Surveying the side effects
Medicine is for the most part straightforward, where a few pertinent questions, a brief examination, a blood test or X-ray is all that is required to distinguish pleurisy from pneumonia, gastritis from gallstones. But when the symptoms are more puzzling, the temptation to initiate a galaxy of costly investigations is best avoided in favour of a few moments reflection on what exactly is going on – a point well illustrated by the following cautionary tale as recounted by Italian physician Caterina Bucca in The Lancet. For the past year her patient, a 65-year-old woman, had been troubled by attacks of lower abdominal pain of such severity she had ended up in casualty on several occasions. These episodes usually occurred after lunch and lasted a few hours before resolving spontaneously and without any other signs of gut disturbance such as vomiting or diarrhoea. During this time she had undergone the full gamut of tests. Nothing. There seemed no alternative other than to open her up to take a look inside but the day before her planned operation, Dr Bucca witnessed a fullblown episode soon after being given her usual blood pressure lowering medication Enalapril – whose side effects include intermittent swelling of the lining of the gut. The operation was cancelled, an alternative medication prescribed and she has not suffered an attack since. “The lesson I learnt,” writes Dr Bucca, “is that one should always take the possibility of drug side effects into account before initiating invasive diagnostic tests.” Sometimes the patients make the connection for themselves – as with a reader from North Yorkshire puzzled at the failure to regain his mobility following a knee replacement. “On leaving hospital I tried to analyse what might be the explanation,” he writes, and wondered whether the acid suppressant drug Ranitidine he took for his heartburn might be responsible. He decided to give them a rest and within a week had come on “by leaps and bounds”. Predictably, his heartburn returned so he took just one pill and promptly noticed that the muscles around his knee became tight and painful. “There could have been no clearer evidence that Ranitidine was the culprit.” His surgeon to whom he recounted his experience was for obvious reasons “extremely interested”.