A Mastedon Makes an Obstruction

I'm beginning to think the Italian sausage theory of my obstruction isn't so crazy after all.  In this post, I'm going to copy a description of how our guts are designed to deal with digesting big hunks of meat we come upon serendipitously, whether by stumbling on a big kill or browsing the lunch counter at Lina's.  

It might fall into the TMI category of more detail than you want about how the gut works, so feel free to ignore it, especially if you are a friend who has to listen to mine sloshing and growling these days.  But if you want to know more about why cancer interferes with normal bowel functioning, this is as good a description as anything I've found.  It's in a book by James Hallenbeck called Palliative Care Perspectives. 

The intestinal tract did not evolve to compensate for mechanical bowel obstruction caused by an immobile, fixed lesion such as cancer. The physiologic changes that arise with obstruction would be adaptive to reversible forms of bowel obstruction that may have occurred for our ancient ancestors, but they are maladaptive for patients with cancer. Similarly, kidneys demonstrate a maladaptive response to heart failure. Decreased renal perfusion is sensed as dehydration. Fluid is retained to compensate when, in fact, the patient is drowning. We adjust for this by "overruling" the kidneys, telling them to get rid of salt and water and not hold on to them. The kidneys can be mistaken. What "misunderstanding" arises in bowel obstruction?

Imagine that you have been very hungry. Your tribe finally hunts down a mastodon, and it is time for a feast. You gorge yourself, eating great chunks of meat and causing a temporary obstruction. Your body would respond in the following way.

1.  Mechanoreceptors and chemoreceptors would be stimulated by the distention caused by the large build-up of food proximal to the blockage. These receptors would tell your brain to stop eating. 

2.  The intestine proximal to the blockage would begin hypersecreting fluid, trying to flood the system and wash the intestinal contents downstream.

3. Intestinal motility would increase, further trying to push contents downstream and causing cramping.

With luck, you would live to hunt another day. While this approach works well for ingested mastodons, it works poorly for malignant bowel obstruction.

In essence, what Hallenback is describing is what made me call my doctor. I was nauseous (stop eating, Pat, and get rid of what you just put in your stomach because it ain't going anywhere). My gut was scramping. Oddly, the best description of the pain for something so serious is that it was colicky. I could hear fluid roaring and sloshing around, trying desperately to wash stuff downstream.

There just wasn't anywhere for it to go.  The blockage formed a little dam, and everything nature was telling it to do, except for not putting in more mastedon, was starting to work against me.

Flat on My Back

The day after I checked in to hospital, test results were all back:  I did have partial obstruction of the small intestine, and my chemo had stopped working.  My oncologist was shocked at the rate at which disease had seeded all over my intestines.  One measurable mass had also grown up in the lower abdomen, but he wasn't nearly as concerned about that as he was about what was happening to my gut.

I declined his offer of surgery for immediate relief of the obstruction.  If my bowel had been kinked or hooked around a mechanical obstacle like scar tissue from previous surgeries, I might have considered the option, and I guess I would have if my current situation were immediately life-threatening.  But, he said, we could try managing the blockage conservatively--which is not generally a word in his lexicon, he being a truly gentle soul with the surgical aggression of a tiger.  I wasn't surprised to learn, then, that what he meant by "conservative" wasn't quite what others did.

The usual treatment involves something elegantly called "drip and suck".  You'll have seen patients walking around hospitals with band-aid colored sticking plaster over one nostril, holding a tube that goes from the nose, past the throat and into the stomach.  That's the suck part--well named.  It's designed to drain fluids that are accumulating in the gut and causing pain and nausea. They also have a bag of IV fluid dripping saline solution to restore hydration and prevent the misery of things like hypoglycemia.

Instead of opting for that (and for reasons I am sure are particular to just what was happening to me in its own particular way), my doc opted to give the gut a total rest.  Nothing was to come in by mouth except sips of water needed for medication.  I was put on total feeding intravenously, with carefully calibrated orange bags of lipids, the kind of food one nurse told me they give babies in intensive care.  I was put on steroids for inflammation, and a hideously expensive drug called Octreotide, injected subcutaneously 3 times a day.  Using only the logic available to hospital personnel, one of those times was about two in the morning.

So for almost 2 weeks, I propelled myself all over the hospital with this hook up.  The only part of the process I could control was to walk as much as possible to stimulate the gut to produce gas, letting us know that normal functioning was returning.  Every fart became precious, and I walked in 30 minute bouts as often as I could, getting up to a total of more than 2 hours a day. 

That's about 1 hour and 45 minutes more than I ever did at home.

The object of all this was to produce poop--and the first time something with two ends came out, I wanted to throw a party.  From there, it was all downhill--or is uphill the good direction?At any rate, the treatment was working, I hadn't starved to death--not that I lacked sufficient stores of reserved fat or anything) and I would live to have some more adventures.

It was all good in the strange Alice-in-Wonderland world of cancer survival, where you become grateful for mercies that come in the strangest disguises.

Might 'a Bin the Sausage

The trouble started at the end of March as I was getting ready for yet another round of Gemcitabine and Cisplatin, my latest chemo cocktail and one, thanks to the bloated bureaucracy of the Alberta Cancer Board, I was having to pay in the thousands for, myself. More about that gong show in another section.

It's a powerful combo, and had been successful in keeping things stable, but at an increasing cost to my stamina.  My guts complained a lot, and so did I.  But as I was laying in supplies for the upcoming chemo week, which always flattened me out, I had an unexpectedly good day and found myself, shopping in my favorite Italian deli, deciding to have a big fat sausage on a bun for lunch.  I never eat big fat sausages on crusty rolls, but it just looked so damned good.

Now, I have no idea whether fat sausages get stuck in your gut or not.  Some of my friends swear up and down that that's what set the whole thing off.  But for sure, over the next couple of days, my gut became increasingly unhappy.  I tend to take a "tough it out" approach to pain, with maybe a fair amount of ostrich thrown in, just in case the trouble might disappear on its own.  So I waited longer than I should have to call my doctor.  I even talked myself into thinking I was having a gall bladder attack.

So some shame on me for not being on top of things a bit earlier, but it's also part of the experience of living with this disease.  From the symptoms that led to my initial diagnosis to this latest adventure, many of the things going on in my body could be signs of other things, or nothing much at all.  Bloating and gut ache?  Who doesn't have that?  Passing gas?  Well, that's a high art in the culture of teenage boys.  Rumbly tummy noises?  When was the last time you were at a luncheon with middle aged women?  One of the truly weird things about ovarian cancer is that it doesn't feel anything like I thought cancer would feel like.

Not that I had any idea of what cancer would feel like--but I continue to be surprised by how ordinary even important symptoms turn out to be.  So when I could hear myself gurgling and roaring from across the room, when my abdomen got distended and full of cramps, and when I felt like throwing up, I had to pay attention, even when I didn't want to.

What got me on the phone was pulling my head out of the sand and going online to match up what was happening to me with what I actually suspected: I had joined the Unlucky 40% Club.  Seeing all this could be, might be, maybe isn't stuff in plain black and white made me cry, and it made me call my oncologist, who had me check into the hospital right away.  "Look," he said, "you live alone.  Come on in and let us take a few tests and look after you for a day or two till we know what's going on."

I started to cry again, packed a little bag, and had Sharon drive me in for a look-see that ended up taking a full 16 days.

What's Going On?

In the past couple of months, I have been phoning and emailing people erratically to catch up on what has been happening to me, health-wise.  It's great to talk, but as a method for keeping everyone in the loop, it sucks.  I've been missing too many of you, in all senses of the word, and I know people get worried when it feels like I've dropped off the edge of the planet.

So I'm going to see if blogging works any better as a way of keeping in touch regularly.  I'll tell you what's up with me, and I hope you chime in along the way so we can catch up with others, too. Nothing fancy.  If I knew how to do that, I'd revive my dormant Face Book account and we could scribble over my walls.  

I'm also doing this to share my experiences with others who may also be living with bowels transformed by cancer.  I've learned a few things since the end of March when my latest adventures started, and I'll try to figure out how to share it so you can find out as much or as little as you want.  I'm planning to include medical stuff, but also my own musings about what it feels like to live with disease that is now making itself  "vocal" in unexpected ways.

Some days it catches me by surprise that I have been living with recurrent ovarian cancer for almost 6 1/2 years.  I've had seven major goes at chemo that put me in the chair or on a bed more than 80 times.  Lost my hair twice, and I haven't felt my fingers and toes properly since last June.  In many ways, my disease has progressed in a text-book fashion, although thankfully more slowly than it does for many.  So the latest adventure, a partial bowel obstruction that occurred at the end of March, came as no surprise.  

Well, that's not true.  It was a shock, but not one of those kinds that come out of the blue.  More like the oh shit recognition that I wasn't going to get past Go on this one.