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21 years of iatrogenic abdominal pain

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Long ago, during my term as a surgical registrar I was asked to see a rather rugged 65-year-old farmer with chronic intermittent abdominal pain. The problem was puzzling the RMO especially as the patient had ‘the thick file’ syndrome. He was a rather likeable phlegmatic man who seemed to have a genuine problem and was embarrassed by his occasional visits to various doctors and the emergency department. He described the pain which was located centrally as colicky, mild to moderate and dull. It was associated with mild abdominal distension, nausea (no vomiting) and constipation with hard pellet like stools. Diagnoses that had been suggested were irritable bowel syndrome and/or abdominal adhesions. He said that the painful attacks which simply felt like ‘a kick in the guts’ would dissipate as quickly as they came. He had a history of a cholecystectomy 21 years previously.

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On abdominal examination he had mild central tenderness with rebound tenderness, minor swelling and the suggestion of a firm mass. We did not have sophisticated imaging such as ultrasound available 43 years ago, so the obvious investigation was a plain X-ray (previous barium enemas had been reported as normal). The X-ray indicated the presence of an abnormal shadow suggestive of a foreign body. This made sense so we organised a laparotomy and not surprisingly found the corrugated drain tubing left accidentally following the cholecystectomy. The thought of litigation did not cross his mind such was the prevailing attitude at the time and the particular nature of the relieved person.

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Fig. 6.1 Corrugated drain tubing left behind accidentally following a cholecystectomy 21 years previously.

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DISCUSSION AND LESSONS LEARNED

  • It is usually possible to evaluate the genuineness of your patient by their personality and demeanour. However, all patients should be considered as having a genuine problem until proved otherwise and managed accordingly.

  • Recurrent incomplete small bowel obstruction showing transient episodes of obstructive symptoms often do not have all classic symptoms or signs present. Abdominal signs may be unremarkable and self-limiting.

  • Adhesional abdominal pain is very difficult to diagnose and is a diagnosis of exclusion.

  • The plain X-ray is still a valuable and effective investigation and often underused.

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A lost cause is a lost testicle

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The mother of Greg N, aged 15, rang to say that he was complaining of severe suprapubic pain following its sudden onset. After an hour the pain was also in his right groin and he had vomited three times. I instructed her to bring Greg to the office, adding that acute appendicitis or a strangulated hernia should be excluded. On examination the right testicle was tender, red and swollen. Its elevation increased the pain. I rang the nearest surgeon and asked him to attend to this torsion of the testis, adding ...

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