Jaundiced

by carlocmd

She was a beautiful young lady who grew up with a choledochal cyst.  After an uneventful childhood, she suddenly developed pain over the right upper abdomen, accompanied by jaundice (a yellowish discoloration of the skin), and fever.

Her pediatrician transferred her medical care to an adult gastroenterologist.  It was then that we saw her.

We talked about how her anatomy predisposes her to developing stones inside the cyst, which caused an obstruction, leading to an infection (ascending cholangitis).

She responded rather well to antibiotic treatment.  When her clinical condition improved, we broached the subject of surgery as a pathway to cure.  This was an option because she was young.  Left untreated, a choledochal cyst may again get infected.  Or a cancer may arise from it.

After a thorough discussion about the risks and benefits of surgery, she agreed to it.  It was a successful laparoscopic choledochal cyst excision with a roux-en-Y anastomosis.  If you’re not a doctor, and found that there were several words in the last sentence that you did not understand, then suffice to say that this was a very complicated surgery that the surgical team did exceedingly well.

She remained symptom free for 18 months, and happily gained several pounds.

I saw her again a few days ago in the clinic.

“Doctor,” she began, “I do not feel well.”

She described going out with friends a few days ago, eating a buffet dinner.  Eating was apparently a favorite pastime of her friends.

She was pale and jaundiced.  She was painfully passing tea-colored urine.  She was running a fever.

“Let’s check in the hospital,” I said.  “Your liver enzymes are elevated.  Your white cell count is very high.  We need to do some imaging of your abdomen.  We need to start you on antibiotics.”

“Ok,” she wearily said.

Inside, I was fearing the worst, as doctors usually do when faced with a similar scenario.  My worst fear was answering this question: Did anything go wrong with the surgery?

I spent a few fleeting moments saying a prayer over her — a prayer of healing.

Her CT scan showed nothing untoward.  Nothing but the expected changes you see in an abdomen that underwent surgery more than a year ago.

The next day, she woke up feeling better.  During my rounds, I was surprised to note that she did not appear yellow.

“My urine cleared up overnight,” she said.  “I did not have fever.  I ate and slept very well.”

Her mother chimed in, “Doctor, whatever you did, it was miraculous.  Thank you for making my daughter well.”

I must have looked funny standing there with my mouth open.  I had hardly done anything, but started organizing her care.  I was furiously running through worst-case scenarios, planning consults, asking my seniors, and trying to prevent a repeat surgery.

Then she gets better without me.

“My friends are planning my return to work with another eat-a-thon,” she said.  “Can I go eat with them?”

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