Shooting in the dark, aiming at Giardia, and hitting lactose intolerance


I have my rules, they’re firm,

In a patient with problem long-term

    Who comes back as a bounce,

    Improved not an ounce,

I’ll treat without knowing the germ.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After an assignment in Barrow, Alaska, the northernmost point in the United States, I’m working on the North Island of New Zealand.

In the summer of 1972 a friend and I bicycled from Connecticut to Colorado.  I livedthat summer outdoors, the experience has colored my life since.  To this day I appreciate water in a way I cannot explain to people who haven’t lived without indoor plumbing.

I learned to bathe with less than a quart.  We drank the water we found dripping off of rocks in road cuts.

I developed lactose intolerance that summer.  By the end of the trip my belly suffered if I drank a glass of milk, and, a few hours later, the people around me would suffer as well.  

Three decades later I required metronidazole as an antibiotic for an unrelated problem, and my lactose intolerance improved but didn’t resolve.  At the same time, my lettuce intolerance evaporated.

In retrospect, I acquired Giardia, a one-celled intestinal parasite, from drinking ground water.  I’m one of the ten percent of people who can harbor the germ as a carrier.  While it didn’t cause a lot of problems, it acted up from time to time in the form of gut distress.

Of course my own personal medical experience influences how I treat my patients.  A person who had been to Mayo Clinic for a vague parade of abdominal symptoms said, “I’ve spent $11,000 and I’m no better.  What can you do for me?”   Stool studies for Giardia come to false negatives thirty percent of the time; the medication, low hazard in the absence of alcohol, runs cheaper than the diagnostic test.  I wrote a prescription for metronidazole.

Two weeks later the patient felt much better; the bloating and cramping had ceased and the unexplained food intolerances had disappeared.

Today I talked to a patient who gave me permission to put this information in my blog.  Long-term, intermittent cramping abdominal pain with diarrhea had evaded diagnosis despite thorough evaluation.  I told about my symptoms and how I’d much better I’d gotten after a coincidental treatment with a cheap antibiotic, and asked if she minded shooting in the dark.

In my business we don’t actually call it shooting in the dark, we call it an empiric therapeutic trial, which amounts to giving a patient a medication to see if it works.  I’ll do it after the patient has had a good workup by a specialist, ruling out the really bad things, without symptom improvement.  While it offends my sense of intellectual honesty, I never pretend I have any special powers, and I’m very upfront to the patient when it comes to options, risks and costs.

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5 Responses to “Shooting in the dark, aiming at Giardia, and hitting lactose intolerance”

  1. 3M Filtrete 3US-PF01 Under-Sink Advanced Replacement Water Filter Reviews Says:

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  2. Bernard Schey Says:

    Milk, by itself, somehow saved lives. This is odd, because milk is just food, just one source of nutrients and calories among many others. It’s not medicine. But there was a time in human history when our diet and environment conspired to create conditions that mimicked those of a disease epidemic. Milk, in such circumstances, may well have performed the function of a life-saving drug.’

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    • walkaboutdoc Says:

      Bernard:

      Only a small proportion of living humans descend from those people who developed pastoralism without developing milk fermentation. For a lot of human history, milk conveyed infection along with nourishment. for my readers, be careful of what sites you check; I don’t endorse them.

  3. Rose Says:

    A shot in the dark sounds good to me. Am tired of docs telling people it’s IBS without any kind of workup.

    • walkaboutdoc Says:

      No patient in town gets the diagnosis of IBS without colonoscopy, EGD, gliadin panel, stool for ova and parasites, stool culture, trial of gluten cessation, and a trial of lactose restriction, CBC, TSH, sedimentation rate, amylase, lipase, ultrasound, maybe a CT scan and HIDA scan, depending on the history. But we have very, very high medical standards.

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