How much testing is enough?
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?
Re 1: A few preliminary questions:
– Any medical treatment (i.e. cisapride etc) tried?
– How long was the interval between the first and the second presentation of symptoms (and examinations)?
Short Interval : – Abdominal-CT scan to exclude tumor
(< 6-8 w) - no tumor: laparatomy and gastroenterostomy - tumor: evaluate resectability (yes even in an 81yo) according to guidelines Long Interval: - unlikely to have malignant neoplasia ---> laparatomy
Re 2: Abdominal CT-scan (yes, it’s quite abundantly availableand not too expensive in Switzerland) further investigations based on the findings.
Looking forward to all other suggestions and final answers to these mysteries.
I would do CT scans in both cases prior to taking these patients to the OR. Is it inevitable that trips to the OR are in these patients’ futures? Yes, most likely. However, more knowledge allows for prior planning, which prevents p___, poor performance, and it also allows for more information to be given to the patients.
The first case is very intresting, Duodenal diverticulum should be considered in the differential diagnosis,it is important to diagnose it preoperatively as being retroduodenal can be easily missed during laparotomy, CT scan is very helpful in demonstrating retroduodenal area. Non visualization of gallbladder by nuclear scan may be due to gallstones which are common with duodenal diverticulae. Reflux of bile to the stomach may be due to, the less common,infra-papillary type of diverticula.
In the second case upper GI endoscopy should be done first, if negative CT scan with oral and IV contrasts is important before further management.
Case 1: 81 year old white female iron deficiency anemic since last year (not sure whether this just refers to 1997 or actually 1 year ago), now has vomiting undigested food and 20 pound weight loss.
Pertinent positives so far on 2 UGI X-rays, 2 Upper GI endoscopies, 1 colonoscopy and 1 HIDA scan with cholecystokinin are:
1. Normal esophagus, stomach, proximal duodenum but only a thin trickle of barium distally and no one can negotiate this with an endoscope (2 separate upper GI endoscopies last year and just recently), no visible mass, no other visible abnormalities.
2. Gallbladder does not fill and the nuclear contrast refluxes into the stomach (most of it ends up in the stomach).
Actually, this is an interesting case. No further testing was done (and I question whether the repeat upper GI endoscopy, repeat upper GI X-rays and nuclear med hepatobiliary scan were really necessary or helpful. Several Surginetters suggest CT instead–this was not done, but would have helped with operative planning, since this lady had a duodenal adenocarcinoma to the left of the mesenteric vessels with positive lymph nodes. Most likely, this was the cause of her iron deficiency anemia last year and actually her last year’s upper GI endoscopy and upper GI X-rays showed a problem in the duodenum.
Second case I was consulted on midway through the testing: 47 year old female with iron deficiency anemia (Hgb 7), anorexia and 20 pound weight loss, healthy life style but has diabetes and hypertension Physical exam done when she presented with these complaints showed a mass in the upper abdomen.
My thoughts on this case are that if she had just the iron deficiency anemia, she would have gotten colonoscopy (perhaps after testing her stool for blood which most likely would have been positive).
If, instead, she presented with an abdominal mass, we might have done a CT (for operative planning).
However, we have both iron deficiency anemia and a mass. This is most likely a GI cancer.
Now, does it matter what is wrong with this patient (that is, is there any advantage to know what this mass is before surgery)? Yes, it would help because if it is a liver or pancreatic mass I would refer her to a tertiary care center.
So what test would give us the answers we need quickest (and most cost-effectively): the CT or the colonoscopy (or as was actually done in this patient both tests even though the CT done first was clearly abnormal and nicely showed the lesion)?
For case 1 the patient may have choleenteric fistula. I n that case no other test can be done. Case 2 benefits from a CAT scan.
47 year old female with diabetes, hypertension and new iron deficiency anemia (Hgb 7) and 20 pound weight loss, found on physical exam to have mass in epigastrium.
CT showed a mass in the transverse colon, with recommendations to do a barium enema.
Colonoscopy showed a large mass in the transverse colon too large to pass the scope through.
At OR she had an 8 cm transverse colon cancer extending into the omentum and attached by a single adhesion to the ligamentum teres hepatis—this combined mass was mobile and not attached to any other structures.
Transverse colon was resected (including, of course, the omentum) including the adherent ligamentum teres hepatis.
We then did a quick intra-op colonoscopy to be sure the remaining right colon was free of polyps.