Famous Patients, Famous Operations, 2004 - Part 2: Retired Army General With Recurrent Jaundice and Itching

Albert B. Lowenfels, MD

Disclosures

July 15, 2004

An 84-year-old male retired army general presented with the chief complaint of recurrent jaundice and itching. His illness began 12 years before admission with attacks of colicky right upper quadrant abdominal pain, occasionally accompanied by jaundice. He had many similar attacks over the next several years, and on one occasion his bilirubin level rose to 20 mg%, with direct bilirubin equal to 16 mg%. Two years prior to admission, both the liver and the spleen became palpable. A gallbladder series obtained about 10 years before admission revealed a faint, pear-shaped shadow with slow emptying of the gallbladder. The image quality was insufficient to determine whether gallstones were present.

Past History: Review of systems and past medical history revealed symptoms suggestive of mild heart failure. The patient had had several attacks of what appeared to be pyelonephritis, which led to a prostatectomy. Bilateral hernias had been present for many years; the right was usually reducible, and the left had been irreducible for 4 years. He had lost about 20 pounds over a period of a few years.

Family and Social History: The patient's father, who was also an army general, died at age 67 years of a stroke. His mother died at age 82 years. The patient had been born in the United States and had traveled extensively in Europe and Asia. He was a pipe-smoker and had used alcohol in moderate amounts for much of his life, although he had not consumed alcohol in the past few years.

Physical Examination: On admission to the hospital, the patient was ambulatory but appeared chronically ill, deeply icteric, with no acute distress. An examination showed a BP of 130/70, a regular pulse, and normal temperature. Lungs were clear. There was a soft systolic heart murmur. Examination of the abdomen revealed a palpable spleen and a palpable globular mass beneath the liver, which extended 34 cm below the costal margin. There were dilated tortuous veins on the abdominal wall and bilateral nontender, irreducible hernias.

Additional Studies: Upper GI series revealed no evidence of esophageal varices. A liver scan showed generalized parenchymal disease.

Disease Course: Jaundice and pruritis persisted. An operation was performed 4 days after admission. The patient progressed satisfactorily for about 2 weeks, but then had a massive GI hemorrhage that required a second operation. About a week later, abdominal pain and distention developed abruptly, leading to a third and final operation. Following the operation, he developed symptoms and signs of hepatic failure and recurrent GI tract hemorrhage. He died a week after the third operation, 5 weeks after being admitted to the hospital. Prior to his death, he said: "I've looked that old scoundrel death in the eye many times, but this time I think he has me on the ropes." An autopsy was performed.

Who was our mystery patient?

  1. Eisenhower

  2. DeGaulle

  3. MacArthur

  4. Kaiser Wilhelm

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What was the preoperative diagnosis before the first operation?

  1. Liver cancer

  2. Chronic hepatitis

  3. Amebic abscess

  4. Chronic cholecystitis, cholelithiasis

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What caused the digestive tract hemorrhage?

  1. Stress ulcer

  2. Untreated, unrecognized pre-existing duodenal ulcer

  3. Portal hypertension with bleeding esophageal varices

  4. Mallory-Weiss syndrome

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What operation was performed to control the digestive tract hemorrhage?

  1. Subtotal gastrectomy

  2. Splenectomy

  3. Porto-caval shunt

  4. Spleno-renal shunt

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What was the reason for the third and final operation?

  1. Perforated stress ulcer

  2. Small bowel obstruction with gangrene and perforation

  3. Subhepatic abscess

  4. Subphrenic abscess

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What factors led to the patient's death?

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What were the autopsy findings?

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Who was the surgeon?

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Where was the patient treated?

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How would the patient be treated today?

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General MacArthur, an intelligent, capable general with superior leadership qualities, was a courageous man, unafraid of danger, but apparently unwilling to follow medical advice. Why? Was it because he distrusted the medical profession or because he feared surgery? Did he believe he was indestructible? For unknown reasons, MacArthur refused to seek treatment for gallstones -- a common, easily treatable condition with a low operative mortality. He never sought treatment for his inguinal hernias, another easy to treat condition. When he finally did agree to surgery, he was a frail, elderly man and a poor candidate for biliary tract surgery because of the coexistence of portal hypertension. His postoperative complications and eventual death can be directly traced to his own reluctance to seek surgical treatment at a time and at an age when he could have been assured of a successful outcome.

http://www.macarthurmemorial.org/

http://www.empereur.com/G._Douglas_MacArthur.html

http://members.tripod.com/~DARTO/macarthur/macarthur.html

http://www.brainyquote.com/quotes/m.html (Source for quotation listed in case presentation.)

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