“Well, how many times a day do you have a bowel movement?” I asked. “On average.”
“Five or six,” she said.
There’s a pad of paper on my desk, and I nibble all day long.
“You have five or six BMs a day? Every day?” I queried, my raised eyebrows no doubt betraying my surprise.
“Sure,” she said. “Doesn’t everybody?”
I remembered an old adage: Listen to your patients; they’ll tell you what’s wrong. I ordered new blood tests, and the results suggested that my patient had celiac disease, one of the most common causes of malabsorption. A biopsy of her small bowel confirmed the diagnosis. Celiac disease is a disorder that can crop up among people with a genetically influenced sensitivity to a protein found in wheat and related foods. When one eats these foods, the intestine becomes so inflamed that nutrients aren’t absorbed well. Other symptoms are cramps and diarrhea of varying severity.
The treatment for celiac disease is to eliminate gluten, the offending protein, from the diet. That means avoiding all foods containing wheat, rye, and barley. Once gluten is no longer present in the diet, the gut heals itself and regains its ability to absorb nutrients.
I told my patient of her diagnosis and explained that the problem was readily fixable. The new, wheat-free dietary regimen outlined by the dietitian to whom I referred her wasn’t terribly appealing; she agreed to stick to it nonetheless. Three months later, her iron level was up to normal. She in turn reported that her paper craving had subsided considerably and her BMs were much less frequent.
“Well, there you go,” I said to myself. “Diarrhea gone, iron deficiency gone, and pica gone. A diagnostic puzzle turned into a therapeutic hat trick.” But my self-satisfied ruminations were cut short when my patient grumbled, “You put me on this wheat-free diet.”
“Yes,” I said, “and you’re doing much better, no?”
“No. Look at me. I’ve gained more than 15 pounds. None of my clothes fit me anymore.”
I checked her chart to confirm the weight gain. In a flash I realized that this once slender woman not only had regained the ability to absorb iron but was also now absorbing most of the calories she ate. In the past she had been able to consume whatever she wanted with impunity. Not anymore. She’d gotten heavier, and it was my fault. I had to suppress a rueful smile as another old adage came to mind: No good deed shall go unpunished.
My patient worked in an industry that placed a premium on personal appearance, and the frustration in her voice made it clear that she would willingly have returned to her six daily visits to the toilet and frequent snacks of Post-its if only she could have her thinner body back. I empathized with her and explained what had happened. I then spoke to her about a low-calorie diet to reduce her weight. Given how highly motivated she was, it wasn’t long before she shed the unwanted pounds.
H. Lee Kagan is an internist in Los Angeles. The cases described in Vital Signs are real, but patients’ names and other details have been changed.
