Inner Orchestra

Your whole life you have lived healthy. You have eaten healthy and patronized good habits. Your good health and sense of good well being therefore, is not an accident, rather the result of your diligence and calculated choices of life. You are active, fully functional and enjoy the finer things in life, friends and family. Then comes the sudden betrayal of life. You have the urge; you have the sense of immediacy that you always depended on. Except you sit, first for few minutes thinking just taking time would help, then fifteen minutes goes by and then thirty minutes! You strain, perhaps by now with some feeling of nausea, you have looked at the favorite magazine flipping through all of its pages, or surveyed all the pages of the old newspaper that had been left in restroom in forgotten past, you had re-examined every component of the potpourri you had stacked away on the vanity table of the rest room, you even had the second and the third look at the little painting of the flower you had hung on the wall of your intimate restroom only now discovering the little imperfections all the while sitting patiently on the commode sit.  But it won’t come. Not that it doesn’t want to come out, but you have the feeling that something is blocking it, something is not letting it out in the open.

Your colon betrays your wish, your body’s wish, defying the signals of your brain and the spinal cord. You come out of the experience frustrated, sweaty, and fearful; but hope for the best and hope that it would solve itself next time around. You redouble your good diet, increasing fiber, and then you visit your neighborhood’s friendly pharmacy buying some remedies, a probiotic perhaps in addition to laxaitives. But next day is the same and more of the same is the following day. You wonder what’s happening and why is it you? The very thought not only makes you scared but even angry. You have all the terrible thoughts: “Do I have colon cancer?” “What did I do wrong” or “Perhaps I am not still eating right”! You second guess, begin to doubt yourself and your mind goes crazy.

This is exactly what happened to my patient Mrs. X. She grew up in Boston. Following New English Irish tradition her early education was completed in Catholic Schools. She grew up in a single parent home and lived in government housing for a time. Those are the days in Boston’s Catholic bastion, children of single matriarchal family were frowned upon, not that anyone told anything openly, but the unexpressed “there’s something wrong with your family or mother” was evident in their expression and refined New England accent.

When I saw her in the office her complaint was constipation. But not the “normal” constipation that people suffer from! It is the constipation that has urgency of bowel movement but as if her colon is betraying her by not relaxing, an act that is essential for a successful and satisfying bowel movement.

In her interview, I could realize right away that she was a born artist; she was born to sing as she claims. Her sentences with New England accent were rich in inflections, her eyebrows and facial muscles danced together like a performing singer on a stage. Her face bore the aura of a Prima Donna, her lips and eyes moved in an inner drama of conflict reminiscent of Tchaikovsky’s Tatiana. In her adult life she had moved from bustling metropolis of Boston to an obscure Texas town in the somnolent shores of the Gulf of Mexico never singing, never been in stage and thus never fulfilling her dream.

I know her for years. She considers herself a failed artist.

Her heart wanted to be an artist and mind wanted to sing. But realities of life had never fulfilled her dream. Instead, her heart and mind became the ground of an internecine warfare, a war that is eternal, and a war that has no ceasefire.

Quite a few years ago, she visited my office for the first time with a nagging pain on the right upper side of her abdomen, which was worse with eating and at times radiating to the upper back. Extensive investigations including CT scans and MRIs showed a swollen bile duct, but no stone in the gallbladder or no tumor or cancer in liver or pancreas. I finally diagnosed her to be having dysfunction of her bile duct sphincter or guarding valve of the bile duct, known medically as Sphincter of Oddi dysfunction. In this condition the valve of the bile duct fails to open or relax in response to a meal when our food content reaches the upper part of small intestine. Bile carries important enzymes for digestion of fat and protein, so the action had to be very rhythmic, precise and timely, like that of a well functioning orchestra. It is a fine sophisticated action, accomplished by interaction of nerve signals, hormone signals and the influence of the food itself.

To give her a relief, I treated her by cutting the valve of bile duct medically known as ERCP with Sphincterotomy which resolved the problem.

Few years had gone by and she again presented to me with the problem of intractable constipation.

Upon careful history taking she was the example of good life and good habits. Her physical examination was naturally quite normal. She is the picture of health, externally. Having ruled out any other new problem by ultrasound and having ruled out Colon cancer by Colonoscopy, my diagnosis was Pelvic dyssynergia. This is another condition where the complex coordination of our brain, spinal cord and action of muscles of colon, rectum and pelvis fails. This results in failure of relaxation of the muscles and therefore the feces or stool cannot come out.

Human colon is a tube made up of specialized muscles and with a length of four to six feet, it is easily the second longest organ of our body after the small intestine. Near the end is the rectum, there is an angle which is important for bowel control. You can imagine a normal successful bowel movement as the performance of a fine orchestra company where each member performs with a supreme delicacy, expertise and discipline: first your brain determines the proper socially acceptable condition, once this is done, the signals from spinal cord reaches to the muscles and nerves of the colon, and even the other muscles around the colon and rectum that you can partly control. Some muscles shrink, while others relaxing at the same time; thus the last angle of the colon near rectum straightens out and the valve muscles of rectum which normally is shut tight finally relaxes. It happens in sequences and stages, resulting in emptying of the last one third of colon.  Once this is done over a reasonable period time, nerve signals let your brain know that the job is successfully done. And, voila, you perform your socially accepted hygienic duty and come out of restroom smiling.

When the time comes and you feel the urge of bowel movement, body’s inner orchestra has to put up a flawless performance via coordination of the gut, nerve fibers, muscles, nerve centers in the brain and the spinal cord. If any member of this fine orchestra plays out of rhythm, the whole orchestra flops.

Mind-Gut Axis, also known as Gut-Brain Axis is well known phenomenon in medicine. Simply stating, it speaks of the intimate communication and correlation of the brain and gastrointestinal tract using various path including nerve fibers, muscles, brain centers, spinal cord, hormones and even gut microbiota or bacterial population of the intestine. Many of us carry the scars of our minds and manifest it through the actions of our gut. Like any disease,  it is a spectrum of manifestations: as simple as discomfort to major dysfunction of bodily function, from simple pain to disabling pain, from hiccups to nausea and vomiting, from upper abdominal cramps to severe lower abdominal cramps to diarrhea. It could masquerade from chronic diarrhea to severe constipation. The old adages, “He has guts”, “I have butterfly in my stomach”, or “gut feeling” truly has basis in human anatomy and physiology.

In my daily practice, I come across people with these conditions. I try to explore their inner world to get an insight into their condition. All constipation and all abdominal pains are not created equal. Patients in this world are hungry; their hunger is for an adequate explanation and then treatment of their condition. This is only possible by a physician who is willing and is personally interested to delve into the inner hidden orchestra of each human body. With careful story, each wound of our mind could be unraveled and managed.