CHAPTER 216: 216 LIU BANXIA’S BOLD CONJECTURE

(Thanks to my friend Chen Si for the reward and encouragement; thanks to Huayu Luofengye, Xueyu Molong, Laojia Xiaomugong, Jijing Xiaowei, and Book Friend 20171213215219169 for the monthly ticket encouragement.)

"Did you all see the examination process clearly just now?" Liu Banxia asked.

Everyone nodded in unison.

"So what’s your diagnosis?" Liu Banxia continued.

"It’s appendicitis; the patient has rebound pain at McBurney’s point," Xu Yino quickly responded.

"I don’t think so. Although Teacher Liu also scanned the appendix just now, he later scanned the gallbladder and kidneys. Isn’t it cholecystitis?" Huang Bo, who was in the same group, voiced his dissent.

"What about the rest of you? Any thoughts? Feel free to speak up, because at this point, even I have no idea what the patient’s exact ailment is," Liu Banxia said.

His words left everyone speechless. How could it be? How could Teacher Liu not know what disease the patient had? Was he joking?

"I really don’t know. There’s no advantage for me in deceiving you," Liu Banxia shrugged.

"Because during the initial examination, two entirely different signs emerged: the abdominal muscles were slightly tense, and there was rebound pain at McBurney’s point, suggesting possible appendicitis. However, the ultrasound examination revealed that the appendix was perfectly healthy."

"I also scanned the kidneys and gallbladder. Although some stones were found, there’s no sign of obstruction in the kidneys. As for the gallbladder, I performed percussion, and the patient had no reaction."

"Have you ever seen acute appendicitis with a healthy appendix? Or acute cholecystitis causing lower right abdominal pain? Anyway, I haven’t come across such cases, so let’s discuss."

"Here’s another friendly tip: the patient will undergo an emergency CT scan, so the results will be out very soon. I will definitely commend whoever among you comes up with a reasonable judgment within this timeframe."

"And if patients with acute abdominal pain aren’t treated in time, the mortality rate can be quite high. So, today, a life hangs in the balance for both you and me. Therefore, you must be quick, yet cautious."

His simple statement brought tremendous pressure to them all. Their previously relaxed faces instantly tightened.

They weren’t novices and knew Liu Banxia was absolutely correct. If the cause of the abdominal pain couldn’t be accurately diagnosed, the only recourse would be an exploratory laparotomy or laparoscopy.

But those procedures brought risks of their own.

Surgery is inherently risky, and such procedures inherently harm the patient. If the cause of the disease still isn’t identified after investigation, medical disputes may arise.

"President Liu, don’t you think you’re putting too much pressure on them?" Xu Hui asked as he approached.

"Without pressure, there’s no motivation. I’m simply helping them get into the mindset quicker. You heard my question just now, do you have any thoughts?" Liu Banxia asked.

Xu Hui shook his head. "I can’t make a determination either. Let’s wait for the CT results. For now, the most likely cause seems to be pain from cholecystitis, though perhaps there was some deviation in the nerve conduction."

"Just like many acute appendicitis patients, the initial pain originates around the navel and gradually shifts to McBurney’s point. Crossed nerves on the abdominal wall are rare, but they do occur."

"But even if there is a deviation in conduction, for acute cholecystitis, that deviation would be quite far, wouldn’t it?" Liu Banxia said with a wry smile.

"Right now, I feel that neither the appendix nor the gallbladder is the problem. The issue could well be with another organ. What if there’s something wrong with the colon?"

"Let’s wait for the CT results," Xu Hui said. "You didn’t see any suspicious areas when you were scanning just now, did you? If it comes to that, we might have to perform a barium meal or an endoscopy. However, under normal circumstances, it’s indeed very troubling if the CT scan doesn’t reveal anything."

Liu Banxia nodded. While instrument inspections are more precise, they can’t identify all diseases. Because instrument inspections have precision limits, they can’t detect anything beyond their effective range.

The best approach is to conduct multiple, different tests for cross-confirmation.

Unfortunately, this often leads to misunderstandings from the patients, who feel they are being fleeced, as every additional test means an additional charge for the hospital.

"So how is your discussion going?" Liu Banxia rejoined the interns.

The answer he received was the same as the conclusion from his earlier discussion with Xu Hui: they had to wait for the CT results before making a decision. The data currently available wasn’t substantial enough for a diagnosis.

However, the patient’s abdominal pain and fever did indicate the presence of inflammation within the abdominal cavity.

In the distance, Qu Feng recorded their discussion. She wasn’t clear about the specifics, but she knew that Liu Banxia and his team had encountered a difficult case—in other words, a complex and challenging medical condition.

The waiting period was somewhat agonizing since the patient’s condition was still unknown. Moreover, this unknown element was accompanied by danger.

The CT results came back, indicating that only the patient’s gallbladder showed some issues. No problems were found in the other organs.

"How are you feeling now?" Liu Banxia asked the patient, who had returned.

"The pain’s still there, and now I feel a bit nauseous. Not sure if it’s because of the pain," the patient said with difficulty.

"So now you’re experiencing nausea? Did you feel this when the pain started?" Liu Banxia asked, furrowing his brows.

"The nausea started just after the CT scan. When the pain hit me yesterday, all I felt was pain," the patient replied.

The patient’s complexion had deteriorated significantly. The pained expression on his face was a testament to the prolonged suffering.

A sudden chill ran through my heart as I contemplated a particularly distressing scenario—the patient might be suffering from a gallbladder perforation due to cholecystitis. Liu Banxia thought.

Because the perforation is so small, neither the ultrasound nor the CT scan could detect it. If the leaking bile had shifted and flowed to the area of the appendix, could this explain the lower right abdominal pain?

Referred pain. This fact kept reminding him that today’s case was anything but straightforward.

Now that the patient was also experiencing nausea, the symptoms were very consistent with acute cholecystitis. Plus, the blood test results showed slightly elevated white blood cell counts.

To confirm if it was acute cholecystitis, Liu Banxia moved to the patient’s right side again, pressing his left thumb on the abdominal wall at the intersection of the right rectus abdominis muscle and the costal margin.

"Take a deep breath," Liu Banxia instructed.

Following Liu Banxia’s instruction, the patient took a deep breath, leaving Liu Banxia and his colleagues momentarily stunned.

What Liu Banxia had just performed was the Murphy’s sign test. Similar to how rebound tenderness at McBurney’s point is key for diagnosing appendicitis, Murphy’s sign is a specific rapid test for acute cholecystitis.

During inspiration, if the inflamed gallbladder moves downward and touches the examiner’s pressing thumb, it triggers pain. Sharp pain strong enough to interrupt respiration indicates a positive Murphy’s sign.

Yet, the patient continued to breathe smoothly, inhaling and exhaling fully with no reaction.

This threw them back into uncertainty, as the signs were still not entirely clear. The only evidence supporting a diagnosis of acute cholecystitis was conjecture, but many findings negated that guess, not least of all the negative Murphy’s sign.

"Doctor Xu, I was thinking," Liu Banxia said, turning to Xu Hui. "Could a perforated gallbladder not cause significant inflammation, yet the leaking bile still result in right lower abdominal pain?"

"It’s a possibility, but it’s not entirely certain," replied Xu Hui, knitting his brow in thought.

"If there is a perforation, even a very small one, the inflammatory reaction should be intense. Unless it was caused by an external factor, such as a puncture injury."

"And this patient’s pain has been going on for quite a while, right? Over this period, if there really was a perforation and leakage, how much bile would have leaked out by now? The abdominal muscles should be even more tense."

"It’s really odd. All the conclusions seem to contradict each other. I’m also inclined to think that the gallbladder isn’t the cause, but I can’t think of any other possibilities."

"Did you do anything in particular before the pain began? Did it start after dinner?" Liu Banxia asked the patient again.

"I didn’t do anything special. After dinner, I joined everyone for some square dancing. The pain didn’t start immediately when I got home. It began after I rested on the couch for a while," replied the patient, his expression worsening.

Liu Banxia closed his eyes and took a deep breath to calm himself, trying to piece together all the information the patient had provided.

The CT scan indicated a possible issue with the internal organs, particularly the gallbladder. But the physical examination results showed no symptoms of cholecystitis. Even the gallbladder perforation I dared to surmise doesn’t fit the patient’s current condition.

If it wasn’t pain induced by an internal organ, then what was causing it?

"Doctor, it’s hurting up here now too," the patient cried out while Liu Banxia was deep in thought.

Liu Banxia quickly pressed the area, and this time the patient’s pain was significantly more pronounced. He performed another Murphy’s sign test, which, defying all logic, was now positive.

"Doctor Xu, have you encountered cases with such a delayed manifestation?" Liu Banxia asked Xu Hui.

Xu Hui shook his head. "I haven’t encountered any in my medical practice. Do you think we should consult another doctor?"

Liu Banxia didn’t respond. Instead, he re-examined the patient’s abdomen. Now, pressing anywhere on the right side of the patient’s abdomen elicited a pain response. This change suggested the patient’s condition had worsened.

As he contemplated the matter, an idea flashed across Liu Banxia’s mind.

"Brother Xu, could it be primary omentitis?" Liu Banxia suggested. "Could the spreading inflammation have caused the painful area to expand? Because it seems the patient’s pain isn’t shifting; it’s expanding."

"Also, the current tension in the patient’s abdominal muscles is the same as when they first came in, without additional rigidity. With the pain spreading like this, it seems only omentitis fits the bill."

Xu Hui was taken aback. "Damn, it’s very possible the omentum is the problem. If it is the omentum, conventional instrument examinations simply can’t detect it."

Upon hearing Liu Banxia and Xu Hui’s conjecture, Liang Xiaolin and their colleagues were all invigorated. Although this was just Liu Banxia’s daring speculation, it seemed quite plausible.