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Medical diagnosis isn't a perfectly exact process, and is strongly driven by prior probabilities. If you present to the ER with pain in the upper right abdomen
by sveiss 4y ago
Medical diagnosis isn't a perfectly exact process, and is strongly driven by prior probabilities.
If you present to the ER with pain in the upper right abdomen, with blood test results showing raised liver enzymes, meeting some or most of the "fair/fat/female/fertile/forty" risk factor mnemonic criteria, and have imaging that doesn't completely rule out gallstones, then the overwhelming probability is that you're suffering from gallstones, and that's the diagnosis you'll be given.
Since the gold standard treatment for symptomatic gallstones is gallbladder removal, that's likely what will happen. Under normal circumstances, far more aggregate patient harm would be caused by trying to make the diagnosis more certain than is caused to the few patients who undergo surgery but don't actually have gallbladder disease.
Unfortunately, these aren't normal circumstances: it appears that the liver damage produced by this lentil product produces similar pain and blood test results to gallstones, the risk factors for gallstones are very common in the US population, and it's actually quite hard to completely rule out gallstones by imaging. So more patients than expected are currently being harmed with unnecessary surgery.
It's important that this be publicized, so that doctors making these diagnoses know that asking "did you eat anything from Daily Harvest" is now a diagnostically relevant question when considering upper abdomen pain, and the answer may change those prior probabilities drastically.
- Engineering-MD 4y agoAt least in the UK, this if not the case. The number of people presenting with RUQ which is not caused by gallstones (even in the presence of deranged liver function tests in an obstructive pattern and with risk factors) is significant. This means USS +/- MRCP is used to diagnose the gallstones before considering surgery. Indeed, in most trusts (hospital areas) funding for surgery can only be acquired with imaging evidence for gallstones due to this issue. Furthermore, approximately 30% of cases of assumed biliary colic do not improve with cholecystectomy, as the pain has been falsely attributed to the stones or gallbladder. Sometimes it’s actually sphincter of Oddi Dysfunction, which is difficult to prove and treat.
- Calavar 4y agoI am an internist in the US. It's the same here. I would never call the surgeon without an image. They would (rightly) refuse to operate without visual confirmation of gallbladder inflammation and/or a stone. Usually I wouldn't get an MRCP unless there was specific reason to suspect cholangitis. My first test would be ultrasound for right upper quadrant pain or CT for poorly localized pain.
- Engineering-MD 4y agoIt’s the same here. I mention MRCP as choledocholithiasis/cholangitis secondary to stones would be an indication for cholecystectomy
- sveiss 4y agoYup, I'm wrong in the specifics here. I think I'm conflating the stats for negative appendectomy and the willingness to go to surgery without positive imaging in that setting with the ~30% of cholecystectomy cases that don't improve with surgery. (Of course, the risk/benefits of missing an infected appendix vs taking out a healthy one are very different to gallbladders with stones.) That said, I do think the underlying point I'm trying to make is still accurate. Most of the audience here are software engineers. Unlike debugging software, where we can often eliminate possibilities with 100% accuracy through objective tests and come to a conclusion with complete confidence, or at least run experiments with no consequences, humans are messy, poorly observable, and heterogeneous. A relevant history helps speed things up when trying to fix software, but it can be vital when fixing humans. Given the rate of asymptomatic gallstones visible to imaging in the population, if these lentils are causing acute liver injury, I think it's reasonable to expect that some people have had unnecessary surgery as a result. If you knew your patient had eaten these lentils, would you still send to surgery with positive imaging, or wait a few days and see if things improved?