Chapter 17
Now I finally know what disease this is.
Kidney stones result from excessive calcium excretion caused by abnormal parathyroid hormone levels, while gastritis results from abnormalities in the stomach's endocrine glands.
Alice blinked blankly.
“The nephrologist just called it kidney stones and pyelonephritis. They said there was no need to consider some rare disease...”
I shook my head.
Pyelonephritis is an infection of the kidneys. This patient does have it. It’s just not the main problem.
Some doctors don’t like complicated explanations, but the human body is complicated.
“There is pyelonephritis, yes. But there must be an underlying cause behind both the kidney disease and the recurrent gastritis. Probably a genetic disorder.”
“Is there a genetic disorder like that?”
“Multiple endocrine neoplasia.”
“Huh...?”
“It’s called Wermer syndrome. It’s a disease that causes endocrine tumors to develop in multiple organs.”
Alice blinked blankly.
“That kind of disease exists? Gross.”
“A gastrinoma causes excessive stomach acid secretion, leading to recurrent gastritis. Excess parathyroid hormone secretion leads to calcium in the urine-”
“Wait.”
Alice stopped me.
She didn’t seem to understand what I meant. Then again, there were no genetic tests in the ’70s. It was only natural she wouldn’t know what it was.
“An endocrine tumor growing in the stomach stimulates stomach acid secretion and causes gastritis?”
“Yes.”
“What does parathyroid hormone have to do with it?”
“Parathyroid hormone increases calcium excretion, right? If too much calcium passes into the urine, it forms kidney stones.”
“Kidney stones... So. The stones in the patient’s kidneys caused the pyelonephritis?”
She seemed to be slowly understanding now.
I nodded.
Alice was still scribbling something in her notebook, looking serious.
Hadn’t we called them nonspecific symptoms?
It wasn’t obvious at a glance.
Fever, mild headaches, back pain, gastritis, abdominal pain. With so many symptoms mixed together, you could never see the connection unless you sorted out the sequence.
“That’s right.”
“No, seriously, how did you even think of this?”
Alice flipped through an internal medicine textbook and eventually found a mention of Wermer syndrome.
It was exactly as I’d described.
Abnormal parathyroid hormone levels and abnormal stomach acid secretion. In rare cases, the pituitary gland could also be affected.
I stood up.
I had to hurry and confirm the diagnosis. I remembered what came next.
***
The next diagnostic step was an upper endoscopy.
There was no reason to delay treatment. There were too many problems to address, and too many symptoms.
We had to start right away.
I was putting on gloves as I prepared for the endoscopy when Professor Rich, whom I’d asked to come, hurried into the endoscopy room.
The dean was an endocrinologist. And the root cause of this patient’s illness was an endocrine disorder.
“You’re here.”
“What on earth is going on?”
“I suspect the patient has Wermer syndrome. I was going to do an upper endoscopy, but there wasn’t a gastroenterologist available, so I was going to do it myself.”
Professor Rich nodded.
“Wait, what’s Wermer syndrome?”
“You know, that strange genetic disease where endocrine tumors develop all over the body.”
“Oh, that.”
Professor Rich nodded as if he remembered. Even in the 1970s, Wermer syndrome was known in academic circles.
Genetic testing and other limitations would have made diagnosis and treatment difficult, but the disease itself had already been defined.
“What does an endoscopy have to do with it?”
“If the endoscopy shows multiple stomach ulcers or lesions, and we confirm kidney stones, we can diagnose Wermer syndrome.”
“It’s uncanny... Why do strange diseases always show up whenever you come around?”
I didn’t answer that.
Maybe these strange diseases went undiscovered because no one like me, someone who digs deep, was there to find them.
We finished preparing the endoscopy equipment.
Everything was ready.
“Please bring the patient in!”
Our patient cautiously entered the endoscopy room and lay down on the bed. They still seemed to be in decent condition, though they did look uncomfortable.
I prepared a sedative in a syringe.
“You’ll be getting a sedative.”
The patient nodded, and I injected midazolam into their IV line.
Professor Rich adjusted the monitor that would display the endoscopy. The patient closed their eyes.
“Will it hurt?”
“No.”
“They didn’t do an endoscopy when I had gastritis last time, but why are you doing one this time-”
As the patient was speaking, the midazolam reached their bloodstream. They passed out before they even had time to feel sleepy.
Professor Rich shrugged.
“Well... We’ll explain it to the patient again when they wake up. Let’s start the endoscopy.”
I nodded.
***
I slowly pushed the end of the endoscope into the patient’s mouth. So far, so good.
The muscles of the esophagus appeared on the screen.
The endoscopic image on the monitor was black and white. Well, the monitor itself was black and white, so there was no helping that. I hadn’t even thought of that.
I saw a small sore where the stomach and esophagus met. There was a little reflux.
“Can we see properly in black and white?”
“No. You have to look directly through the eyepiece.”
Professor Rich was right.
Besides the image on the monitor, the endoscope had a function that let you look directly through the eyepiece via its optical fibers.
Interesting... This wasn’t black and white.
Because I was looking at it with my naked eye.
I kept advancing the endoscope while watching the black-and-white monitor, and its tip reached the stomach.
Professor Rich looked at me.
“By the way, where did you learn to do endoscopies?”
“I’ve done it a few times since I was an undergrad.”
It wasn’t a lie.
Professor Rich furrowed his brow, looking intrigued. Of course, I could do it because I’d performed endoscopies many times before I was reborn in America.
“You surprise me every time. It seems way too early for you to be doing endoscopies properly, especially when you’ve barely done any.”
“Thank you.”
I kept advancing the endoscope, and one gastric ulcer after another came into view on the black-and-white screen. There were a lot of them.
“I found them.”
“You really did... You were right.”
That confirmed the diagnosis of Wermer syndrome.
Here’s how it works. When an endocrine tumor grows in the stomach, it produces gastrin, which stimulates stomach acid secretion.
The stomach acid then causes gastric ulcers.
Professor Rich took hold of the endoscope himself.
“Was abdominal pain one of the symptoms?”
“Yes. But the patient’s had it for so long that they seem to have gotten used to it.”
Professor Rich nodded gravely, sinking into deep thought.
“If it weren’t for you, this could have gone very badly again. Wermer syndrome... Who else could have found it?”
“You’re too kind.”
There were more ulcers than I’d expected. They must have been terribly uncomfortable. Still, wouldn’t antacids or acid suppressants help treat them?
What mattered most, after all, was the symptoms.
It must have made daily life difficult at this point. At least the ulcers could be treated with medication, which was a relief...
The endoscopy went smoothly.
I finished cleaning up the endoscopy room and went back to the patient’s bed. They were lying still, staring into space.
Mumbling something.
“Are you feeling a little better now?”
“I’m gonna be the Pirate King...”
Had the sedative not worn off yet?
They still seemed to be recovering. I shook them awake. Nothing was wrong, was there?
“Huh? Oh. My head hurts a little...”
I nodded slowly.
“We found several gastric ulcers during the endoscopy. Medication should take care of them, and we now have a diagnosis.”
“We do?”
“I think you have Wermer syndrome. It’s a disease that causes abnormalities in several hormones. In your case, it’s caused kidney stones and gastritis.”
The patient frowned this time.
“Can it be cured?”
“We can treat it until your symptoms are nearly gone. But it’s not the kind of illness we can completely cure or make disappear.”
Since it’s genetic, there’s no neat solution. It can only be managed.
“Still, we finally have an answer. I’ve had those problems my whole life, and only now have we found the underlying cause...”
This was something you sometimes saw in patients with chronic illnesses. Patients were people too, and sooner or later they grew tired.
How many doctors had seen this patient so far? How many had looked at them, failed to find the cause, and simply repeated that they didn’t know?
It couldn’t have been just one or two.
Being able to give a name to an unknown illness that had tormented them for years seemed to bring the patient some relief.
Still, it was a good thing.
***
Alice looked at the new upper endoscopy report added to the patient’s medical record. It was exactly as her colleague had said. Amazing.
She’d thought, Could that be right? But he was never wrong.
Dr. Orville, the nephrologist who had been treating the patient, scratched his head sheepishly.
“That resident was right. I thought it was nonsense, but I never expected it to really be Wermer syndrome.”
While the professor was looking up what Wermer syndrome was, Alice drifted into a daydream.
I need to hurry and go see the whale sharks.