I received a call to see Albert, a 35-year-old man, while he was admitted to our hospital. Albert had been through a bout of hematemesis (vomiting blood) and was admitted to determine the cause. Although dramatic in nature, hematemesis is a common complaint that we gastroenterologists are trained to evaluate and treat. Most patients have garden variability problems, such as stomach ulcers or esophagitis (inflammation in the esophagus from acid reflux), which can lead to hematemesis; these problems can generally be easily managed. But not this time.
Albert told me he had been feeling bad for several months, with symptoms that seemed to come and go. He often experienced severe left back pain that came out of nowhere, hurt him for a few days and then suddenly disappeared. Sometimes he got stomach pains that would leave him double, only to make them disappear for weeks at a time. This time he had been home feeling fine when suddenly he started to have stomach cramps and nausea. He ran to the bathroom and gagged violently, eventually bringing the blood up. Of course, the episode terrified him. He called 911 and here he was.
On our first visit, Albert seemed fine. He was in the hospital for almost a day and felt like his old self. He was not taking any of the medications known to promote ulcer formation – over-the-counter anti-inflammatories such as aspirin or ibuprofen are among the most common – and denied ever having symptoms of reflux. His physical exam and blood tests were essentially normal. I suggested that we schedule an upper endoscopic exam for the next day, where we insert a flexible camera into his mouth to evaluate his esophagus, stomach, and the beginning of his small intestine, looking for a source of blood loss.
On to the ICU
When I arrived at the endoscopy lab the next day, I couldn't help but notice that Albert's name had been dropped from the patient list. I asked our receptionist what had happened and was told that Albert had been moved to intensive care; he was too unstable to undergo his endoscopic procedure. Assuming he had vomited blood again – recurring episodes of hematemesis are also common – I went to the ICU to see him, only to hear surprising news from the responsible physician: Albert had had severe hemoptysis (coughing up blood from his lungs). ), which had prompted his transfer to intensive care. He was currently on a ventilator because he was struggling to get enough oxygen himself.
This was a remarkable development; Hematemesis and hemoptysis are very different clinical entities, and usually the diseases that lead to one do not lead to the other. Could Albert have two separate disease processes taking place simultaneously?
It was possible, but seemed unlikely. I still wanted to see Albert's esophagus, stomach, and small intestine. The IC doctors also wanted to have a good look at his lungs via another form of endoscopy, the so-called bronchoscopy. We agreed that we would both do our respective examinations the next day, in the ICU, where he could be closely monitored. I also suggested a CT scan of Albert's chest, abdomen and pelvis.
That night I got a call from the radiologist on duty about the CT scan results – never a good sign. Albert was found to have a mass in his left kidney, as well as similar smaller lesions in his lungs and stomach lining. The radiologist told me this turned out to be kidney cancer that had already spread to many other places in the body.
This was clearly very disturbing and ominous news. Yet it seemed to explain Albert's symptoms and provide an unambiguous diagnosis; cancerous lesions in the stomach and lungs may bleed. I logged into my computer at home to look at the CT scan myself, and it definitely looked like the radiologist described to me. But … I also noticed that the radiologist also reported that Albert had previously undergone surgery to remove his spleen, a fact that Albert had not mentioned to me when I asked about his medical history.
By the time I got to the ICU the next day, Albert had been taken off the ventilator and was breathing on his own. He had already heard the results of his CT scan and was understandably depressed. While we were preparing to do his endoscopy and bronchoscopy, I asked him what happened to his spleen. & # 39; Oh yes, & # 39; he said, clearly recalling something he hadn't thought about for a while, 'I had a car accident in high school and my spleen ruptured and needed to be removed. I've completely forgotten. "
After Albert was sedated, I put the endoscope through his mouth. His esophagus was normal. I saw several raised red lesions in the lining of his stomach. I have performed many thousands of endoscopic procedures and seen more than my share of cancer. But these lesions did not look like cancer at all! I was cautiously optimistic. Still, the lesions were abnormal, so I dutifully took a biopsy of some of the areas of concern. The rest of his exam was normal. When the pulmonologists looked into Albert's lungs with their bronchoscope, they saw similar spots. I suggested they biopsy it too, and started to wonder if Albert was missing the spleen. Maybe we were wrong about his diagnosis.
Ventilate his spleen
The next day, the pathologist assigned to the case called me about Albert's biopsies. He wanted to make sure we had biopsy done in the right places. What he saw under his microscope did not resemble stomach or lung; it turned out to be biopsies of the spleen. Now we got somewhere.
Albert had no cancer, I concluded: he had a spleen. This is a rare condition in which tissue from a patient's own spleen migrates to other parts of the body. Trauma to the spleen – in the event of a car accident, for example – can cause spleen tissue to be released into the abdomen and / or the bloodstream. From there, the tissue can settle almost anywhere in the body. How tissue from the spleen can self-transplant is not well understood. Spleen lesions can be solitary or multiple, and we weren't the first doctors to think a patient with spleen had cancer. Sometimes the spleen lesions are completely asymptomatic, but they can cause bleeding or pain, compress other organs, and even lead to seizures if they take hold in the brain.
The treatment of spleen is to remove or take away symptomatic lesions. The pulmonologist and I repeated our respective procedures and, using devices that could cauterize tissue, burned as much of the errant spleen tissue as possible. We also removed the mass in Albert's kidney; it was also spleen tissue.
All of this was the result of a car accident that happened almost two decades ago. The spleen tissue lived in Albert all this time. Why the lung and stomach injuries decided to bleed almost simultaneously remains a mystery. Albert still has spleen implants in his body that can be treated in the future if needed, but he was over the moon with his final diagnosis. It was certainly better than metastatic cancer.
Douglas G. Adler is a professor of medicine at the University of Utah School of Medicine in Salt Lake City. The cases described in Vital Signs are real, but names and certain details have been changed.