She’s a frail old lady, barely five feet in height, just 30kg in weight. She looks every bit of her eighty years. And now she’s looking at me, absolutely quiet and afraid of what I may tell her. She’s been having bouts of severe abdominal pain and has been unable to eat her meals properly. She’s also had repeated attacks of pneumonia.
Her scan reveals that her foodpipe is several times the normal size with lots of food stuck inside it – in medical terms we call it grossly dilated esophagus with food residue. The diagnosis: achalasia cardia – a poorly understood condition in which the non return valve between esophagus and stomach (we call it the cardioesophageal junction, or simply “cardia”) fails to relax, causing an obstruction. As a result, the food that was supposed to nourish her body is stuck in the esophagus and is now endangering her life by slipping into her windpipe, causing repeated chest infections.
The next important step is to rule out a cancerous growth causing the block (pseudoachalasia). We plan to do an endoscopy to confirm the findings, rule out a tumour and treat the achalasia by literally blowing the blocked area open with a balloon-like device: an effective and well accepted procedure.
But she won’t have any of it: her family members inform me that she is absolutely unwilling to undergo the treatment. She is very afraid.
As she stares at me with teary eyes, I explain that she won’t have to stay more than a few hours in the hospital and can go home by evening. And repeat that classic line that convinces almost no one, “don’t worry, you won’t feel a thing”. Right, I can almost hear her say from behind the mask.
Somehow, she agrees for the endoscopy and gets hospitalised for the procedure. Under a short general anaesthesia, I manoeuvre an endoscope down her throat, only to be confronted by huge food balls stuck in her esophagus. I work my way down to the cardia and am relieved to find that there is no tumour. But her stomach is swollen and has plenty of acute erosions – the cause of her abdominal pain. Achalasia is a painless condition but an uncomfortable and dangerous one.
I pass a guide wire through the scope and withdraw the scope out of the body, leaving the wire in the stomach and comfortably across the cardia. Next, I pass a sophisticated device called an endoscopic balloon dilator over the wire and place it halfway in the esophagus and halfway in the stomach, confirming it’s position with a live x ray beam using a machine popularly known as “c-arm”.
The next step is to inflate the balloon at a specific pressure to dilate the cardia. This is quite a delicate task: too less inflation means a failed procedure and too much can tear the esophagus, causing torrential bleeding or a life threatening perforation.
I inflate and deflate the balloon twice in its deployed position, just to be sure. I remove the wire and the balloon and pass my scope in again to check if all is well, and am pleased to note that there are no local complications. The food stuck in the esophagus has already started passing into the stomach – a sign of success.
She is shifted back to her room shortly thereafter. By late afternoon, her daughter calls me up and informs me that she is feeling fine and wants to go home. I have already given instructions for her to be discharged by evening. I don’t expect to find her still in the hospital when I reach for my evening rounds, but there she is, beaming at me. She didn’t feel a thing and has no pain.
I ask her what she had for lunch. She replies, “toast and tea”. Then clasps my hand and adds softly, “for the first time in several months”.
Everything is suddenly worth it all over again. The decades of hard work becoming a doctor. The decades of hard work to make your reputation as someone your patients can trust. The abuses people hurl on us on social media. The names politicians call us.
It’s still not all clear yet. She will need another endoscopy after a few months to confirm that the achalasia hasn’t returned. As she steps into my cabin a couple of weeks later, she’s visibly looking more active and is positively chirpy. Who would think someone can be so happy just to be able to eat chapattis and vegetables again. She’s got me a little gift.
It’s a very sweet gesture from a lovely person. But the sweetest gift one can ever give a doctor is that one line uttered with an indescribably beautiful smile and a clasp of grateful hands: “For the first time in several months.”