By Fritz Hofheinz, M.D.
Medical care is complicated. The normally functioning human body is an extraordinarily complex machine, which we are only starting to fully understand – never mind when that body is challenged by illness. With this as a backdrop, it is not surprising that experts will differ on appropriate diagnoses and care of patients. Therapies differ widely between different disease states (cancer vs. infection vs. chronic inflammation and autoimmune disease), these conditions are sometimes difficult to differentiate and the therapies between them are dramatically different.
The following case illustrates why multiple opinions for complex and ongoing cases are so important.
A previously completely healthy 31-year-old man shows up in the emergency room with classic symptoms of a ruptured appendix “right lower quadrant abdominal pain and peritoneal signs”. The patient is quickly and appropriately brought to the operating room where the surgeon removes a “grossly infected appendix” as well as infection throughout the inside of the abdominal cavity. The patient receives several days of intravenous antibiotics in the hospital to calm the infection and then is discharged home. Often, the story would end here.
Unfortunately, not long after discharge, the patient continued to have symptoms and signs of infection. He is readmitted to the hospital with fever and fatigue and found to have an abdominal abscess (a walled off infection) that is drained and again gets a short course of antibiotics. Abscesses in this setting are not uncommon and again, the story could end here. The patient gets initially somewhat better, but…
For the next several months this previously healthy, vibrant man continues to have symptoms: fever, fatigue, joint pain. He undergoes a colonoscopy where continued inflammation is noted in the cecum (the area of the intestine near where the appendix used to be). Biopsies near the cecum show “the possibility of Crohn’s disease”. Crohn’s disease is a chronic inflammation of the intestines treated with a variety of sometimes quite potent anti-inflammatory medications. Based upon the colonoscopy, biopsy, and symptoms the patient is given the diagnosis of Crohn’s disease. He is started on a number of different Crohn’s “cocktails” of medicines. Some of the therapies seem to help a bit but relief is never long lasting and the patient continues to have disabling symptoms of fatigue, diarrhea and intermittent fevers. Exhausted and at the end of his rope, fully a year later, the patient reaches out to Best Doctors asking “are there any other therapies I can try for my Crohn’s disease?”
Best Doctors physicians wonder — might this not be Chron’s disease at all? A gastroenterologist with world’s expertise in Crohn’s disease suggests a re-review of the biopsy at a center of excellence. This time, the reading is not definitive. In other words, Crohn’s is not a slam dunk.
Looking further, it turns out that severe abdominal infections like the patient had can occasionally result in a spread of the infection within the pelvis, which would actually be a simpler explanation of the patient’s confusing symptoms rather than Crohn’s disease. On this basis, it is recommended that the patient stop the Crohn’s treatment and instead have a surgery to take out the inflamed area of bowel around the Cecum and a prolonged course of antibiotics. Several weeks later, the patient was markedly improved and was no longer complaining of the symptoms that led to the diagnosis of Crohn’s.
People are complicated; diseases are complicated; pathology is complicated; diagnoses are complicated. All providers make their best, and usually not unreasonable, judgments given the information they have at hand. Sometimes those with slightly more experience will see things from a different perspective. In this case the original physicians were wrong. As a result, this patient endured a year of Crohn’s disease therapy that he didn’t need and experienced significant disability.
Given the complexities involved, the value of having a new, fresh set of eyes consider your situation cannot be overstated.
