What Was Causing a Healthy Older Man to Be Nauseated by Food?
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Version 0 of 1. “Dad, you have to come home, right away,” the woman said calmly but insistently on the phone to her 73-year-old father. He and her mother had just embarked on a two-week European vacation with close friends, but he told his daughter that he had never felt this sick. It frightened her that this man, who was in excellent health, competed in triathlons and whose stoicism was a family joke, felt bad enough to call her from France to tell her how the very smell of food nauseated him. Eating, he said, was even worse. For days, he hadn’t been able to do much more than nibble the bread and sip the water and try to pretend that he was having a good time. He and his wife had been looking forward to this post-retirement trip for so long that he couldn’t bear to ruin it. But he wasn’t sure he could make it to the end. The daughter, an emergency-room physician, knew that a few days before this trip, her father hadn’t been feeling great — he was nauseated, especially after eating. When he called her then, she worried that he was having a heart attack. But he went to a local walk-in clinic, and his EKG was normal. There was no sign that it was his heart. The clinic sent him home with a prescription for an antacid and a medication for nausea and told him that he might be getting an ulcer. Relieved by the test results, his daughter gave her blessing for this trip. But the pills hadn’t done much, and now she knew that he had to come home to figure out what was wrong. She arranged for her parents to travel directly from the airport to the emergency department of the Yale New Haven Hospital, where she worked. She had already asked one of her most respected colleagues to see her father. Although her father told her that he wasn’t able to eat much since the nausea started, she was still shocked by his appearance. He’d lost about 15 pounds over the past couple of weeks. His clothes looked at least a size too big, and his eyes seemed to have retreated deep into his skull. To her, everything about him shouted that he was sick. In the emergency room, he was seen promptly. Tubes of blood were drawn. He wasn’t anemic; there was no sign of infection; it wasn’t a heart attack; his kidneys and liver were fine. A CT scan didn’t show any abnormalities other than a small hiatal hernia. After a few hours, the doctor admitted defeat. He couldn’t find anything wrong with the man. Perhaps, someone suggested, retirement wasn’t agreeing with him. His daughter dismissed the notion immediately. She sent her parents home, knowing that her father had an appointment with his primary-care doctor the next day. Her father had known this doctor for decades. He was a great internist and would figure it out, she was sure. Dr. Alan Lebowitz saw the patient the next day in his office in Darien. The man explained how, a couple of weeks earlier, he suddenly started feeling nauseated after he ate. The feeling came out of nowhere and seemed to get worse over a few short days. By the time he got to France, even the smell of food could trigger the rumbling and tumult within. There was no pain. He never vomited. At that moment, there in the doctor’s office, he felt fine. Maybe he was a little tired; these days he really had no energy at all. His physical exam was uninformative, save for the significant amount of weight he had lost. Lebowitz wasn’t sure what was going on but referred him to a gastroenterologist for evaluation and, he hoped, an endoscopy of his patient’s stomach and upper GI tract. The patient was scoped. His stomach showed signs of mild gastritis, along with evidence that food wasn’t moving out of the stomach as fast as it normally did — a disorder known as gastroparesis. But what was causing this? The specialist couldn’t say. The patient returned to see Lebowitz the next week. The doctor examined the patient once more. This time, when he placed his stethoscope over the patient’s upper abdomen, he heard something: a quiet, rhythmic, shushing sound. This kind of noise, called a bruit, is caused by turbulence in the blood flowing through an artery. Had he simply not heard it before, or was it new? He wasn’t sure. But if it was new, he now had two clues: The patient had gastroparesis and he had some kind of problem in one of his arteries. If he could link them, maybe that would lead him to a diagnosis. Perhaps his patient had a blockage in one of the arteries that fed his colon. The bowel at the upper left corner of the abdomen is the most vulnerable part of the GI tract. Most of the intestines get blood from two arteries — if one became blocked, there is a built-in backup system. But the segment of the colon next to the spleen received blood from only one artery. If anything happened to that vessel, the blood supply would be cut off and the tissue there would be injured or even die from a lack of blood. This is called ischemic colitis, and it usually causes terrible pain, especially right after eating. But the injury to the gut wall should be visible on a CT scan. He’d had one at Yale New Haven, and nothing unusual was seen. That made ischemic colitis a lot less likely. Three weeks later, over the weekend, another thought came to Lebowitz, who was still concerned. Could the patient have something called MALS? In this disorder, a ligament supporting the diaphragm, known as the median arcuate ligament, cuts off circulation not to the colon but to the stomach, by obstructing the artery that delivers blood there. MALS causes nausea and usually pain after eating as well as gastroparesis. Although the classic patient is a thin, middle-aged woman, most of the other evidence fit. He called the patient on Monday and explained his newest theory. He ordered an ultrasound of the artery, which showed an obstruction creating the turbulent blood flow. A CT scan of the arteries of the chest and abdomen showed a narrowed, misshapen vessel, just as Lebowitz predicted. Lebowitz referred the patient to Dr. Richard Green, a surgeon at NewYork-Presbyterian/Columbia University Medical Center who had experience with repairing this kind of obstruction. After looking through the patient’s records and imaging, Green met with the man and his wife. “I know what you don’t have,” Green said after he greeted the couple. “It isn’t MALS.” Then he added: “I know what you do have. And most importantly, I know how to fix it.” There was a blockage in a blood vessel, but it was not caused by an obstructing ligament. The imaging showed that the muscular inner wall of the artery had been torn open by the fast-moving blood coming from the heart. The blood had invaded the inner layers of the vessel wall, creating a new narrower passage and blocking off the old pathway. A couple of weeks later the man went for an operation to bypass the obstructed artery and create a new route for the blood to travel. His wife and daughter, who had been warned it was going to take a few hours, tried to distract themselves when it took eight. Relief and tears overwhelmed them when the news came that all was well. It has been two years since that operation, and the man finally feels back to the self that he and his wife and daughter remember best. Getting back into his exercise regimen was hard: not just physically, but mentally as well. The man worried — despite reassurance from Green — that vigorous exercise might undo the good accomplished in the operating room. But he finally conquered that fear and is back to exercising regularly. Although it was the surgeon who relieved the pain, the patient gives most of the credit to the doctor who knew him well. “Anyone who didn’t know me would have just said, ‘You need to see a shrink,’ ” he told me recently. “The relationship is what saved me. That plus his stethoscope.” |