As soon as Dr. Benjamin Day entered the room, he could see that the 67-year-old patient was in pain. The man sat with his arms crossed, his head and shoulders bent over as if he was protecting his midsection. “I’ve got pain right here,” he told the doctor, placing his hands gently on his belly, just below the rib cage. It had been hurting off and on for more than a year, he reported, but for the last two weeks the pain had been constant. He had no appetite, and when he forced himself to eat, he would often vomit.
Day, an intern at the V.A. Medical Center in Birmingham, Ala., knew that the man had been to that emergency room at least once a week for the past month, and 22 times over the past year. Most of those visits were for the same terrible pain.
The man had kidney failure and started dialysis three days a week around the time his pain began. He was sure the dialysis was the cause. If he couldn’t get rid of this pain, he told Day, he was going to stop getting dialysis, even though he knew that without it he would die.
He had already had an extensive work-up. An endoscopy indicated mild inflammation in his stomach, for which he was prescribed powerful antacids. They didn’t help. A colonoscopy had shown a few polyps, which were removed. They weren’t cancerous, and he felt no better after. His gastric motility — a measurement of how quickly food moved through his system — was normal. Five CT scans from the past year were unrevealing.
Day felt anxious. The patient had been seen by so many doctors that he worried he wouldn’t have much to offer. He was just an intern, not even halfway through his medical training. He knew that nausea and vomiting are common in patients getting dialysis. Why that happens isn’t fully understood. Still, this man seemed to be in far worse shape than most dialysis patients. And his chart confirmed that he’d recently lost over 10 pounds.
Day examined the patient’s abdomen carefully. He pushed down firmly, applying as much pressure as he could, then lifted his hand rapidly. In patients with an infection or severe inflammation outside the gastrointestinal tract, releasing pressure quickly like that would cause excruciating pain. The man continued to look uncomfortable but no worse than before. The rest of his exam was unremarkable.
Once Day completed his exam, he sat and thought about the case. One possibility that hadn’t been explored was something called chronic mesenteric ischemia, where inadequate oxygen delivery to the GI tract triggers pain that worsens with eating. Narrowing of the arteries from atherosclerotic disease can limit how much oxygen-carrying blood gets to the gut and cause an agony that wouldn’t be found during the physical exam.
The patient had risk factors for this: He had diabetes that wasn’t well controlled and high blood pressure. Those things were probably the cause of the kidney failure that put him on dialysis. Maybe they were also the cause of his pain. He would need a CT scan with contrast to show where the blood did — or did not — go in his GI system.
An Unappreciated Detail
Day’s supervising physician was Dr. Robert Centor. Centor sometimes reviewed cases with the residents in the hospital when patients were admitted rather than hearing about them over the phone hours later. He thought of himself as more of a teacher than a boss. From Centor’s perspective, the best classroom was in the hospital, at the bedside.
It was late afternoon when Day met with Centor. Day told Centor this patient’s story, described his exam findings and outlined what he thought was going on. Then he took Centor to see the patient. After Centor heard the patient’s story and examined him, the two men headed back to the workroom.
Centor asked about the lab findings. The blood tests looking at the function of the kidneys were a mess. In patients whose kidneys are not working, these levels vary based on how long ago their last session of dialysis was, so they are often hard to interpret. The patient was scheduled to have dialysis later that day, which meant his labs were as abnormal as they would ever be; Day hadn’t paid much attention to them.
Centor pointed to one lab: The lactate, an acid made by the body when blood flow is poor, was slightly elevated. In mesenteric ischemia, lactate levels could be high, Day responded. Centor nodded. That does support your hypothesis, he told the intern, but you also need to consider other possibilities. What else might present with abdominal pain and elevated lactate?
Just that morning, Centor had taught the residents about elevated lactate and its possible causes. Day thought for a minute, remembering the talk. Lots of disorders are known to trigger lactate production: Liver disease can, though there was no evidence of that in this patient’s labs; alcohol intoxication can, but this man didn’t drink. More unusual causes would include deficiency in a vitamin called thiamine and excessive exercise. He didn’t think thiamine deficiency would cause abdominal pain, Day told his teacher, and the patient had been too sick to exercise. He still wasn’t sure what this man had, but he could tell by the smile on his supervisor’s face that Centor was. “I think he has a thiamine deficiency,” Centor announced, pleased by his intern’s surprise.
A Case Worth Studying
Thiamine, also known as Vitamin B1, is an essential nutrient; deficiency causes a disease called beriberi. For centuries, the condition has been known to cause heart failure, which is called wet beriberi, and weakness and confusion, known as dry beriberi. In 2004, a third type, gastrointestinal beriberi, was described. A paper presented two patients, admitted to an I.C.U. with severe abdominal pain, nausea and vomiting. Both had elevated lactate. Both were found to have low thiamine and improved almost immediately when thiamine was given. Since then, other reports of GI beriberi have been published.
Thiamine, which is found in whole grains, pork, poultry, beans and nuts, is essential for the uptake of oxygen and glucose from the blood, making it a key player in many body processes. Our bodies keep limited stores; deficiency can occur after two or three weeks without the nutrient. Moreover, as a water-soluble vitamin, it can get flushed out during dialysis. It was the patient’s lack of appetite that tipped Centor off; patients with mesenteric ischemia tend to continue to feel hungry despite their pain.
Day ordered a thiamine test and started the patient on intravenous thiamine. Centor had told him that the response would be quick, so before going home for the night, Day stopped by the patient’s room. The man was still in pain. His dinner sat untouched on the table next to him. Day wondered: Could this be mesenteric ischemia after all?
The next morning, Day entered the hospital early and headed to the patient’s room first. He could see the change from the doorway: The man was wolfing down his breakfast. His pain was gone. Centor had been right. This was GI beriberi. Two weeks later, the thiamine results confirmed the diagnosis: It had been low.
The patient went home a couple of days later with a prescription for thiamine, which he was to take every day. When the pain returned some weeks later, the doctors realized that dialysis was still clearing the vitamin out of his system and instructed the patient to take the vitamin before bed so that it would have a chance to do its work before he had dialysis.
In considering the case, Centor observed that many patients who have dialysis have abdominal pain and nausea, like this man. A loss of appetite is also common among this group. Perhaps dialysis causes a thiamine deficiency more often than we realize. Centor and Day plan to study thiamine levels in dialysis patients who have chronic abdominal pain to see if they have GI beriberi.
I spoke to the patient recently. He feels great. He is eating and back to his normal life. And he is pleased that he was right: Dialysis had been the cause of his pain. He’s also proud to spur research that may help other patients who suffer with pain the way he did.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write to her at [email protected].
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