Medical Mysteries: A surgeon's ominous pain and a question of grilled meat
Seated next to a radiologist, Thomas P. Trezona scoured the images of his CT scan, dreading the thing he was sure he would find: evidence of pancreatic cancer, the same disease that had killed his mother. Given his age, sex and family history, that was the most likely explanation for the violent abdominal pain, nausea and rapid weight loss that in July 2021 hijacked the life of the retired surgical oncologist.
To Trezona's enormous relief the scan showed no sign of cancer. His internist suspected he was reacting to grain in his diet, while blood tests performed after the scan suggested a rare, chronic gastrointestinal disorder.
The cause of Trezona's debilitating symptoms, confirmed nearly two months later following surgery, turned out to be none of those things. The surgeon's persistent, methodical approach to his own illness - honed during his long medical career - coupled with the assistance of his longtime gastroenterologist led to the discovery of the unusual and preventable reason for his alarming decline.
Trezona, now 72, recovered, although the experience left him shaken. He hopes to alert others to a frequently overlooked danger hiding in plain sight and spare them a similar ordeal.
"I know I have very privileged access to the medical community, and knowledge most people don't have," said Trezona, who lives outside Eugene, Ore. "Most people would have suffered for a much longer period of time with this."
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Possible parasite
The vague pain in Trezona's upper abdomen began July 13, a few days after he returned from a two-week rafting trip in the Grand Canyon. A few days later the pain worsened, and he felt bloated and nauseated and had trouble eating.
Trezona, who retired in 2020, noted that the pain came in waves and tended to be milder in the morning, intensifying as the day wore on. He began putting together a differential diagnosis - a list of possible conditions that share symptoms - a bedrock tool used by doctors.
"This is what surgeons do," he said. "We are the specialists called to the ER to see people who present with significant abdominal pain." Trezona also began keeping a daily symptom journal to track his problem.
His initial suspicion - that he had contracted an infectious disease caused by a parasite - was quickly ruled out. Trezona and his wife, Amy, had drunk filtered water on the trip; she was fine. And he didn't have diarrhea, a hallmark of such infections.
The next possibility was far more ominous. Trezona had treated many patients with gastrointestinal malignancies and had watched his own mother die of pancreatic cancer a few months after her diagnosis at age 74. In a previously healthy 71-year-old male, Trezona observed, persistent abdominal pain and unexplained weight loss was cancer until proved otherwise. He needed a CT scan ASAP but couldn't get an appointment with his internist until Aug. 2.
Increasingly worried, he sent a text to his friend and gastroenterologist Jonathan Gonenne, who was on vacation in New England.
During a phone call the next day they discussed Trezona's symptoms. The gastroenterologist called his office to order a scan, which was scheduled for early August.
Gonenne remembers feeling concerned. "This is not a guy who complains or exaggerates," he said.
A week before his test, Trezona was struck by spasms of pain so severe they left him writhing on the bathroom floor. Weak, bloated and nauseated but unable to vomit, he was taken to a nearby emergency room by his wife. Maybe, he hoped, he could get that scan sooner.
Trezona saw a nurse and a physician assistant who drew blood and ordered lab tests. After more than four hours in the waiting room, Trezona still hadn't seen a doctor when his phone pinged with his results. All were normal except one. His eosinophil count, a type of disease-fighting white blood cell, was elevated. That could indicate an allergy, a parasitic infection or cancer.
After learning he might need to wait another four or five hours before seeing a doctor, Trezona decided to head home. "I thought 'I'm not going to die in the next 24 hours,'" he said. He had no fever, his pain was receding, and his total white blood cell count was normal, which ruled out a major infection or perforated bowel.
The following week he saw his primary care doctor who discounted the elevated eosinophil count and handed Trezona information about a grain-free diet.
Trezona said he immediately thought - but did not say - that the notion that his problem was food related was "the stupidest thing I've ever heard in my life." He contacted Gonenne, who called in a prescription for an antispasmodic drug that slows gut contractions and an opioid painkiller. Neither helped much.
Trezona was deeply worried that his pain, bloating and nausea were intensifying; in less than a month he had lost more than 15 pounds. When he examined his abdomen, he couldn't feel anything suspicious; a colonoscopy performed six months earlier was normal.
The pain came in waves and tended to be milder in the morning, intensifying as the day wore on.
On Aug. 2 Trezona underwent the CT scan and reviewed the images with the radiologist. "I was pretty happy," he said of the normal result. But he did not feel entirely relieved as he thought of patients with normal scans whose cancers had been discovered later during surgery.
He turned his attention to another cause that seemed increasingly possible: eosinophilic gastroenteritis, a rare chronic digestive disease caused by the accumulation of eosinophils in the GI tract that can trigger malabsorption, pain and bowel obstruction. "I sure as hell didn't want that," Trezona recalled.
Gonenne scheduled an endoscopy to inspect the upper GI tract and take biopsy samples. That was another dead end. The exam and biopsies were normal, which ruled out eosinophilic gastroenteritis. "I was partly relieved but left scratching my head as to what was going on," Gonenne recalled.
Trezona felt unmoored. His pain was getting worse, and he was continuing to lose weight, but nobody could find anything. He worried his doctors might think he was "a bit crazy."
Gonenne called contacts at the Mayo Clinic where he trained for suggestions about what to do next. They recommended CT enterography, an imaging study that inspects the small intestine.
Because Trezona had already undergone a CT scan, Gonenne decided to order an MRI enterography, which he thought might provide better visualization.
It was a decision that led to a discovery - and a cause - no one suspected.
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A peculiar discovery
In late August, a week before his MRI, Trezona suddenly felt "much, much better. The pain, bloating and nausea just stopped, and I was eating again," he recalled. Trezona was inclined to cancel the test, but Gonenne persuaded him to keep the appointment.
Immediately after the procedure Gonenne called Trezona to say that while nothing was found to explain his pain, the radiologist had spotted something peculiar: an unidentified metal "artifact" in Trezona's left upper abdomen. Had he undergone an abdominal procedure that used a magnetic metal clip?
He had not, Trezona replied, but in 2020 he had undergone a prostate procedure that uses wires. Perhaps a wire had migrated through the prostate to his abdomen. The possibility seemed far-fetched but not impossible.
Trezona called the radiologist and arranged to come in the next morning to compare the CT and MRI scans. They determined that the metal abnormality had been visible on the CT but was interpreted as a normal calcification on the wall of an artery, which it resembled. The prostate explanation was quickly ruled out after Trezona learned that the procedure involves nonmagnetic stainless steel wires. The wire in Trezona's gut was magnetic.
"Now we were really stumped."
That left two unresolved questions: Where did the wire come from and how did it get there?
"I wonder if it's moving?" the radiologist mused and offered to perform a limited scan. Trezona hopped onto the exam table. The new test revealed that the wire had moved a few centimeters; a small, calcified gallstone in Trezona's gallbladder that had not been seen previously was also visible.
"Now we were really stumped," recalled Trezona, who had no history of gallbladder problems.
The next night a few hours after dinner, Trezona developed severe abdominal pain, nausea and nonstop vomiting that lasted nearly two hours.
This time Trezona knew exactly what was wrong. His gallbladder was inflamed. Acute cholecystitis, inflammation of the gallbladder, is often caused by gallstones. Surgery to remove the gallbladder is the usual treatment.
"I've cared for it hundreds of times," Trezona said. His age coupled with rapid weight loss - about 21 pounds in less than two months - made him a prime candidate. Trezona put himself on a zero fat diet to prevent a recurrence and made an appointment to see a surgeon.
By then Gonenne felt increasingly certain about what had caused the baffling cascade of events.
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An exact match
Some years earlier Gonenne had treated a patient who suffered a microscopic perforation of the esophagus after unknowingly swallowing a wire bristle from a metal brush used to clean the grates of a barbecue grill. The wire had broken off and stuck to food where it went undetected.
Such injuries are believed to be uncommon but underrecognized. In 2012 the Centers for Disease Control and Prevention reported six cases treated at one Providence, R.I., hospital over a 15-month period; all were linked to the consumption of grilled meat. Two patients required emergency abdominal surgery.
In 2014 doctors reported the case of a man who died of peritonitis caused by a grill brush wire discovered during an autopsy.
A 2016 study estimated that between 2002 and 2014 1,700 American children and adults sought treatment in an ER for such injuries; one in four required hospitalization. Two years later Consumer Reports warned about the potential danger wire brushes pose; the Consumer Product Safety Commission recommends the use of nylon brushes or balled up aluminum foil to clean grills.
Gonenne suspected that Trezona unknowingly swallowed a wire stuck to his steak that traveled down his esophagus and into his stomach where it caused painful spasms before it migrated through the thick wall of the stomach. The resulting rapid weight loss probably led to a gallstone.
"We didn't go into surgery knowing this was a grill bristle," Gonenne said. Trezona, who said he had never heard that grill brushes could pose a hazard, was determined to find out if it was the culprit in his case. Using one finger he easily popped a wire off his brush.
On Sept. 13 the surgeon who removed Trezona's gallbladder also managed to extract a small portion of abdominal tissue containing the two centimeter long wire.
A few days after his operation Trezona took the wire he had detached to the pathology lab for comparison with the one retrieved from his stomach. Under the microscope it was an exact match down to the carbon pattern, which was determined to be burned barbecue sauce.
"It was just incredible," said Trezona, who had already tossed his grill brush.
Trezona, who has fully recovered, said that his two-month ordeal stirred memories of some of his oncology patients. And it led him to appreciate in a way he hadn't previously how severe undiagnosed pain made him feel alone, frightened and desperate, despite his long experience as a surgeon.
"I remember thinking 'I'm dying from this thing, and no one can figure out what it is,'" he said. Gonenne's steadfast support and help, he added, were invaluable.
For Gonenne, Trezona's case reinforced the importance of reviewing images from scans and other primary data himself, not just accepting the conclusions of other doctors. "It's so important when cases aren't straightforward," he noted.
"Tom is phenomenal at that," Gonenne added. "He's very detail oriented."
In Gonenne's view, Trezona's determination drove the search for an answer. "This is not something at the forefront of a work-up for abdominal pain and weight loss," the gastroenterologist observed. "I might ask about aspirin use and medication, but not 'Have you been grilling?'"
But, he added, "It's a case I'll not forget."
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