Root Beer, the Other Bodily Fluid

“Kriegs, I’ve got a paracentesis for you… she’s becoming a regular… uh, Dixie Johnson. I don’t think you’ve done one on her yet.” Mary Sue, one of our ultrasound technologists, raised her eyebrows quizzically looking for my reaction to see if I’m grumpy and bothered or if I’m in a receptive mood to do this procedure. (By the way, I only occasionally get grumpy!)

“I know that name, but I don’t think I’ve done a para on her before.” Then I remembered. A few weeks ago she had been bleeding internally after a surgery and I embolized a small artery on two occasions. Both times it had only worked for a day or two and she re-bled. After the second time, they took her back to surgery and successfully stopped the bleeding. Now, apparently, she was having a problem with fluid in her belly, ascites.

In the ultrasound suite, the patient was waiting for me, lying on the table. She seemed a bit groggy, but much more alert and alive than when I last saw her. Her belly was protruding making her look like an undernourished third world child. She was in her thirties, but looked older. Mary Sue had set up a tray for me and was standing in a rather impatient position with her right hip jutting out and the ultrasound probe in her left hand sort of dangling there, like she had been standing there for hours.

“It’s about time the doctor got here!” I joked. “Hi, Dixie, I’m Dr. Kriegs.” We’ve met before but you may not remember me.” She had been pretty out of it when I last saw her. “We are going to drain some of the fluid again from your tummy just like before. Okay?”

She nodded her head and looked at me but didn’t say anything.

Grabbing the probe from the “patiently” waiting Mary Sue, I started scanning Dixie’s tummy to localize a spot to insert a catheter to drain the fluid. But something struck me as odd.

“Looks like… bubbles?”

“That’s how it has looked the last few times. We thought it was just debris floating around.” Mary Sue had been present for the last couple of drainages on Dixie.

“Very strange. It looks like …” I paused, not sure I should say it, “…bubbles that are streaming, like when you first pour a Guinness… I think it’s carbonated!” Mary Sue and I chuckled a little, since that was rather preposterous. Still, I wasn’t comfortable about it. “We need a CT first. I want to know if this is air and, if so, figure out where it is coming from.”

If this was air, my main worry was it might be from infection. I looked up the results from the previous fluid analyses (from her other drainages) and there had been signs of fairly significant infection, which was being treated with very powerful intravenous antibiotics. Another uncomfortable thought or fear was she might have a bowel perforation. With that, she would probably be quite a bit sicker, but sometimes patients do okay for a while and then crump all at once. A CT was needed.

The CT appearance was striking. There was a lot of air layered with the fluid. However, the large space containing the air and fluid was loculated, or partitioned off by a rind of thick tissue. This rind of tissue was consistent with her known infection. But the large amount of air was very suspicious for a leak from the GI tract. I noticed a tube in her stomach, a gastrostomy, was in place, and it appeared to cross through this air-fluid space on its way from the skin to the stomach. Could she be leaking from around the gastrostomy?

“She doesn’t need just a paracentesis; she needs a drain left in that space. Looks like an abscess. Let’s just do it here. I don’t need ultrasound for this.” Before they set up another tray, I called the patient’s doctor to let him know what I found and what I was going to do and obtained a new consent. “After I place the drain, I think I will take her over to the fluoroscopy suite and inject her gastrostomy… see if it is leaking.”

Using the CT as a guide, I placed a drain into the air-fluid collection. Approximately two liters of brown colored fluid was removed and sent to the lab for analysis. Amazingly enough, the fluid really did look carbonated!

“If I didn’t know any better, I would say this looks like root beer,” I said. The tech and nurse laughed, since this was not one of the standard food/drink analogies.

The patient, who had been sedated, stirred a little and then mumbled, “Love root beer.”

We started to laugh again, but my heart jumped as I remembered the possible leaking gastrostomy site. “Dixie, have you had any root beer lately?”

“I have some every night.” Pause. “It’s my treat.” Now I was convinced. This really was ROOTBEER draining out of Dixie’s tummy!

This time I called the surgeon. He came down with his team to IR as I documented the leak from the stomach around the gastrostomy tube. In an attempt to stop the leak, I exchanged the gastrostomy catheter for a larger tube, with an internal balloon and external button, trying to pinch the wall of the stomach up against the abdominal wall.

This combination of a new gastrostomy and the drain I placed in CT was not successful; a CT the next day showed no real change. They had to take her back to surgery. Dixie’s initial surgery had been for a benign pancreatic mass. The same surgeon operated on her again this time.

“Kriegs, you gotta come see this!” Surgeons always have a knack of paging me right as I’m going to lunch. He was in the O.R. with Dixie and had definitely grabbed my interest, so I ran up to the O.R. and looked over his shoulder at Dixie’s open tummy.

“Hey, Kriegs, thanks for coming up. This is the space with the root beer… look at this rind of thick tissue totally covering everything… we call it an orange peel.” Just an analogy in this case. “The inflammation has caused this prolific tissue granulation and scarring.”

He was right; the texture looked like an orange peel, only more of a light maroon color with whitish areas. No identifiable features of any underlying organs… they were totally covered.

“This is going to be very difficult to deal with. I need to keep a gastrostomy tube in place after I’m done, but I don’t want any feedings into the stomach. Can you get a tube through the stomach into the small bowel so we can use it for feeding?”

“As a matter of fact, the type of tube I put in downstairs has an option with a jejunal limb for that exact purpose.”

Working in surgery always amazes me; always something new. I had never put a gastrostomy tube in while holding the stomach in my hand. Except with Dixie, it was hard to tell stomach from anything else, which is why the surgeon needed me. With the portable fluoroscope supplementing the “feel” of things, it was fairly simple to get the tube in through the previous hole and advance the extra limb far into the small intestine. The surgeon then sutured everything tight to prevent leaking and tossed in two large drains to boot.

It took quite a bit of time, but Dixie eventually healed and went home. She never lost her taste for root beer, but was instructed to abstain for several months, until the gastrostomy tube was out and the tract healed.