The limousine pulled into the driveway of a small Georgetown mansion. Ben Kaplan and Joe Trujillo, Ben’s Nurse Practitioner, got out and were directed inside the house to a large combination bedroom and sitting room at the rear of the first floor. A tall elderly man with military bearing invited the 2 visitors to be seated and immediately began his story.
“I very much appreciate your both coming up to D.C. to see me. George, my son-in-law, thought it best. You see, I have this strange abdominal pain and doctors at Bethesda Naval Hospital can’t seem to figure it out. My primary care physician doesn’t know what’s wrong so he referred me to a gastroenterologist. She seemed quite puzzled and referred me to a general surgeon who was equally without a clue. George then arranged for consultations at George Washington Medical Center. No answers there either. One specialist at GWMC told me to go back to my PCP as my problems, he told me, were more of a general nature. So I did that but my PCP said he didn’t know what to do anymore than he did when I first went to see him. He suggested another specialist. Now you may know that I’m a retired Navy Admiral. When there was a problem on my ship, if nobody else knew what to do they came to me. I had to deal with it. The buck stopped with me. And I was usually able to think things through and come up with some sort of plan. I was usually able to grab the bull by the horns as they say, and move forward. My doctors however have not been able to do that.”
“Admiral Smyth, it’s very nice to meet you,” said Ben. “Please tell Joe and me about your pain.”
“It’s a dull but intense ache in the center of my abdomen. I’ve had it for about 6 months and it’s getting worse. But here’s the funny thing. It only comes on when I walk. As long as I walk at a brisk pace it stays with me. When I stop the pain fades away fairly rapidly. I may be 90 years old but I still like to be active. I play golf and I like to walk instead of using the golf cart. But I just can’t manage that anymore because of this pain and nobody seems to know what in the name of all that is wonderful the problem is.
“I’ve had tests galore. They’ve looked down from above into my stomach and they’ve looked up from below into my colon, all with scopes of course. I’ve had an abdominal sonogram and an abdominal CAT scan. Nothing was found on any of these tests according to my doctors. I’ve had tons of blood work and also urine tests. No answers,” said Admiral Smyth.
“Admiral, have you ever had a blockage of an artery anywhere in your body?” asked Ben.
“I had a blocked carotid artery in my right neck. They found that after I had an episode of weakness on the left side of my body. It lasted only minutes. They called it a TIA. The artery was surgically unclogged. They called the procedure an endarterectomy. That was 8 years ago. I’ve never had another TIA. Then I had chest pain about 5 years ago. They found a blocked coronary artery and put a stent in it. No trouble since. And I had a blocked artery in my right thigh. I was getting pain in my right leg when I walked. They did a bypass to correct that, about 3 years ago. I think they called the operation a femoral-popliteal bypass. It worked. No more trouble,” said the Admiral.
“Joe, do you have any questions for the Admiral?” asked Ben.
“Sir, have you ever been a tobacco user and are you currently on cholesterol lowering medication?” said Joe.
“I quit cigarettes 15 years ago Joe. I was a 2 pack per day smoker. I do take a statin drug for my cholesterol,” said the Admiral. “I think you have copies of all my test results.”
“We do sir. Your blood and urine results are remarkably good,” said Joe.
“Can we do a physical examination on you Admiral?” asked Ben.
“Of course,” said Admiral Smyth.
Ben and Joe then did a hands on physical examination on their patient. The only abnormal finding was that of slightly reduced pulses in both feet.
Ben was now ready to have a conference with Admiral Smyth.
“Admiral, Joe and I would like talk about your case with you present. Is that OK?” said Ben.
“Yes indeed, Dr. Kaplan. Go right ahead,” said Admiral Smyth.
“Thanks Admiral. Joe, I believe that the answer to the Admiral’s case is to be discerned entirely from his medical history. The fact that his abdominal pain comes on when he walks suggests to me that the pain is due to lack of blood flow to his abdominal organs,” said Ben.
“Ben, are you saying that because when the Admiral walks, his leg muscles demand more blood flow, and that because of that increased demand for blood by his legs there is then a reduction of blood flow to his abdomen?” asked Joe.
Admiral Smyth then piped in excitedly, dropping all formalities. “Ben, are you saying that my leg muscles, when I walk, are stealing blood from my intestines and that this lack of blood is causing my abdominal pain?”
“Exactly Admiral! You’re a genius sir! When you walk, the lack of blood and the oxygen that it carries is being shunted away, or stolen, from the arteries that supply your intestines and instead is delivered to your legs. There isn’t enough blood flow to adequately supply both your legs and your abdominal organs when you’re walking. This is causing you to have ischemia of your abdominal organs. That ischemia causes pain. We call that pain abdominal angina.” said Ben.
“Ischemia, doctor? What is that? And how do you pronounce it?” asked Admiral Smyth.
“It’s pronounced isskeemia Admiral. It’s what happens when the flow of blood, with the oxygen that it carries, is reduced. So ischemic colitis occurs when the colon is deprived of blood. Ischemic heart disease, which can cause chest pain or angina, occurs when the blood supply to the heart muscle is reduced. That occurs when coronary arteries are blocked,” said Ben.
“Ben, doesn’t your theory require the presence of an artery or arteries connecting the abdominal circulation with the circulation to the legs?” said Joe.
“It sure does Joe. You’re right on target! One or more of the three major arteries that come off the aorta in the abdomen to supply blood to the stomach and intestines are likely blocked. Let’s just refer to those organs, the stomach and intestines, as the gut. Sometimes a small artery or even a network of small arteries run between one or both of the internal iliac arteries, which supply blood to the legs, and one or more of the 3 arteries that supply blood to the gut,” said Ben.
“Ben, are you describing collateral circulation?” asked Joe.
“Exactly Joe,” said Ben. “These small arteries, collateral arteries, can enlarge and become a vascular bridge between the gut circulation and the leg circulation when those circulations have chronically reduced blood flow due to atherosclerotic blockages. So when the legs demand more blood as they do when a patient walks, there is less blood available to the gut through the collateral vessels. That causes ischemia of the gut and the pain that results is called abdominal angina.
“So what do we do Ben? How do we move forward?” asked Admiral Smyth.
“We need an imaging study to definitively map out the circulation in your abdomen and pelvis. Because your kidney function is slightly abnormal I’m going to recommend a magnetic resonance angiogram, an MRA, with gadolinium as the contrast agent. I think that will give us the detail we need to map out your circulation including the collateral arteries. Gadolinium is easier on your kidneys than the contrast agent we use for CAT scan imaging of arteries.
“After this MRA study has been completed we’ll know what your options for treatment are,” said Ben.
“Ben, you’ve given me hope. You’ve listened to my story and come up with a hypothesis to explain my pain as well as a plan for the next step. You know Ben, I don’t know why the other doctors that I saw could not have done this. It seems to me that a doctor needs to work through the tough cases like mine and not just refer out all but the easiest cases.
“Ben, can I ask you a personal question?” said Admiral Smyth.
“Sure, Admiral,” said Ben.
“What is the most important thing in the world. What is the thing against which everything else, everything, pales in importance?” asked the Admiral.
“That’s an easy one Admiral. A personal relationship with the Messiah, the Lord Jesus Christ, is the most important thing,” said Ben.
“You don’t know how glad I am to hear you say that Ben! None of my other doctors are Christians. George told me you’re a Christian, a Jewish believer in Yeshua, but I wanted to hear it for myself. I’ve known the Lord Jesus for 60 years now,” said the Admiral.
“I’m so glad to know that Admiral,” said Ben.
“Now, if you and Joe will just wait a minute, George wants to thank you for coming up from South Carolina, and I think he also wants your opinion on the pre-tribulation rapture,” said the Admiral.
“Sure. And we’ll talk with you further soon, Admiral,” said Ben. “But Admiral, how about a word of prayer before Joe and I leave you?”
“I would really like that, Ben!” said the Admiral.
The three men joined hands and Ben asked the LORD to provide peace and a good outcome for Admiral Smyth. All three men then praised God.
On the trip home
“That was quite a case Ben. How do you know George or should I say POTUS? How did he decide to call you up here to see his father- in-law?” asked Joe.
“We were classmates in college Joe. It was good to see him again after all these years,” said Ben.
3 weeks later
“Great news Joe! The Admiral just called. He is doing really well. Two of the three arteries to his gut were completely closed off, but the middle artery of the three, the superior mesenteric artery, was not completely blocked and a stent was inserted into it. That increased blood flow to the gut enough so that he is no longer dependent on blood flow through the collateral arteries and he can now walk without any abdominal pain. He started back on the golf course this week!
“The Admiral also sends thanks and regards to us both from George,” said Ben.
“Fantastic! Thanks, Ben,” said Joe.