Mubarak’s Gallbladder Removal Doesn’t Remove Questions

Here is what came in the news. By Samer al-Atrush (AFP) – March 6, 2010

CAIRO — Egypt's President Hosni Mubarak had successful surgery to remove his gall bladder on Saturday, a German hospital said, after the veteran leader handed over power to his prime minister while he recovers.

Heidelberg University Hospital said in a statement that a growth was also taken out of Mubarak's small intestine, and that the president was fully conscious after the operation.

Mubarak, 81, had suffered from chronic calculus cholecystitis, an inflammation of the gall bladder accompanied by gall stones, and a duodenal polyp, said the statement.

"Accordingly, a successful open surgery was carried out this morning to remove both the gallbladder and the duodenal polyp safely," Dr. Marcus Buchler was quoted as saying.

"The frozen sections taken during the operation were all negative," he added without giving any details on the tissue that was examined and what ailment the tests were meant to detect.

"I am fully satisfied with the performance and outcome of the surgical intervention conducted this morning," said the German doctor.

This opens many questions in my mind:

First of all: Cholecystitis usually presents as a pain in the right upper quadrant. This is usually a constant, severe pain. This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies and fried foods. It is usually accompanied by a low grade fever, vomiting and nausea. More severe symptoms such as high fever, shock and jaundice indicate the development of complications such as abscess formation, perforation or ascending cholangitis. The symptoms of chronic cholecystitis are non-specific, thus chronic cholecystitis may be mistaken for other common disorders: Peptic ulcer, Hiatus hernia, Colitis, functional bowel syndrome. That means the president case is more complex to diagnose. Nevertheless, the president must have suffered many episodes of pain before. One has to ask the first question: what did the president do during those episodes?

2nd Question: The president had an episode of collapsing while giving a speech before. It was explained before as suffering from flu and antibiotics during fasting Ramadan. That could very well be true. It may have been also a severe episode of gallstones moving through the cystic duct, which leads to shock and jaundice.

3rd Question: Even though the chronic symptoms can be confused with many other common disorders, one has to think that the president doctors ventured into at least doing an ultra-sound to rule out the gallbladder possibility. The chronic cholecystitis develops over years. It is hard to believe that a president in his 70s has not had ultrasound in several years to reveal this disorder given that he must have had episodes of abdominal pain. Either his doctors in Egypt are extremely incapable or they have done it and they were able to diagnose the cholecystitis. It is really hard to miss the gallstones on the ultrasound.

Let us assume that Mr. Mubarak did not do a single ultrasound in years even though he got episodes of abdominal pain. Here is the 4th question. Cholecystitis - Caused by blockage of the cystic duct with surrounding inflammation, usually due to infection. Typically, the pain is initially 'colicky' (intermittent), and becomes constant and severe, mostly in the right upper quadrant. Infectious agents that cause cholecystitis include E coli, klebsiella, pseudomonas, B. fragilis and enterococcus. Murphy's sign is positive, particularly because of increased irritation of the gallbladder lining, and similarly this pain radiates (spreads) to the shoulder, flank or in a band like pattern around the lower abdomen. Laboratory tests frequently show raised hepatocellular liver enzymes (AST, ALT) with a high white cell count (WBC). With such a chronic case that Mubarak’s German doctors described, his liver enzymes most likely have been elevated particularly because of the blockage of the cystic duct. It is hard to believe that during the past few years, Mr. Mubarak (who is 81 and is after all the president) did not do a single liver function lab work particularly after suffering episodes of pain.

Why am I asking this 3rd question about ultrasound and lab work? Cholecystitis is cured by removing the gallbladder. This can be done in one of two ways: Laparoscopic procedures or open surgery. Laparoscopy can have less morbidity and a shorter recovery stay. Open procedures are usually done if complications have developed or the patient has had prior surgery to the area, making laparoscopic surgery technically difficult. Doctors almost always prefer to perform laparoscopy particularly in a patient who is 81. If the doctors have diagnosed Mr. Mubarak’s disorder before, why didn’t he undergo a laparoscopic procedure few years ago? If they havent diagnosed it before, then one has to wonder about the kind of healthcare that Mr. Mubarak is receiving and the capability of his doctors in Egypt unless they were able to diagnose it and were not able to operate because of other complications that nobody knows about yet? It could also very well be that they had to do an open surgery because of the detection of the Duodenal Polyps.

Screening for duodenal polyps is usually done with a duodenoscope, a pencil-thin, flexible tube inserted into the mouth and guided down the esophagus, through the stomach, and into the duodenum. If polyps are found, they may be removed or cauterized during this procedure.

If duodenal polyps become large or numerous, the duodenum may need to be surgically removed. It could be that the detection of both the polyps and the Cholecystitis has led doctors in Germany to make the decision to operate with an open surgery. But this tells that the case was not a simple one but has been let’s say above average in terms in number of polyps and the extent of the Cholecystitis. Which again, opens all the previous questions. These cases develop over years and they cause pain and even if they do not, one has to wonder why the president of Egypt who is 81 years old did not undergo a single ultra-sound, a single duodenoscope, or a single liver function lab work in the span of years? Or if he has undergone any of those, why weren’t the results diagnosed properly. And if they were diagnosed properly, why didn’t doctors operate early on using duodenoscope or the laparoscopic surgery?