The 25-year-old man was shivering. Although the weather in Milwaukie, Ore., was cold and rainy that March evening, his apartment was too warm to explain his chills. He had been having abdominal pain for the past several weeks, but that night it was excruciating — like a knife plunged deep into his belly, sharp and burning. All the strength seemed to seep from his body, and he thought he might pass out. That’s when he asked his roommate to call 911.
The E.M.T.s were concerned by the man’s pallor and low blood pressure and took him to Kaiser Permanente Sunnyside in Clackamas, just north of the small town where he spent much of his childhood. In the E.R., initial blood tests showed that he had lost a tremendous amount of blood — nearly half the blood in his system. The man shook with cold beneath the several blankets layered over him. With trembling hands, he signed the consent forms for a transfusion to replace some of what he had lost.
Months of Bizarre Symptoms
It had been a strange winter. In January, he noticed a bulge in the left side of his abdomen while taking a shower. He pressed on it, and it disappeared, only to reappear when the pressure was released. It didn’t hurt, but it was weird and new. He got in to see a physician assistant 10 days later. The P.A. couldn’t see or feel the lump but ordered an ultrasound to look for it. And they found it: a mass the size of a large grapefruit, about six inches in diameter.
Three weeks later, before any follow-ups had been planned, the man was sent a Valentine’s Day lunch by his girlfriend. He had just started eating when he developed a stabbing pain in his abdomen. It lasted less than a minute. But every mouthful after that moment triggered the same searing pain — even water. He drove himself to a nearby urgent care center. A CT scan showed clearly that the grapefruit of fluid now filled his entire upper abdomen, compressing his stomach, pancreas and spleen. He was admitted to the hospital.
Before Dr. Amit Sadana, the gastroenterologist assigned to his care, met the patient the following day, he had already reviewed the images showing the mass. It was probably digestive enzymes leaking from the pancreas into the abdomen. The man’s body had responded by walling off the fluid with inflammatory cells, forming what is called a pseudocyst. This was usually seen after trauma — often a serious car accident in which the seatbelt was slammed against the abdomen. The man recalled an accidental hit sustained while wrestling in the snow with a friend a couple of months earlier. Sadana looked dubious — it usually took more force than that.
In any case, the doctor said, he could put a tube into the pseudocyst and let the fluid flow into the man’s stomach. That would reduce the pressure and allow the inflammatory mass to resolve. That was done the next day, and for the first time in weeks, the young man was able to eat and drink with no pain. He was sent home a day later; the plan was to let the fluid drain for three or four weeks and then remove the tube. Sadana sent the fluid to the lab to see if there was something else going on. The results showed no evidence of cancer. Pancreatic cancer is rare in someone this young, but it could cause a leak of pancreatic fluid. And it’s not a diagnosis you want to miss.
A week passed before the young man noticed a new symptom. His stools looked strangely dark, even black at times. At first he figured it was the foods he was eating. But when it persisted, he checked the internet. Black stools could be a sign of bleeding in the stomach. He called Sadana’s office. Probably this was acid irritating the site where the tube entered his stomach, the covering doctor told him, and he prescribed a strong acid reducer. This helped a little. But three nights later, on the March evening when he asked his roommate to call 911, the water in the toilet was pure black, as if filled with coffee grounds.
A Brush With Death
In the E.R. that rainy night, after two transfusions, the young man started to feel better. The bone-crushing cold relented. As the third bag of blood was trickling into his system, the E.R. doctor returned with troubling news. The blood they were giving him wasn’t showing up on their tests. His blood count had improved a little, but not nearly as much as it should. He was still bleeding somewhere, and they had to stop it.
In the morning, the doctor said, an interventional radiologist would thread a tiny catheter through his blood vessels to the likely source of the bleeding. It should take an hour, maybe less.
The young man’s sister and parents came the next morning to see him before his procedure. The family settled in the waiting room. An hour passed. Then two. Finally, nearly three hours after the procedure began, the surgeon entered the waiting room. He looked somber. They hadn’t been able to find the source of the bleeding with the catheter. The next step would be to cut him open to keep looking. It was a serious operation, and he had already lost a lot of blood. There was a very good chance that he would die during surgery, but without the surgery, death was inevitable. He needed their consent to perform the operation.
It was early afternoon when the surgeon finally reported back to the terrified family. The young man survived. The surgeons discovered that pancreatic enzymes had eaten through the massive vein that led from the spleen to the liver, causing the uncontrolled bleeding. They took out his spleen and the remnants of the pseudocyst. Samples of the pseudocyst were sent to the pathology department. He was going to be fine, he was told. And he was. He recovered quickly and was ready to move on with his life.
But everything changed a few weeks later when he got a call from Sadana. The doctor’s voice was serious, his speech halting. Did the young man have some time to talk? When he heard this, fear gripped his heart. Sadana went straight to the point. The news was bad: He had pancreatic cancer. A tiny spot was found in the fragments of the pseudocyst they removed. The spot was so small that they hadn’t been completely certain if this was really cancer or if it was just cells that appeared abnormal because of the inflammation. So they had sent the sample to Brigham and Women’s Hospital in Boston for a second opinion and received an answer the previous evening: This probably was cancer.
Treatment and Painful Waiting
The words “pancreatic cancer” took the man’s breath away. All he knew about it was that it was usually deadly. Sadana sent him for a PET scan that showed no signs that the tumor had spread, which was reassuring, but it takes the escape of only a few cells — too small to be seen with even the best imaging studies — to allow the cancer to come roaring back.
Pancreatic cancer is so deadly in part because often it causes no symptoms. The cancer just grows and spreads, and only in the later stages does it make itself felt. It was only because his cancer happened to eat into his blood vessel, causing noticeable symptoms, that was it discovered. If that hadn’t happened, chances are his disease would not have been found until it had spread. More than 95 percent of people with metastasized pancreatic cancer are dead within five years.
The patient had six months of chemotherapy to kill any escaped cells and then surgery. It became clear on the operating table that the end of his pancreas closest to the spleen was riddled with tumor. The surgeon removed the affected part plus a half inch more for safety. The man recovered from the operation easily. The surgeon was optimistic that they had gotten all of the tumor, but they would continue to monitor him to make certain that no rogue cells remained in his system. He would need frequent scans and blood tests.
Finally, after five years dotted with doctor’s visits and hours of anxious anticipation of test results, the man got the words he’d been waiting for since that bulge first appeared. It was over. The cancer had been gone for long enough that he could consider himself cured. It’s strange, but the man was lucky that he had nearly bled to death five years earlier: That terrible event actually saved his life.
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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