Common Chronic Disease Patterns in Arabian Gulf, Saudi Arabia & YemenDr. O. P. Kapoor
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How the Investigations Keep
the Abdominal Symptoms "going on"!

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One fact is certain that, the Arabs are fond of investigations— more so invasive ones—any test where slight pain or discomfort is involved is appreciated (except collection of too much blood which they dislike).

But all the modern investigations are "Bi-edged" weapons. Although they do relieve the anxiety, suspicion and tension of Arab patients (which is half the battle won), there are problems created by the reports of these investigations and make many patients more neurotic and keep the symptoms "going". This is less common in poor and middle class Indian patients who, most of the times cannot afford the cost of modern investigations and are being treated according to clinical impressions only.

The following are the examples-

Stool Report—Often the stool report shows presence of occult blood. In private practice this is one of the most misguiding investigations. Without going into the detail of the reasons for this, it suffices to say that a single report like this, on an average diet, has more often no meaning. But the amount of psychological trauma it gives the Arab patient can be appreciated from the fact that when the patient now visits the next specialist, he complains of presence of "blood in the stool" as one of the presenting symptoms! The poor specialist, with all the language difficulties, cannot find a cause for it even after X-rays, endoscopy etc. are done.

At other times the mention of "muscle fibres, unabsorbed starch fat" etc. gives the patient the impression that he has indigestion.

Often a stool culture examination is asked for by the specialists. A positive culture report showing E. Coli with a list of ten drugs showing antibiotic sensitivity would make even a normal person neurotic! It is then very difficult to convince these patients that it is a normal flora of the G.l. tract.

Barium meal examination of the G.l. tract—Duodenitis is a very common report presented to these patients. In order to disprove or to confirm this report, I often ask for endoscopy which, on majority of the occasions does not tally with the X-ray report. Even when chronic duodenal ulcer is reported on a Barium meal X-ray examination, on majority of the occasions, there are no parallel findings on endoscopy.

Then there are radiologists who still diagnose "Gastritis" depending on the findings of the rugosity of mucosal folds. Though endoscopy is a superior investigation to diagnose this entity, such X-ray reports do increase neurosis and anxiety of the patients and keep the symptoms going.

Incomplete filling or non-visualisation of an appendix is another report frequently sent by a radiologist. So often these are normal findings. The local tenderness elicited by the radiologist is that of the caecum. The patient already having a "surgical mind" looks forward to have the appendix removed. The physician is afraid that the operation will not solve the problem. A couple of weeks or months after the appendix operation, some patients will come back with severe exacerbation of symptoms. In the meantime, it is a pleasure to watch them after the operation. They are very happy and in a very good shape of mind (at least temporariIy) .

Oral cholecystography—Difficulties encountered in clinical correlation of gall stones and its symptoms are well known all over the world. Many radiologists report chronic non-calculus cholecystitis because of the poor contraction after a fatty meal (consisting of eggs, bread, butter and milk). The situation is made more complex by the patient saying that he was miserable after that "meal" which the radioloaist administered. After seeing the report he is thus impressed that his gall bladder ("Marrara") is affected.

A lot of these patients have "fat" dyspepsia because of irritable bowel and peptic ulcer syndromes. Many of them continue to suffer from these complaints even after gall bladder has been removed .

Sonography of gall bladder—Many sonographers are making matters difficult for the Arab patient who brings the report of sand ("Raman") in the gall bladder. It is then difficult to convince the patient, that it is not responsible for his symptoms. Many of them have had attacks of renal colic in the past, when their X-rays were normal and the doctors had told them that the attacks were due to sand ("Raman"). Being familiar with this word, they now become strongly suspicious that the gall bladder is the culprit of their disease!

Liver Scan—Liver imaging has created a few problems in Arab population. First of all a "Hepatomegaly", which is sometimes reported, has little significance when clinically the liver is not palpable. We know that unless mathematical calculations are used, the gross size of the liver seen on liver scan is erroneous and misguiding. Unfortunately, the moment these patients experience pain in the right hypochondrium, they blame the liver ("Kaibid") as the cause of pain. I have also observed that with the above symptoms and the report, a number of clinicians prescribe antiamoebic drugs with the diagnosis of Amoebic hepatitis !

In my monograph on "Amoebic liver abscess" I have explained that possibly this entity does not exist. Absence of a positive serological test for amoebiasis in high dilution would be in favour of this hepatomegaly being non-amoebic.

Occasionally whenever I discover a slight hepatomegaly (except in those having sickle cell disease or Thalassaemia) in an Arab, he is usually a merchant and has an alcoholic fatty liver. (Hepatomegaly is surprisingly a rare finding in Yemenis in spite of past history of Bilharziasis) g.G.T. levels which are diagnostic of the "alcoholic liver" are often found raised. I have not tried to differentiate 'alcoholic fatty liver' from 'alcoholic hepatitis'. Liver biopsy has not been done, as it is not liked especially by Bahraini population. Soon NMR imaging will be available in Bombay and it would help to pick up a fatty liver without a biopsy. Till that time, I use my clinical knowledge that patients of "alcoholic hepatitis" are "sick" patients with grossly abnormal liver function tests, while "alcoholic liver" is an incidental finding.

More problems arise when a cold area is spotted on a liver scan. Two things should be kept in mind. As more and more "routine" liver scans are ordered by clinicians on Arab population, more and more cases of benign lesions of non-clinical importance .are likely to be encountered. "Ghost" cold areas are seen in at least ten per cent of patients. The isotope imaging report is not the 'last' word. It is not safe to investigate all such patients by liver biopsy. Till routine CT Scan or NMR imaging are available, a good principle would be—if imaging report shows a cold area, then study the liver function tests—specially serum alkaline phosphatase. When these are absolutely normal, do not ask for liver biopsy.

Once a cold area is detected, sonography is the next investigation to exclude a cyst. Although I have seen an occasional Arab patient having hydatid cyst of the liver, it is not a common disease. In patients where on sonography, the mass is echogenic, if possible CT scan or NMR imaging should be done, the former being already available in Bombay.

I have seen by now dozens of Arabs having a cold area on liver scan with normal liver function tests, the area not being sonolucent on sonography and in whom laparoscopy report has been normal. Although I would call these cold areas as "ghost areas", it is possible that some of them have hemangiomas of the liver or bilharzia granulomas missed by sonography and laparoscopy. In future the investigation of CT Scan is going to throw more light on such cases.

The problem in Yemem patients is that many of them have suffered from Bilharziasis in the past. Some of them have granulomatous lesions due to the same. In few such patients, we have done liver biopsy and seen bilharzia granulomas. However, this is not a common disease, especially if the patient is a non-Yemeni.

Many a case of over-diagnosis of liver disease can be avoided, if the complaints, physical signs and the isotope scan report are all "put together".

Oesophagogastroduodenoscopy—As there are many Arab patients who feel satisfied after this investigation, so are there others who develop a severe neurosis after reading the reports of "erosions" and "congestion". Only an occasional Arab with symptoms of "peptic ulcer syndrome" has a chronic duodenal ulcer which is seen on endoscopy. This is not so in more than five per cent of such cases! Many of them have slight areas of congestion in stomach or duodenum or an occasional erosion or two,—all these findings certainly could not have caused symptoms of peptic ulcer syndrome of few years duration! And then there will be difference of opinion between different endoscopists! And again, many of these patients are on drugs which could have caused these erosions!

Many Arabs develop more symptoms of anxiety and want "endoscopy" to be repeated to know whether the "erosions" ("garhaa") have healed. An Arab patient is very scared of having a "Garhaa" (ulcer), but he does not get upset if he is told that his symptoms are due to inflammation ("Altehaab") or hyperacidity syndrome ("Homodaa") and not an ulcer!

Sigmoidoscopy is one of the investigations which has to be asked for in a number of patients who complain of symptoms of irritable bowel syndrome. And of course in more than 95 per cent of cases, it is normal. Very rarely, bilharzia or other diseases proved by a colonic biopsy would be encountered. But on most of the occasions, an Arab patient who is so satisfied after this investigation, would look at the part of the report in which you are least interested. And that is the mention of "early Piles" or "Minimal Piles"!! There starts your headache!!

 

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