Saturday, April 6, 2013

The Remnant

Yes, the title of this blog post is the same as the tenth book in the Left Behind series. You'll see why.

So, what has happened since the last Mom update on Monday, March 25? Dialysis went well again on Wednesday the 27th, with no clogging of the machine and no problem getting the needles into the fistula. Friday, Mach 29 was a different story, however. The machine did clog at some point which meant they had to totally clean it and throw away a bunch of stuff, which also means they threw away a lot of Mom's blood because it was in the machine when it clogged up. But the machine did fine on the restart.

Things started to get interesting after dialysis that Friday, though. Mom went to see her internist, Dr. M, about two things. One was a bump of some sort she has noticed on her stomach, below the skin in the same general area as the insertion point for the peritoneal dialysis (PD) catheter (inserted June of 2012; removed October of 2012). Mom thinks it’s either scar tissue or a hernia, and it is becoming more painful for her. The other item is a lump she discovered under a bruise on her left breast. It's probably related to the bruise, but since she had a lumpectomy on that side about 15 years ago she knows not to ignore things like that.

Dr. M sent her for a CAT scan Friday afternoon to look at the spot on her stomach. Regarding the lump on the breast, she wanted Mom to have an ultrasound and a mammogram, but Mom always goes to the same place for her mammograms, which is the doctor who did her lumpectomy and has all of her records in that area. So her primary doctor sent her for just an ultrasound on Friday (in addition to the previously mentioned CAT scan). When she got to the ultrasound place, they said they wouldn't do an ultrasound unless she had a mammogram done at the same time. So she didn't have the ultrasound.

So the weekend passes while we wonder whether or not Mom has a hernia, and if she does, will she need surgery to repair it. Monday morning arrives, and Mom calls me with some wonderful news. Her internist, Dr. M, had called her regarding the CAT scan results. It looks like there was something like a small piece of cloth left inside her when the PD catheter was removed in October. Dr. M has contacted the office of the surgeon who removed it, Dr. K, and told them he must see Mom today. So Mom has to cancel today's dialysis session so she can see Dr. K just before noon.

Here is a portion of the CAT scan results Dr. M had, which we obtained later:

A marker has been placed over the right upper quadrant, a ventral abdominal wall to indicate the region of pain. At this level, within the right rectus abdominis musculature, there is a cylindrical focus of hyperdensity (image 87 of series 2 and image 23 of series 300) which is concerning for a retained catheter fragment or retained component of cuff for catheter. In this region there is soft tissue swelling. The soft tissue swelling extends superiorly along the muscle to a more well-circumscribed fluid attenuation collection within the deep subcutaneous tissues. In total this region measures approximately 1.5 x 2.0 cm transaxial dimension and extends approximately 6 cm craniocaudal dimension. Superiorly there is a tract extending to the skin likely at the port entrance site (images 63-89 of series 2 and images 10-23 of series 300). No defect is visible within the ventral abdominal wall in this region.

Based on that paragraph it definitely sounds like there is a remnant that was left behind when the PD catheter was removed. (My alternate choice for the title of this post was "I've got you under my skin.") Since I was fortunate to have a disc with Mom's CAT scan results in my possession one morning this past week, I can show you the specific images being referred to in the results paragraph above. In both of these images, I added the arrow pointing to what I believe is the item inside Mom that isn't part of her. (Referred to as a "cylindrical focus of hyperdensity.") 

In both of these pictures the arrow is pointing to a small ellipse that is slightly brighter than the surrounding light gray area. In the first picture, the bulging gray around around the ellipse is the area of soft tissue swelling. It is quite obvious when stepping through the series of slices before and after this image. This is the bump Mom has been noticing under her skin.

Abdominal cross section. (Belly button at the top, spine at the bottom)

Slice across abdomen, parallel to spine. (Top is toward the head, bottom is toward the feet.)

So now it's Monday morning and instead of wondering whether or not Mom will have surgery to repair a hernia, we're wondering when she will be hospitalized to have this thing removed, is it infected, does she have peritonitis, etc. Since Monday was April 1, I was also wondering if this was an April Fools' joke by Mom's doctor.

After waiting the rest of the morning anxiously wondering what the rest of the day would be like, I got a call from Mom after her appointment with Dr. K. And what did he have to say about the item that was left inside her? It turns out that it's most likely a piece of felt that is used to help close up incisions. (Google "surgical felt" for more info.) He said he puts that there when he inserts PD catheters, and it's supposed to remain so scar tissue can form into it and around it, forming sort of a patch. He always leaves it in place when he removes catheters, since the scar tissue has already started to form. It doesn't get absorbed into the body, so it will be there forever or until it is removed. He has seen them become infected, but usually there are obvious signs of infection, none of which Mom has at the moment. He asked her to get a disc made with the CAT scan results and take that to his office so he could look at it, and he also asked her to call him in a week to tell him how she's doing.

Well that was anti-climactic, but I suppose it's better than needing surgery to remove a foreign body. As I mentioned, Mom was asked to pick up a disc with her CAT scan results and take it to Dr. K's office. Mom picked up the disc Monday afternoon, and things worked out such that I picked it up from her Monday night so my wife or I could take it to Dr. K's office on Tuesday. I assumed the pictures would be in some proprietary format such that I wouldn't be able to view them on my computer, but I had to try, right? Oh boy, was I pleasantly surprised. The disc had an application that is compatible with the Windows operating system, and the image viewer automatically opened when I inserted the disc. I was able to step through the images or scroll through them like a movie. I was even able to save the entire disc to my computer and run it from there, plus I made a copy of the disc before my wife took it to Dr. K's office. (I love playing amateur radiologist.)

Hopefully this area of swelling will calm down and she won't need surgery to have the surgical felt removed. At this point all we can do is wait.

Something else happened this week that would normally be a big deal but was overshadowed by the drama with the surgical felt. Since the fistula access has been going well after they gave it a week of rest, they decided to remove her permacath. That was done on Thursday, April 4. I took her to that appointment, so it was my first visit to the vascular clinic. I think it was Mom's 5th or 6th visit there to have a catheter inserted, replaced, or removed. As we were leaving and talking to the receptionist I asked Mom if she got her frequent patient card punched. One of the nurses said Mom had been there so many times they were just going to make her an employee.

So that's where things stand as of today, April 6, 2013. We'll see how this latest bit of drama unfolds.

=====Monthly Blog Status Update

Total posts: 70 (6 in March)

Total pageviews: 1310 (~290 in March)

Email subscribers: 4

Number of countries that have viewed the blog: 34

New countries that viewed the blog in March:

Hong Kong
South Korea

[11-5-13: Corrected minor typo.]

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