THE SUNDAY TELEGRAPH – 12 December 1999
Bad bowels, excess bile and forty years of misery
AMONG THE several pitfalls the unwary doctor can tumble into, one of the most treacherous is thinking that the "obvious" diagnosis is the "correct" one. To explain. Several months ago I described the case of a middle-aged woman with recurrent bouts of severe diarrhoea. She saw a specialist who did all the usual tests to investigate the inner lining of the bowel, including a barium enema and colonosopy. They were all negative.
When, as here, there are no signs of inflammation, or a polyp or tumour to account for bowel symptoms, the "obvious" diagnosis is some abnormality of function, otherwise known as Irritable Bowel Syndrome. She was duly treated with strong anti-diarrhoeal drugs – to no effect. "It remained severely painful and unpredictable… I dared not arrange social events and holidays were out of the question." And she lost one and a half stone.
After a year of this, she sought a second opinion, and this time the specialist noted that her gall bladder (where the bile salts from the liver are stored) had been removed in the past. Perhaps, he speculated, her bowel had become over-sensitive to these bile salts. If so, Questran, which mops them up, should be helpful. "The result was instant relief," she wrote. "And I have regained my lost weight and social life."
When he read my original account of this case, Mr J. S. Dembinski, from Surrey, wondered whether it might apply to him. He, too, suffered from severe diarrhoea, but here the "obvious" cause was rather different. A barium X-ray had revealed lots of small protrusions (or diverticulae) from the lining of the lower bowel, and he had been told that his problem was caused by inflammation of these protrusions, otherwise known as diverticulitis. He had been treated with all the standard medications for this condition, again to no avail, and he remains very prone to "accidents or near-accidents". He inquired of his family doctor, whether he, too, might try Questran, in case the "correct" diagnosis in his case might also be sensitivity to bile salts. The verdict? "Questran is first-class – my diarrhoea has disappeared."
And now to the third example, this time an 85-year-old woman afflicted with severe diarrhoea for four decades – ever since she had had a stomach operation for an ulcer, involving cutting the nerves that stimulate acid secretion. This type of procedure can, for a variety of reasons, alter bowel function and prevent absorption of fat.
It was "obviously" the cause of her diarrhoea. "My bowels had gone from bad to sheer hell," she writes. "So many doctors in the past had said, ‘Sorry, this is just something you’ll have to put up with.’ "
Her new family doctor suggested she might try Questran, "just in case" bile acids might be the culprit, and within four weeks she was going to the lavatory only once a day. "Thank you," she wrote to him, "for ending 40 years of misery – and without the worry I also feel 20 years younger." So here are three "obvious" explanations for diarrhoea, none of which turned out to be correct, with severe consequences of prolonged and unnecessary suffering. How can one avoid a similar fate?
There are two general points worth noting. When it is easy to do lots of investigations – X-rays, scans, endoscopies – they are likely to turn up "abnormalities", such as arthritis of the spine or diverticulae in the bowel, which might be quite unrelated, indeed irrelevant, to what is going on.
So be warned against the danger of your doctor jumping to conclusions, and make sure that your symptoms fit those associated with any abnormality that is uncovered.
Second, the litmus test of a correct diagnosis is whether the symptoms get better with treatment. If they do not, then enquire whether there might conceivably be another, "less obvious but correct" explanation.
Copyright: Telegraph Group Ltd