I was recently asked to review the tragic case of a large woman who was so fearful of the " hassle" of medical intervention that -- exacerbated by the insensitive treatment by some in the
medical system -- she deteriorated and died unnecessarily. If there is one thing that is true of
many or most, fat people it is fear of seeing the doctor. As a physician I am ashamed to acknowledge that the vast majority of my colleagues attribute most medical problems in large people to weight. The more people seek
help, the more they are frustrated by the
suggestion that nothing will resolve unless
and until they lose weight. In fairness, obesity can aggravate or lead to some medical
problems, but it most certainly is not the
source of all (medical) evil.
Another dilemma that leads many large
people to avoid seeking medical help is the
embarrassment and discomfort of undergoing diagnostic testing. This is especially
true of invasive procedures such as endoscopy or biopsy procedures. "Will I fit
into the gown, break the machine or be humiliated in front of the staff?." These are all
I encourage you never to ignore abnormal symptoms or avoid important diagnostic testing. You can be accommodated
if you are aware of what is involved. In this
issue I will focus on the new technologies
of gastrointestinal diagnostics so that you
know what to expect.
Some people have a history of large (lower) bowel problems. If stool is abnormal in
consistency, shape, or timing of evacuation, or if one has varying amounts of
bleeding or dark colored feces, there might
be trouble brewing. In order to assess for
abnormal growths (polyps), inflammation
(e.g. colitis) or tumors amongst other aberrations, doctors may want to slip a long flexible hose in the rectum. A direct view is possible by means of fiber optic technology.
For the week leading up to the procedure
patients are advised not to take any iron
containing vitamins or aspirin products.
These may cause oozing, that might confuse
the outcome of the test or actually promote
bleeding during or after the procedure.
Approximately 24 hours prior to the test
resign yourself to clear fluids, lots of clear
fluids! Clear soups, juices, carbonated beverages, gelatin, tea, coffee, and even hard
sugar candies are acceptable. The key in
preparation is to clean out your bowel and
that means you will have to take a powerful laxative. Sweetened Senna is a natural plant bowel stimulant and is commonly consumed in a dark liquid form.
Also very popular is Phospho-Soda which
tastes like concentrated sea water. A small
bottle is usually taken in the morning and
then again at supper time with a glass or
two of Ginger Ale (which hides the taste
Be prepared for some nasty diarrhea
to keep you running to the bathroom every
half hour or so and watch the toilet bowl
to make sure that a very liquidy, often yellowish, fluid is all that remains in your
bowel. Too much fecal material left in the
bowel will muck up the procedure, rendering it ineffective. Once midnight comes
you should have nothing at all to eat or
drink (with the exception of a tiny gulp of water with any regular medication you are
supposed to take on a daily basis). Hide
your tooth brush and coffee cup to make
sure you don't unconsciously drink in the
THE RUBBER HOSE TREATMENT
Make sure that your doctor and the institution where your test(s) will be done are
aware of your special requirements. This
might include a chair without arms to sit
in and a hospital bed on wheels (as opposed to a thin hard stretcher), which will
serve as the berth for both the procedure
and your recovery,
Although many examining gowns are
available for purchase by a variety of outlets that supply people of size, most major institutions now carry large sizes in
stock. Regardless of whether you encounter nurses and ancillary staff that are
sensitive to your predicament, tell yourself that from this moment on nothing else
matters but your health and comfort.
Once in the procedure room you will
likely receive a short-acting sedative and
pain killer combination by intravenous
injection. Even if you have a sleep disorder like sleep apnea or a heart condition
there is little reason for worry. Midazolam
and Fentanyl are drugs whose effects are
short-acting or can be rapidly reversed, if
necessary, by an antidote. Be prepared to
lie on your side --usually the left-- and ask
to actually watch the procedure on a TV
screen. It is a very interesting diversion,
and makes for engaging conversation
(how often can one say they have seen
their insides "live" and "in action"?).
As the scope moves into the colon, air
is used to inflate the area for a better view.
The air, as well as the movement of the
scope at kinks in the bowel, may cause
cramps and the doctor will press on your abdomen or ask you to move on your
back to allow easier passage. The procedure is surprisingly brief, lasting about
fifteen minutes. Your speech may be
slurred for a half hour or so and you can
expect some bloating and cramps. Be prepared to blow gas for an hour or two as
you get rid of the air trapped during the
procedure. Roll around on your bed with
your bottom elevated and don't be shy
about letting loose with some "rippers';
you will feel relief shortly.
Some time later you may notice a bit of
blood in the stool if the doctor had to
"snip" a polyp or other sample of your
bowel during the procedure. Don't worry unless you are losing a lot of blood or
abdominal pain persists. In this case contact your doctor or return to the hospital.
"THE TUBE": SIGMOIDOSCOPY
The sigmoid is the bottom 10 to 15 inches of the bowel. Since the majority of serious tumors are found in this area, a
physician may choose to do this very brief
procedure with little preparation, right in
his or her office. Expect to be on your
hands and knees and experience a bit of
cramping for five minutes. If this position
is uncomfortable or impossible, ask your
doctor to allow you to lie on your left side.
Most physicians use a more comfortable
flexible scope (which you should insist
upon), but some still utilize an old fashioned rigid tube. Make sure that the
physician uses lots of lubrication.
Barium enema sounds like a way to dispose of a slain foe on the battle field. In
fact, it is an excellent x-ray test which outlines the nooks and crannies of the large
bowel that might be missed by the physician's scope. Preparation is very similar
to that for colonoscopy. A radiologist sticks
a tube into the rectum and inflates the
bowel with a liquid contrast medium and
air. Some cramping is to be expected, and
one can anticipate being turned in a variety of positions on the x-ray table during
the procedure. Because the urge to defecate may occur, a balloon is occasionally
inflated to keep the contrast material in
the bowel. After the first set of films are
taken you will be allowed to void. About
a half an hour later another set of x-rays
is done to see if any barium remains stuck
in abnormal pockets of the bowel.
Some cramping and pain at the rectum
may necessitate the use of an anesthetic
ointment or mild enema after the procedure.
The easiest and most comfortable of all
the procedures involves swallowing a barium milk shake to reveal many abnormalities of throat, food tube, stomach, and upper small bowel. People with heartburn,
excessive vomiting, bloody regurgitation
or unexplained anemia or weight loss are
often candidates for this procedure along
with gastroscopy. The major difficulty with
this test involves the fact that you will be
positioned on a mechanical table that tilts
your body in a variety of positions. Unfortunately, many companies still produce
tables that cannot support very large people, therefore it is important to discuss
this potential problem with the radiologist or technician who will be performing
the procedure well in advance of the appointment.
The gold standard for upper gastrointestinal examination is direct visualization with a flexible scope. After the patient
is given some mild sedation, the doctor
sprays a local anesthetic in the back of the
throat. It tastes lousy and there is often a
brief scary sensation of not being able to
feel yourself swallow. But fear not, the procedure is very safe.
Once you are lying on your left side, the
doctor puts a "bite block" mouth piece
between your lips to prevent you from accidentally clamping down on the hose.
There will be a few moments of gagging
as the tube passes down the food pipe but
most people adapt quickly to this strange
sensation. Even though you will not be
able to speak while the tube is in, there is
no need to panic: air flows freely in the
nose and mouth.
The technology has become so sophisticated that some skilled physicians can
actually introduce a tiny accessory scope
into the diminutive passages that connect
your gall bladder and pancreas to the
small bowel, enabling discovery of any
cryptic blockage or other abnormalities.
The technical term for this added procedure would take a full page to write and
explain so I will simply refer to it by its
common abbreviated name "ERCP."
Sometimes the body's waste treatment
and blood production plant (also known
as the liver) produces problems that elude
exact diagnosis by non-invasive tests. The
best way to make a definitive diagnosis involves obtaining a small chunk of liver tissue directly.
Often, sedation isn't necessary because
the procedure is very brief. However, you
should have an injection of local anesthetic in the skin overlying the liver in the
right upper quadrant of your abdomen. A
small incision is made in the anaesthetized
skin while a patient lies on his or her left
side. Expect to hold your breath for a few
seconds after exhaling to bring the liver
close to the surface. A very thick needle is
then quickly jabbed into the liver, and a
core specimen is "pickled" for examination in the laboratory.
People with bleeding tendencies have
to be cautious in undergoing the test, but
for the most part there is little pain and
no untoward problems. On rare occasion,
a little air gets trapped under the diaphragm causing shoulder tip pain.
Make sure that your physician gives you
a thorough report of test results within a
reasonable time period (sometimes up
to a week is required for special microscopic or other laboratory procedures).
Above all, never let the fear of humiliation
or embarrassment about your size or appearance deter you from taking care of
your health. Even the most ignorant and
insensitive health care professionals will
forget all about you when they look at their
own human frailties in the mirror.
As always, I welcome your letters. Be
well and enjoy life. ß