I have not been posting much on Surgical Blog because I have not encountered any interesting or difficult cases recently, however, the following 2 cases (not mine) made me wonder how much testing is enough and what testing is really appropriate.
1. 81 year old white female with iron deficiency anemia x 1 year and nausea, vomiting undigested food and about 20 pound weight loss, had UGI endoscopy last year which was normal except scope could not pass through duodenum (that is, the scope met resistance and could not be passed further–no masses, just a difficult curve to follow (which is highly unusual in UGI endoscopy), colonoscopy last year normal, UGI X-ray last year showed poor filling of the duodenum (looking at the X-rays there is a sudden transition from normal sized duodenum to a thinner but normal looking duodenum–no masses.
This year presents with above symptoms and gets nuclear med hepatobiliary scan with cholecystokinin which shows no gallbladder filling, passage of contrast into duodenum and spillage of most of contrast back up into stomach (highly unusual).
What would you do at this point?
(The surgeon did another upper GI X-ray and another upper GI scope with findings unchanged from last year, then he decided to operate. I’ll tell you his findings after I get input on what would have been appropriate testing if any before laparotomy at this point.)
2. 47 year old non-smoker non-drinker diabetic refuses insulin hypertensive who presents with 20 pound weight loss and anorexia plus hemoglobin 7 and is found to have a mass between the xiphoid and umbilicus on abdominal exam. What tests, if any, would you do before taking this lady to surgery?