Sunday, April 23, 2017

Obstructive Jaundice

      An elderly man walks into the clinic with painless jaundice. What would you do? After the usual history and physical, I would typically get a full panel of blood work and CT scan. Depending on the results, he may need an MRI, ERCP (Endoscopic retrograde cholangiography), or EUS (Endoscopic ultrasound) with biopsy. The only problem…. we don’t have any of those fancy tests in the middle of the Highlands of Papua New Guinea. We can check a bilirubin and an ultrasound. In the hands of an inexperienced ultrasonographer (like me), we could only narrow the diagnosis to obstructive jaundice (something blocking the bile ducts). The most likely source is pancreatic cancer, but without any of the tests we’re used to having available, how do we confirm the diagnosis and determine if he is a candidate for surgical resection? Good old-fashioned abdominal exploration. 
      After extensive counseling regarding what we may find and what procedures we may do, Dr. Ben and I took the patient to the operating theater. Upon exploration, we were happy to note no evidence of metastatic disease. Then we were amazed to find a normal pancreas. We finally identified the source of his jaundice – a fibrotic, cystic abnormality where the cystic duct joined the common bile duct. It was unclear if this was a choledochal cyst or a type of Mirizzi Syndrome. Either way, we resected the gallbladder and the obstructing lesion and performed a common bile duct exploration (a procedure I only did a handful of times in residency, but for which I was well trained by Dr. Jain and Dr. Kittur). It will be more than a month before we have pathology back, but in the meantime, our patient is recovering well. 
       Yesterday during hospital evangelism time, I met his family and spent some time praying with them. When I asked how I could pray for him, his response was, “I have no complaints, I only want to thank and praise God.” 
Paul has been a pastor in a nearby town for over 30 years. He was previously told that his problem was inoperable and that he would die of his disease. Now he is praising God that the surgery was a success. I praise God too for this wonderful man and his strong faith. I thank God for the mentors he gave me in residency who prepared me for surgeries such as this. Additionally, I thank God for this hospital and the opportunity to serve the people of the Highlands who otherwise would not receive care. Finally, I thank God for the mentors he has given me here, Dr. Jim and Dr. Ben, who are teaching me how to treat both the physical and spiritual needs of our patients in a resource limited setting.

Dr. Ben and I performing laparoscopic surgery (on a different patient)

Dr. Jim sharing with patients during hospital evangelism time. 

(Note: Patient name and picture were shared with patient's permission)

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