Did my doctor cut me for no reason?
August 1, 2007 8:54 AM   Subscribe

So the doctor diagnoses me with diverticulitis, and then performs a left sigmoid colectomy on me. Per the normal routine, the section of my colon was sent to a lab for analysis, which said there was no diverticuli present.

Does this mean that my doctor's initial diagnosis, and reason for the surgery, was wrong? Would my insurance company want to know this?

I'm not feeling well. I'm not sure if this is due to complications from the surgery, or from a continuation of a problem that the surgery did not correct (since it was to correct a non-existent problem).

I'm primarily concerned with getting a proper diagnosis at some point. I do have a follow-up appointment with this doctor next week. But I'm thinking I should consider a different doctor.

I know you're probably not a doctor or a lawyer or whatever -- just tell me what you would do in this situation.
posted by yesster to Health & Fitness (15 answers total)
My first step would be to discuss the findings with my doctor. Did you ask him what his thoughts were?
posted by SirStan at 8:57 AM on August 1, 2007

+1 to talking to the doctor about your concerns first
posted by criticman at 9:19 AM on August 1, 2007

Did you mean that there was no diverticulitis present or that the lab found no diverticuli were present, because that is a very different diagnosis?
posted by Pollomacho at 9:22 AM on August 1, 2007

The lab report (I don't have a copy with me) stated that no diverticuli were present.

And yes, I will talk to the doctor next week.
posted by yesster at 9:35 AM on August 1, 2007

I would talk to him (her) first before going forward. Could be a mistake, which doesn't always mean he did anything wrong, could have been a smart gamble that didn't pay off, who knows?

Talk to him first though.
posted by John Kenneth Fisher at 9:45 AM on August 1, 2007

I have had tests before where a lab will say "no XYZ present" but the doctor saw XYZ while taking the biopsies for the test. Also, it depends what the lab bases its results on. Maybe you 'abc' count is normal but the doctor will say 'ghi' looks a bit low and that is another sign of your illness.

Anyway, good luck!
posted by criticman at 9:53 AM on August 1, 2007

2nd opinions are always good too. Most insurance companies do cover 2nd opinions (I work at one of them) and would actually prefer that you get one if you are uncomfortable with the primary opinion.
posted by slavlin at 10:50 AM on August 1, 2007

There is a difference between diverticulosis and diverticulitis - see here. Basically, diverticulosis is the presence of diverticuli (outpouchings in the intestine), while diverticulitis is the infection of those outpouchings. The treatment of a first episode of diverticulitis does not usually involve surgery - rather, IV antibiotics, no oral food intake, and IV fluids.

But your doctor still may not be incorrect in acting as he did - you did not state whether this was the first episode of diverticulitis you've experienced.

I would not go by what the lab slip says, rather, I'd discuss with your doctor next week, as you mentioned you would. Ask him what his thought process was. Ideally, this discussion should have happened before a major surgery, but what's done is done. Do you have a colostomy tube now?

The best of luck to you.
posted by cahlers at 11:09 AM on August 1, 2007

Surgery was in April. Surgery went well, and my recovery was the fastest the doctor ever saw - I was out of the hospital less than 48 hours after the surgery. Fortunately, no colostomy.

It just seems weird. I had an ER visit due to intense abdominal pain. Doc had MRI done, then I was in the hospital on IV antibiotics for 3 days. Later, I did the colonoscopy. He said there were diverticuli present, in a "diseased" area of the colon. He said that's what he removed in the surgery. Yet that lab report said "no diverticuli present."

Now I'm having frequent pain and discomfort, really obnoxious gas and difficult/unusual bowel movements, and am just not "right" inside. We're not really equipped to localize sensations internally very accurately, I know, but it feels like the region of pain/discomfort is right where the colon section was removed.
posted by yesster at 11:20 AM on August 1, 2007

I think the answer to whether your doctor was wrong probably depends on 4 things:

1. Whether this was an emergency colectomy or an elective colectomy, and what your symptoms were like preoperatively
2. What the colonoscopy and/or CT and/or barium enema findings were preoperatively.
3. What the histology shows (the microscopic findings) from your resected sigmoid
4. And most importantly whether your symptoms resolve

I hope this helps when you talk to your doctor, and please give us an update afterwards.
posted by roofus at 11:21 AM on August 1, 2007

(Should have previewed obviously)
posted by roofus at 11:24 AM on August 1, 2007

(I'm an nonoperating physician.) Diverticulitis is pretty much the same thing as appendicitis. Either can be a difficult diagnosis. Since appendicitis can turn nasty if untreated, the practice has been to operate if appendicitis is at all suspected. That means some people will get an appendectomy who didn't have appendicitis, and that's okay. Traditionally, it's been said that about 85% of those operated upon should have it. Less than 85% means the surgeon is operating too much, more than 85% means he's missing some cases. Widespread use of CT scanning has improved diagnostic accuracy a little bit (don't know how much).

I'd like to hear Atul Gawande's take on this.
posted by neuron at 12:15 PM on August 1, 2007

I can't see where the next step would be anything other than discussing the result with the surgeon who operated. Maybe call him or his nurse before your appointment to let him know what the concerns were; that way he can discuss the case with the reading pathologist before you meet him.

As far as the questions you ask, the answer to the first is "it's possible," and I don't know the answer to the second.
posted by ikkyu2 at 1:24 PM on August 1, 2007

Since I do this for a living, I'll make an educated guess on what happened: the pathologist is a lazy git (assuming that your surgeon/GI docs made the proper diagnosis and you really did have tics - it's usually a pretty easy diagnosis). What happens at a busy grossing bench when a non-cancer colon specimen for diverticulosis arrives is this (as fast as possible):

- Measure the specimen
- Open colon lengthwise with scissors (clean out feces - thanks for skipping the bowel prep and eating pizza and pistachios the day before your procedure!)
- Look for the tics: they're usually pretty easy to find if they've been inflamed because they make all of the pericolic fat very firm.
- Section into the tic, take a nice little square of tissue to make a tissue block.
- Take a section of two of normal looking mucosa
- Put the colon back into it's formalin-filled container and stick it into its home for the next six months (until it gets thrown out)
- This whole process probably takes me about 2-5 minutes.
- You move onto the cancer staging and other cases that are a real pain in the ass to gross in right and can stretch on for hours (hunting for lymph nodes and margins)
- The tissue you saved gets magically turned into slides by your histology lab elves
- You look at slides the next day at the microscope and make a diagnosis.

Sometimes the proper section to evaluate a diverticulum just didn't make it onto the slide. What is supposed to happen is that the pathologist (or his slave - oops I mean resident) goes back to the bucket, pulls out the specimen and makes proper sections of the diverticuli so you can see them at the microscope. I would bet money that they just didn't do this.

Pathology is a customer service business... our customers are surgeons. We strive to keep them happy or we lose business. We are used to making them happy and we generally try to jump through hoops to make them so.

Ask your surgeon to verify with the pathologist that no diverticuli were seen when the specimen was grossed in (or if you have a copy of the report, it *should* say this is in the section titled 'Gross Description'). If they were seen grossly then the surgeon should insist that the pathology amend the report to have the final diagnosis reflect this. Because if the diverticuli were identified grossly, then they should go back and do it right. If they didn't, then they are lazy and give the rest of us pathologists (who are trying to improve the image of the specialty) a bad name.

(If your surgery was in April, colon may be long gone by now. Labs are only required to keep wet tissue for 2 weeks after the final diagnosis is issued. Most keep them for a lot longer (6 months at our lab), but we are not required to do so).
posted by i_am_a_Jedi at 4:38 PM on August 1, 2007 [2 favorites]

FWIW: I recently had intususcepcion of my ileum, and the CT scan showed diverticulosis. Great, I think. No more popcorn. Boo hoo for 4ster.

Then I have a follow-up colonoscopy, and it reveals no diverticulosis whatsoever.

The doctor tells me that they are just two different tests, and the one that looks at the inside can tell them more than a CT scan (that was really looking for a kidney stone anyway).
posted by 4ster at 6:20 PM on August 1, 2007

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