Gastroenterology

Hi,

Ok, so my first week on my medicine rotation, which is based around the GI system (top to bottom, including associated organs such as liver, pancreas etc.) and I get back to the 'proper' hands on medicine. Nurses, endoscopies, cardiac perfusion scans, X-ray meetings, hepatitis, a patient who has severe intestinal bleeding, seemingly from switching to a purely raw food diet (not healthy), 'on take' and  ERCPs topped off with an upsetting surprise finding that a patient only had around 3 months to live because of a tumour found instead of gallstones. While sad in places, this is more like it. Much more proactive and time is spend 'doing things' instead of sitting around waiting for the next patient.

Lets get started on my week. To start off our medicine experience we were meant to be with the nurses for a little to 'warm up' at the start the rotation. With shifts starting at 7AM this was no mean feat, I was not used to getting up early after psych where the ward rounds started much later to give the patients time to 'get going'. While far too early for me (most definitely not a morning person) it was nice to fraternise with the nurses for a bit. Helping them give medication to the patients and get them out of bed led to just chatting with the patients as the nurses got on with their general day to day activities. What a lovely way to start the week! I got to hear some wonderful stories from someone who grew up in Australia on a station (a ranch) and how his life led him to the UK. While this was strictly not a nursing activity, I persuaded myself it was for the good of the patients, to prevent boredom, so continued at my leisure. I think the nurses were happy to have me out of their hair anyway. While the nurses there were more than lovely, there is sometimes a bit of disagreeability between the doctor and nursing professions. Some doctors seem to have a very patronising attitude towards nurses, and see their role as menial, and the nurses obviously do not appreciate this. Some nurses see doctors as stuck up, too big for their boots (which some are, in my opinion)  and overpaid. Usually these feelings seem well under the surface though, and don't seem to affect patient care, though we have overheard one nurse telling patients that they would be 'stupid to consent to having a medical student sit in' as it was a waste of their time and we were only nosy. If we qualified as doctors without seeing any patients we would be a danger to society! We have to start somewhere.

Some time spent in the hepatitis clinic with a doctor was a real eye opener. In the morning, despite having solid appointments from 8.30 'til 12 there was only one patient before 10.30. An elderly gentleman who had contracted hepatitis from a blood transfusion some time ago, but had only found out recently. The clinic was for follow up for those who had just been diagnosed with hepatitis to see if they wanted treatment, or if their body was clearing the infection (there is a chance the body can clear the infection, depending on the strain). The only people attending the clinic were people who had the B or C strain as the other strains (A,E,G) do not lead to permanent infection. Many of those in the community who are catching hepatitis are IV drug users and in the morning they need to pick up their methadone, so will not turn up for appointments. Perhaps a different plan needs to be made for when to carry out the clinic. After 10.30 plenty of patients were showing up. Many of them apparently homeless from their unwashed state and ruined clothing, but polite and kind none the less. Drug users get a bad press, which is perhaps fair enough as it is a large cause of crime, but I think judging people in this situation is exceptionally unfair. Many of them have had horrific childhoods including problems such as abuse, and how can you look down on someone for turning to drugs in that situation when you have not been in it yourself. One of the most interesting patients who turned up to the clinic had turned up with his wife, but on reading the covering letter with which he was referred (before the consultation, to find out a little before it started) we found out that the patient had not told his wife how he had caught hepatitis C. The truth was that he had relapsed into using heroin after about 10 years abstinence due to stresses at work, and had been using since. He had told his wife that he had caught it while nursing his father, who was currently suffering from end stage liver cirrhosis due to too much alcohol. At least the patient got the right organ to lie about. In this clinic it is very important to know exactly when the patient caught the virus, as there is a chance of them self clearing it in the first 6 months, but after that if it still remains it will be permanent so treatment should be considered. Treatment is 1/2 a year or a year worth of daily pills and weekly injections to stand some chance of cure, depending on the type of Hep C the patient has. It's got terribly side effects and has been likened to chemotherapy. Putting someone who is unstable, without a home or support, on this medication is not a good idea, so treatment is planned to be when the patient is in the best environment, which is not always easy. Anyway, the patient managed to help us send the wife out of the room under a pretence, so we could ask the questions we wanted. Why he bought his wife along in the first place is what surprises me!

Anyway, I spent some time this week in a variety of places in the hospital. With a loose timetable, the plan is that the student will spend some time wandering the hospital picking out things that they want to do. While this can be quite exciting, it can also be a bit of a chore. Being turned away from places and having to compete with fellow students for that space-for-one in the MRI room can be a little time consuming. Anyway, I got some great experience sitting in on some endoscopies. Not doing them, not by far, but watching the procedure and having it explained, so when the time comes I will know what to look for and how to carry out the procedure. I saw a variety of problems with the stomach and duodenum, which was good for learning, from oesophageal varices (often caused by drinking damaging the liver and thus raising blood pressure) to a completely obstructed duodenum meaning a good few litres of  partially digested food had to be sucked out of the oesophagus and stomach to see what the problem was. The procedure is called an OGD (Oesophogastroduodenoscopy) - as in it looks at the oesophagus, stomach and proximal duodenum. Nice and self explanatory. Patients can choose to have sedation (still concious but 'out of it') for the procedure or a numbing throat spray. The nurses were recommending the patients have the throat spray but after seeing both of these in action I would personally go for the sedation every time, you are too 'out of it' to really notice the procedure and are unlikely to remember it in the end. The throat spray doesn't seem to numb too well, though when I tried some myself it seemed to be very effective. I suppose its a little different if you are having a great big tube shoved down your throat.

I also saw cardiac perfusion scans being carried out. Creating an image like the one below, a radioactive isotope is injected into the patient to see the blood flow around the heart, to see if there are any problems. Our patient was, surprise surprise, a smoker. It seems so many of the diseases in medicine can be caused by, or exacerbated by, smoking. In all honesty it is a surprise it is still legal. Some politics going on there perhaps, but the phasing out in public places is definitely a good thing. It has reduced the number of people coming into hospital with respiratory problems and heart attacks significantly. The X-ray meeting I sat in on was interesting to see. The gastro consultants had collected up the most complicated scans from this week (mostly CT and MRI, despite the x-ray meeting name) and were showing them to a consultant radiologist, who was helping interpret them. The hospital is like a spider's web, with all of these different specialities working together. Its impressive that it all works (most of the time).

When on a ward round we came across a patient who was suffering from numerous ulcers in the stomach and duodenum. I don't really have much to say about her, other than the only reason that we could think of for all of these ulcers to be in her digestive tract was her recent change in diet to only eating raw food. The gastro consultant was very scornful towards these 'fad diets' and 'strange ways of eating' but I suppose if you spent all of your days picking up the pieces of those which go wrong then perhaps you have a right to be angry towards those who promote such things.

The 'on take' I did this week was great fun. Patients usually come into the hospital from either A&E or a referral from the GP. Patients in A&E are assessed and those who cannot be dealt with there and then and sent home are sent to be clerked by the on take team. The same goes for patients who are referred by their GP and need to become in-patients. On clerking there are plenty of questions that should be asked, about family, social situation and the like, and it is a good idea for a full examination of the patient so that when they are on the ward the doctors can see changes in condition or signs, and they have a good idea about what is wrong with the patient. When I was on the elderly ward, I remember the first thing you would always look at in a patient's notes was the clerking from their admission. Filling out these forms seemed very important, far too important to leave for a medical student to do! You don't want to miss a sign or a key part of the history, as whatever you clerk them in with, most doctors will take as read and not bother asking these questions again. I clerked in a patient who was experiencing chest pains, with a strong family history of heart attacks with 3 brothers who had died of heart attacks. She had her little girl there with her, about 7 still in her school uniform and very upset. The girl hated hospitals, after her grandad had died in one (again a cardiovascular problem) late last year. I tried to make her feel more comfortable by being friendly and nice, but it wasn't that easy in an acute medical ward, stuck in a tiny room curtained off from the corridor. Hope I managed to get down all the relevant parts of the history in the history. I left the investigations needed and the treatment plan boxes though, no need to stretch those limits on my first week and end up killing someone! A neurological examination on a lady with unexpected occurrences of syncope yielded nothing at all. I don't like not knowing the answers, so I plan to pop back in after the weekend and see if the cause has been found yet with the more specialist investigations. Medicine is detective work, and I love it!

 Finally, I spent some time sitting on on some ERCPs. This is both a diagnostic intervention and treatment, and involves putting an endoscope down the throat (like I was seeing earlier in the endoscopy clinic) and pushing a small wire up into the common bile duct from the duodenum. The plan is to find out if there are any gallstones in the duct from the gall bladder. The doctor carrying out the procedure can see down the endoscope, so can see what is ahead, and there is an X-ray machine above the patient so the doctor can see an X-ray of where the wire is (because the endoscope cannot go into the common bile duct). Down the X-ray the image looks just like the image below.

The large black worm like thing from the top right and curling at the bottom is the endoscope that has been passed down from the throat. The vertebrae can be seen behind it. Just above the top of the endoscope you can see where the wire has been passed out, vertically up, and the doctor has injected a contrast which shows up as darker on the X-ray. This contrast travels along the tubes of the bile ducts, and any blockages can be seen as the contrast will not be able to travel past them. In the picture above the contrast has travelled perfectly up into the liver (top left, with many branches where the bile is produced) and along the duct to the pancreas (the duct branching off to the right and upward). This is because the pancreatic duct joins the bile duct just before they empty into the duodenum. A large problem that the doctor carrying out the procedure seemed to have was getting the wire into the bile duct and up to the liver, rather than up to the pancreas. This is important as the wire is passed up the tube, and then a balloon is inflated on the end before it is pulled out. This has the effect of catching any small stones that the thin wire has gone passed and pulling them out into the gut where they can be passed without causing more problems.
Anyway, one of the patients I saw this carried out on had a large area of blocked flow in the common hepatic duct (the straight thick piece of duct moving down and slightly right after the branches join together and before the wiggly line joins from the left (the gall bladder). This was not clearable with the ERCP trawling technique, and this coupled with the history of onset (gradual jaundice coming on over 2 weeks, without pain) meant that it didn't seem to be due to stones in the gall bladder. Due to the position of the obstruction and the relatively slow onset (gall stones cause a sudden blockage and hurt a LOT [women who have had gall stones say that the pain can be worse than their labour pains]) the most likely cause of this is gall bladder cancer. A rare cancer, but most common in women over 70, the patient fitted the bill perfectly. The cancer has to be advanced to be big enough to start obstructing the flow of the bile, and unfortunately this means that the patient has a poor prognosis as it will have started spreading. The consultant said that other patients he has seen with such symptoms and results from the ERCP tend to live for another 3 months or so. 3 months?!?! What a shocking result for a very healthy and chatty lady who was lovely to me when i went to chat with her before the procedure to ask consent. It was not a definite diagnosis, just based on clinical experience, so the patient will need scans to check the mass, and the consultant would then talk with the surgeons to see if they would have any interest in operating on the mass, should it look operable from the scans. Unfortunately the doctor said that surgeons rarely operate on such advanced cancers.
So this lady likely has approximately 3 months left to live, with little chance that there are any possible treatments to cure her. And she doesn't know yet, because this has to be confirmed with scans and talk with the surgeons. I feel bad knowing this sort of information about this lady when she doesn't even know herself, but I suppose it's not fair telling patients these sort of things when you are not sure, as it may well be a mistake and be something easily treatable, and no-one wants the stress of being told they likely have cancer and 3 months left to live, then being told next week that actually its all fine.

I would like to finish with a question for you, if you would care to answer. How would you like me to write this blog? Would it be better if it were a lot more science/medical describing conditions and treatments in more detail so improve knowledge? Would it be better if it concentrated more on how I felt throughout my training / my encounters with patients (however horrific that sounds) - Any feedback would be much appreciated!