Sauce of the Problem

By CodingStrategies on May 18th, 2018

Anyone can be forgetful. For example, people might forget computer program passwords, the name of a casual acquaintance, to feed the pet, take off the stickers before they wash new clothes, take medicine on time, take out the trash, or where they left their purse, wallet, keys or cell phone. Professor Einstein was once traveling from Princeton on a train when a conductor came down the aisle, punching the tickets of every passenger. When it was his turn to present his ticket, Einstein reached in his vest pocket. He didn’t find the ticket there, so he checked his trouser pockets. Still no ticket, so he checked his briefcase and the seat beside him. The ticket was not found in either location.

The conductor said, “Dr. Einstein, I know who you are. We all know who you are. I’m sure you bought a ticket. Don’t worry about it.” Einstein nodded appreciatively and the conductor continued down the aisle punching tickets. As the conductor prepared to move on to the next car, he turned to find the great physicist down on his hands and knees looking under his seat for his ticket. The conductor rushed back and said, “Dr. Einstein, Dr. Einstein, don’t worry, I know who you are. No problem. You don’t need a ticket. I’m sure you bought one.” Einstein looked at him and said, “Young man, I too know who I am. What I don’t know is where I’m going.”

A 41-year-old British woman began experiencing pain and bloating in her abdomen, so she sought medical attention in 2011. In general, her pain typically lasted for about three days, subsided and then returned. Her appetite was normal, she wasn’t losing weight and her blood tests did not show anything unusual. She was not infected with an intestinal parasite, but a colon biopsy demonstrated some polyps which could be a sign of Crohn’s disease, also known as regional enteritis (ICD-10-CM category K50.-). Crohn’s disease is an inflammatory bowel disease that most commonly occurs in the last section of the small intestine (ileum) or the large intestine (colon). Typical symptoms include diarrhea, abdominal pain, fatigue, unexplained weight loss, and blood and mucus in the feces. Although some cases can be severe, mild, chronic Crohn’s disease is not uncommon.

The physician prescribed an anti-inflammatory drug and continued to monitor the patient. Four years later, the pain had moved lower down in her abdomen. In the absence of a tumor or infection, her doctors continued to treat her under the assumption that she had chronic Crohn’s disease. Even with medication, the patient’s condition worsened and she was admitted to the hospital four times due to small bowel obstruction attributed to the Crohn’s disease (ICD-10-CM code K50.012, Crohn’s disease of small intestine with intestinal obstruction). MRI enterography revealed a thickening of her intestinal walls, with multiple bowel strictures and dilated ileal and jejunal loops. Her doctors considered changing her medication, but due to the repeated hospital stays and worsening pain, they opted for surgery. The surgery changed everything.

During the operation scheduled to remove part of her bowel, the surgical team noticed a mass at the very end of her small intestine. Closer examination revealed two pieces of plastic bearing the iconic logo “Heinz” on them; these foreign bodies had perforated the ileocecal junction of the woman’s intestine, leaving it inflamed. This means that the actual source of continued pain and inflammation was not Crohn’s disease, but was instead a condiment package lodged in her small intestine. ICD-10-CM codes for the patient’s condition include:

K52.89                    Noninfective gastroenteritis and colitis, unspecified

S36.438A              Laceration of other part of small intestine, initial encounter

T18.3XXA              Foreign body in small intestine, initial encounter

The physicians removed the six-year-old plastic condiment wrapper pieces, and the symptoms dissipated almost immediately. The operation and postoperative recovery were uneventful, and the patient remains asymptomatic. The patient has no memory of eating the sauce packet, nor does she remember a meal where this packet may have been inadvertently consumed (although it might be difficult to recall a single meal from six years ago). Nearly 80 percent of foreign objects pass through the gastrointestinal tract without the need for intervention, and doctors state that this case marks the first time synthetic plastic packaging mimicked symptoms of life-altering Crohn’s disease. Perhaps this scenario gives a whole new meaning to watching what you eat.



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