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“Belly pain for … a year?” I sputtered. It was the end of his shift, and Vince, the attending physician, was signing out patients. He shrugged at me. “He’s been in jail for six months. Maybe they thought he was malingering. The odd thing is, I did feel a tender mass on the right.” I glanced at the young African American man on the stretcher. The handcuffs and two guards with him did, admittedly, lower the odds that he was experiencing a real disease. Prisoners are notorious for weaseling day passes to get out of lockup, but Vince looked concerned about this mass he had found.

“An abscess for a year?” I went on. “Not spreading or getting worse? No history of medical problems?”

“None,” Vince replied. “Except he had a perirectal abscess drained a few weeks ago at another hospital.”


“And now it’s better?”

“Almost,” Vince said. “He finished his antibiotics three days ago. It has nothing to do with this year-old pain, though. And the mass is higher up on the right than your typical appendicitis. The CAT scan I asked for is still pending.”

I turned to the prisoner. “Tell me about this pain,” I began. “Does it come every day?”

“It hits me more when I eat, doctor,” he replied.

“For a year?”

“Yessir. Some nights I can’t sleep, it’s so bad. Diarrhea comes too. Then I’m so tired I can barely do my work.”

“Any vomiting?”

“Only when I drank that CAT scan stuff.” On exam, the right middle area of his abdomen did hurt when I pressed deeply; I sensed a fullness, but it wasn’t hard and cancerlike. Whatever it was, it didn’t seem to bother him too much. Plus, you can’t have appendicitis for a year.

“I think you’ll be OK,” I told him. “We’ll check the CAT scan.”

“Thanks, doc,” he replied as the guards looked on with disinterest.

Only a few weeks earlier, I recalled, I had seen a 28-year-old Irish American woman who described four days of sharp abdominal pain. “I keep trying to go, but I can’t,” she groaned. “I’m so constipated.”

On exam, her right lower abdomen was mildly tender. Rare as it is for someone her age to have a stool impaction, I did a rectal exam just in case. Empty. “I don’t think it’s appendicitis or anything acute,” I told her. “A CAT scan would be a lot of radiation for nothing. Let’s give you a bowel cleanout, and I’ll recheck you tomorrow.”

The next day the woman’s misery continued. “I drank everything you prescribed. I’m empty. But I still have to go,” she told me. A plain X-ray showed a bowel empty of stool. This was not constipation. On exam she was still tender in the right lower quadrant. Had I missed a smoldering appendicitis? I bit the bullet and did the CAT scan, but it came out fine.

“There’s no appendicitis. Normal,” I said. Her shoulders sagged.

“Then what is it?” she pleaded. “I’m going crazy.”

My favorite gastroenterologist happened by. “A 28-year-old,” I told him. “No medical history; persistent lower-right quadrant pain and negative CAT scan. Could you take a look?” A colonoscopy, which fiber-optically examines the lining of the intestine, could detect maladies—like cancer and inflammatory bowel disease—that a CAT scan can miss.

“Tomorrow,” he replied with a wave.

For both patients, if the problem wasn’t appendicitis, it still seemed that something must be wrong in the gastrointestinal tract, 25 feet of delicate absorptive tissue exposed to trillions of compounds and microorganisms each day. Its mission: absorb the nutritious and bar the noxious in the things we eat.

Assaulted by everything from hot coffee, alcohol, and cigarettes at the start; stomach acid, bile, and myriad planetary foodstuffs midway; and industrial quantities of anaerobic bacteria at the end, the GI tract comes with its own immune system. Bristling with antibodies and aggressive killer cells, it will clobber any parasite or pathogenic bacterium trying to burrow its way into the body.

Each part of the GI tract performs its own tasks. The stomach, liver, and pancreas launch a barrage of digestive juices, then the small intestine takes in nutrients and essential vitamins. The last segment of the small intestine, the terminal ileum, specifically absorbs vitamin B12 and bile. The colon mostly reclaims water. The stomach (with its ulcers) and the colon (with its tumors) are the best-known sources of medical troubles. The small intestine can make its own brand of mischief, however.