic ulcer disease. He also ordered a HIDA scan for her to evaluate gallbladder function.

During her visits to the Emergency Department they had done ultrasounds. One of the findings noted on the ultrasound was that there were no visible gallstones in the gallbladder. There was also no signs that a stone was stuck in the common bile duct (CBD) that connects the gallbladder to the small intestine. Her lab results also did not scream out that something was stuck in the duct resulting in an obstruction.

A week or so later we were back in the hospital, this time for the HIDA scan. I don’t remember what service I was on at that time, but I remember being able to accompany Allie to the procedure. I went with her to get checked in. They took her back; but Allison returned shortley to tell me it would take a few hours to finish. Rather than waiting in the waiting room, I went to the cafeteria and got some breakfast. I returned a few hours later to pick Allie up and take her home. She said that during the test she did feel some pain and it was similar (but less intense) to the pain she had been feeling during her episodes.

Is it strange to think that I hoped the test was abnormal — that I had hoped that it would find something wrong? I suspect my wife was also quietly hoping the same thing. Because if we had a diagnosis, we could start looking for a treatment.

*****

A few weeks later she went in for her EGD. She was told that she had to come with a driver, per policy, as she would not be able to drive home after receiving sedation for the procedure. Fortunately I was assigned to a service that was at the main University hospital so I was near already. It was also not a very busy service so I was able to be her designated driver. This was the first time in our relationship that I had to be her designated driver too.

After the procedure was completed (it did not take very long), I was called back from the waiting room to join her. She was coming off the effects of the moderate sedation². She was quite talkative but I could tell she seemed a bit “off.” As I watched her talking away to her RN, the GI doctor handed me a printed out report that included pictures from the procedure. As I scanned down the report, he told me that the exam was normal. There were no signs of any peptic ulcer disease. In fact, the whole procedure failed to find any abnormalites. Considering the EGD was normal and that the HIDA scan showed some decreased function in the gallbladder³, our GI doctor decided to place an outpatient consult to Surgery. We would follow up with GI in 3 months.

I tried to stay positive. At least we had ruled something out. Allison tried to stay positive as well. As we digested the fact that she had completely normal results we started shifting our thoughts to a biliary cause of the pain. We hoped that the surgeons would take a look at her case and be happy to operate on a young, relatively healthy woman.

*****

Life continued. I finished my second year of Internal Medicine residency. Allison, spending what felt like most of her time on the freeway, began looking for work that was closer to home. She looked at positions in the outpatient setting. She looked at patients in the inpatient setting. She sent out multiple job applications. Replies were slow. It was during this time that we made another trip to the Emergency Department due to another paralyzing episode of abdominal pain.

Again, this pain came out suddenly and again, the pain started in the morning. Allie really did not want to go to the Emergency Department again. She was frustrated with being in the emergency department for pain medications. We already knew that the tests would come back normal. I think she also did not want to be looked at as someone who was seeking pain medications. But I convinced her to go, if only to have the episode broken so that she could gain some relief.

This time, we sait in the waiting room for almost 7 hours. The local county hospital had received some sort of threat, or so the rumors swirled. And all of thier patients were being diverted to the University Medical Center. All the while, she sat there in the waiting room crying until her tears ran dry. At one point a concerned patient who was also waiting her turn came over to pray for her. We eventually got in to be seen. First, though a medical student interviewed her, then the resident, and finally the attending.

They wanted more tests.

Eventually came the talk we knew so well. They had run the tests and everything had come back normal. Since the pain was improved, they wanted to send her home. They were assured that the pain wasn’t due to some emergent situation requiring some intervention or hospitalization.

I finally expressed my own frustration that night. I told them how we were awaiting a surgical consultation as an outpatient. I realized that this was not an emergent surgical case. No surgeon would be rushing her to the operating room. So I asked why they did not at least consult surgery to speed things up? Why not have her seen in the ED so that the surgeon could come by and write in the note to follow up as an outpatient? At the very least, I asked, could the ED just recommend that we follow up with surgery soon — like within a week?

The resident said he would see what he could do. Within the hour, though, a surgery intern was at our bedside to evaluate Allison. We went through the entire story again. We talked about how GI felt that the problem was biliary despite normal ultrasound and “normal” HIDA scan. The intern said she would return with her senior.

Within the next hour the surgery senior arrived. We actually knew each other from medical school. He shared that they were not convined that this pain was of biliary origin due to the numerous “normal” tests. However, if they GI felt it was biliary, we ought to follow up with them. We also discussed surgical intervention. I asked if he had any recommendations on which surgical attending to see in clinic. He recommended someone I will refer to as Dr. S, stating that he would be more lenient with his requirements to go to surgery and may be willing to try a surgical intervention to see if it would solve the problem.

We thanked him for his time and recommendation.

Almost 24 hours after we arrived, Allison was discharged home. It was Saturday morning and we were exhuasted.

On Monday, Allie made her an appointment to see Dr. S in surgery clinic. She also made a follow up with her GI doctor.

1. Biliary pain is pain that originates in the biliary tree/biliary system. The biliary system includes the gallbladder and the bile ducts connecting it to the small intestine. See here for more. [↩]
2. For the EGD they used moderate sedation. This means that Allison was not completely knocked out like one might be for a surgery in the operating room. She was given enough medications to make her very sleepy. Usually, though, patients are still able to follow simple commands during this type of sedation. This is actually preferred because they need her to swallow the scope. [↩]
3. While the radiologist had said that her gallbladder function was normal, our GI doctor noted that at 25 years of age, Allie’s gallbladder function shouuld be significantly higher than it was. She was hovering at the very low end of normal. This would be expected for a senior citizen. Instead, she should have been at the higher end of normal. [↩]