On call last night my first patient was a man who presented with features of a bowel obstruction and anemia (hemoglobin of 7...normal is >12) However, the confounding factor was that he was newly diagnosed with HIV... or he knew and didn't want to tell us. The cat was out of the bag when our testing came back positive. We test all patients here as the positivity rate can be up to 30%. I could tell from his body habitus that he was NOT the healthiest man in the village...in fact he was skin and bones. When I examined him, his abdominal exam was not tender, just distended. The abdominal XRAY showed dilated bowel and a little fluid, but not much else. His vitals were stable and he wasn't septic looking. (no fever, tachycardia, etc.) His WBC was normal. In Kenya, bowel obstruction equals OR...but I didn't want to rush an ill looking, wasted, anemic, end stage HIV patient to the OR. So, we watched him for half a day and ran some more tests, and waited for blood. Later that evening we eventually made it into the OR where we found....an entire abdomen filled with stool and gas. Yummy. Not what I was expecting. Enlarged lymph nodes dominated his abdominal cavity, (along with the stool) distorted his anatomy, and filled his retroperitoneum (the space behind your belly). This was consistent with lymphoma that had caused his entire sigmoid colon to fall apart, spilling stool all through his belly. In a normal person, he would have been extremely tender on his exam, septic, and with a high heart rate. In retrospect, he had so much free air on his abdominal XRAY that you couldn't even see it...because it took up his entire abdomen. Because of his HIV (which destroys your immune system) he couldn't generate an immune response to the infection, and therefore the magnitude of his illness was hidden. I told the resident that I would buy her lunch if she could keep him alive over night. I owe her lunch, as he is still hanging in there. Nice job Liz.
Just after we finished with that case, the residents took me to see two Maasai babies in the nursery that had come in that evening. One baby was a boy who had been born that morning (a home birth of course) and the other was a 2 day old girl. These newborns had arrived to Tenwek at the same time...in fact, they rode in the same car. I'm sure they would have been brought in on a motor bike, but the journey was too long. The story that the resident told me went something like this.
"The mother of the baby girl born yesterday noticed that her baby hadn't pooped since she was born and that her stomach was getting distended. When momma looked at the anus, she noticed that there wasn't one. She told her sister in law (who had just given birth that morning to a baby boy) of her findings and this prompted her to check out her son's backside. Well, what do you know...no anus on him either."
Newborn cousins sharing the same problem at the same time...imperforate anus. This prompted me to wonder how you say in Maasai, "Does your baby have an anus? No? Mine neither. We better go to Tenwek to get our babies a place to poop out of."
We stabilized the babies overnight and today I did diverting colostomies for both Maasai cousins. For the pediatricians out there, the girl had an associated cloaca, and the boy had no evidence of a rectouretheral fistula (a more rare form). We will fix the lack of anus once the babies get bigger (6 months to a year.) Truthfully, I'll be waiting for a visiting pediatric surgeon to teach me how to fix a cloaca.
We will see what tomorrow brings.
XRAY of one of the babies showing lots of gas in the abdomen, and no gas going to the anus (where the coin is taped to his butt.
Baby boy parts and no anus.
Making a colostomy
Finished product...for now.
Another interesting case of a 4 year old with a brain abscess that we drained. She initially couldn't mover her left arm and leg, but is now slowly regaining function. Not sure why she got the infection in the first place. All too common story.
Everyday brings new challenges and more education. It's good to be back to work.
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