Between Sept to Dec 2009, I had given her a few injections (about 20 to 25 in number) to make the pain bearable.
Her abdominal pain kept coming on frequently. It was associated with epigastric fullness and vomiting. Vomiting used to be greenish at times. The hyper peristalsis had stopped and bowel sounds were normally heard during the abdominal pain attack. I surmised that the D2-J was the source of the problem. As I had not come across similar situation in the past, I took second opinions from various consultants from Mumbai, Pune, Goa and UK. No one had come across similar case in the past. Despite watching the full video and the Ba meal FT, one of the consultants felt that it could be an eosinophilic granuloma. He therefore got her on Prednisolone at 30 mg / day (~1 mg/kg/day). Surprisingly, within 4-5 days of starting steroids, her abdominal pain vanished and she began eating well. Her weight increased from 35 to 42 from Dec 2009 to Feb 2010. She did not require any pain relief from 10th Dec 2009 to March 2010.
By Jan 1st week, she began having eruptions of fluid filled blebs on the buttocks where Pentazocin was given in the past. This later went on to become cutaneous gangrene of full thickness skin. It was a dry gangrene all throughout. These eruptions were numerous and many of them were quite away from the place where the Pentazocin was given in the upper lateral quadrant of either gluteal region. The area involved was a large portion of the gluteal area with islands of normal skin in between.
By 5th March she had another bout of severe abdominal pain with vomiting green stuff. I did another Ba meal FT. The findings were hold up of the Ba at the duodenum proximal to the D2-J for more than 1 hr. The proximal duodenum was massively dilated. After 1 hr, the dye made it into the efferent loop that was highly convoluted but undilated. By 1 .5 Hrs, the Ba reached afferent loop that was massively dilated and was composed of D2- D3 - D4 -jejunal 1st loop upto the anastomosis. Rest of the bowel was normal with normal IC-JN which was the treated area in the previous surgery. Gastro-Colic time was less than 16 hrs.
I advised the fourth surgery to tackle the afferent loop.
Because of A) cutaneous reactions on buttocks and patient's demand for pentazocin and B) possibly the development of a feeling that I was blowing hot and cold between the surgical focus from IC-Jn to D2-J, the relatives lost faith in me and took her to Mumbai to be shown to various specialists practicing medical gastro-enterology, surgical GI consultants and psychiatrists to tackle the so called 'addiction to pentazocin'. They did this back and forth between Mumbai and Pune for about 3 .5 months. In this time patient was administering herself pentazocin per rectally. She was stealthily procuring this from the nearby pharmacies as she had no other way of bearing the pain and in Sept 2009 to Dec 2009, that was the only pain killer which had brought some relief to her.
In these Mumbai consultations, she was put through a battery of superfluous tests that were already done in the past. These included CBC, uroporphyrins, Ba Meal FT, MRI brain for pituitary fossa, endocrine studies, abdominal USG, electrolytes, Oesophago-gastro-duodenoscopy, colonoscopy, etc.
On the positive note: Patient gained about 5-6 kilos in weight between 10th Dec 2009 to 5th March 2010, during which time her abdominal pain was very less or absent on many occasions.
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