[Medical Human Story - Episode 69] The Memory of the Silent Bile Duct-4
Part III: At the Crossroads of Choice and
Survival
The Second Emergency
The day began with the sky
hanging low, weeping a torrential downpour. Through the window of the Radiology
reading room, thick streaks of rain cascaded down like veins of blood. While I
was scanning abdominal CT images by the glow of the monitors, the internal
phone rang sharply.
"Professor, this is the
ER resident. Patient Kim Seo-yoon has just arrived by ambulance again."
I stood silent, unable to
respond. It wasn't shock or bewilderment. Since the moment I confirmed the
micro-inflammation within her liver in my outpatient clinic a month ago, I had
sensed that this day was, sadly, only a matter of time.
Faster, Deeper
When I pulled back the ER
curtain, Seo-yoon was broken—far more devastated than she had been during her
discharge a month prior. Her face was ashen, drained of all color, and her body
was wracked with uncontrollable tremors. Her lips, parched by a high fever,
were charred and blackened.
"Her NRS (pain score) is
currently 8, Professor. Even after administering Tylenol and analgesics, she is
experiencing severe right upper quadrant tenderness and rebound
tenderness," the resident reported, nervously monitoring her vitals. I
carefully pressed my hand against her abdomen, just below the right rib cage.
"Ah… Ugh! It hurts…
Doctor… please…"
As my fingertips made contact,
Seo-yoon let out a short, stifled scream and twisted her body. The moment I
felt the firm resistance of the abdominal wall beneath my hand, my brain
flashed with a realization. This time is different. This was far beyond
the simple cholangitis from before. It was a clear, dangerous signal that the
fire of infection had penetrated the liver parenchyma more rapidly and more deeply.
What the Numbers Tell
The emergency blood test
results, which arrived in just 30 minutes, confirmed my grim intuition.
|
Test
Item |
Result |
Clinical
Significance |
|
WBC
(White Blood Cells) |
24,000
/μL |
Extreme
elevation |
|
CRP
(C-Reactive Protein) |
28.5
mg/dL |
Explosive
increase |
|
AST / ALT
(Liver Enzymes) |
450 / 510
U/L |
Severe
hepatic stress |
|
Total
Bilirubin |
4.2 mg/dL |
Impaired
liver function |
|
Lactate |
3.8
mmol/L |
Critical/Danger
zone |
Along with the skyrocketing
WBC and CRP, the one number I dread seeing most in the ER—Lactate—was rearing
its head above the danger threshold. The rise in lactate was a silent scream,
indicating that her major organs were no longer receiving adequate oxygen and
had switched to anaerobic metabolism.
"Her blood pressure is
gradually dropping. 90/60 mmHg. Professor, I think she’s entering the early
stages of sepsis," the resident said, his voice thick with concern. I
nodded heavily. The moment had finally arrived; I sensed that the time for a
critical decision, from which there was no turning back, was upon us.
A Step That Cannot Be Delayed
"Get the emergency CT
scan ready now. I’ll read it the moment it’s done. We don't have time to wait
for an MRI appointment."
What was needed now was not
precision, but speed. When a patient’s life is slipping away by the minute, a
doctor must act without hesitation.
Soon, the emergency abdominal
CT images, enhanced by contrast dye, flooded the reading room screen. I
frantically scrolled the mouse wheel to zoom into the right lobe of the liver
and, for a fleeting moment, held my breath. The interior of the swollen bile
duct pouch was filled with murky opacities; the infection had breached the
wall, dissolving the liver parenchyma to create a massive, 4 cm abscess.
Liver
Abscess.
This was beyond a simple
bacterial infection—it was the theater of a total structural failure caused by
the anatomical defects of Caroli disease.
[Medica Insight]
The Threshold of Choice
I called Seo-yoon’s mother
into the ER consultation room. When she opened the door, her eyes were already
bloodshot, and her pupils, devoid of focus, were trembling like aspen leaves.
"Mother, Seo-yoon’s
condition is much worse than it was last time. The inflammation that was
silently progressing over the past month has resulted in a large pus pocket
inside her liver—a liver abscess. The bacteria from this abscess are now
beginning to spread through her blood, marking the onset of sepsis."
Her mother couldn't even
scream. A shock of this magnitude robs a person of their voice. It was only
after a long silence that she managed to choke out the words with trembling
lips:
"…Does she… have to have
surgery? Do you have to cut open her stomach?"
I shook my head and explained
calmly.
"Her current physical
condition and blood pressure cannot withstand an open abdominal surgery right
now. The fastest and safest method is an interventional procedure: inserting a needle through the skin into the abscess to place a drainage tube and draw out the pus. We must proceed immediately."
Choice Always Arrives Late
In clinical practice, the
choices humans make always seem to lag a step behind the velocity of disease.
While we comfort ourselves by saying, "Let’s try medication a little
longer" or "Let’s wait to see the results next week," the
disease inside our bodies continues its path of destruction without resting for
even a second. Disease never waits for human circumstances or fear. That is
why, as a doctor, I must be decisive and cold-headed at every moment.
In the Procedure Room
After the local anesthesia,
the massive monitors in the Interventional Radiology Suite flickered to life.
As a radiologist, I took the scalpel myself and stood by Seo-yoon’s side.
Through the ultrasound, I
aimed for the abscess in her right liver lobe, which was fluctuating in
real-time. Using the X-ray beam of the fluoroscopy as my guide, I carefully
lowered the long, sharp drainage needle through her ribs and into the liver. I
had to penetrate the center of the abscess with pinpoint accuracy. It was a
hair-trigger moment where even a slight error could rupture surrounding blood
vessels.
"Target fixed. Inserting
guide wire."
As the tip of the needle
settled into the abscess, a thick, dark, greenish-brown pus began to flow
through the tube. The acrid, pungent smell of infection filled the air of the
procedure room.
I closed my eyes for a moment,
then opened them. The reality of the disease—the very thing that had been
hiding behind the monitors—was raw and tangible at my fingertips.
The Meaning of Saving a Life
The procedure was a success.
The drainage tube (PTBD) was safely positioned in the deepest part of the
abscess, and the pressurized pus poured into the drainage bag. As Seo-yoon left
the procedure room, her blood pressure on the monitor began to rebound,
stabilizing.
Yet, as I removed my
procedural gloves, I could not feel true joy. I knew too well what this success
meant. This was not a cure that uprooted the disease entirely. It was merely a
"temporary brake"—a way to buy time for a young life that was about
to collapse from sepsis that very night, delaying the inevitable by a few days
or months.
The Question Faced Again
Four days later, Seo-yoon’s
condition had improved significantly after moving from the ICU to a general
ward. Her fever had subsided, and the pus draining from the tube at her side
had turned into the clear color of bile.
During the afternoon rounds, I
pulled up a chair to her bedside. Gazing at the drainage bag hanging from the
IV pole, Seo-yoon looked at me with clear, yet deeper eyes and asked:
"Professor… I’ve
weathered the immediate storm, right? But… do I have to live with this drainage
bag at my side for the rest of my life? What is going to happen to my life
now?"
The fundamental, inescapable
question of her battle with illness—one that we eventually had to face—was
finally thrown at me, not in the office, but at the bedside. I took a deep
breath, reached into my pocket, and took out a blank sheet of paper and a pen.
Three Paths
I drew three long, parallel
lines on the paper and began to explain that these were the three paths of fate
lying before her.
- Conservative Treatment: Antibiotics + repeated drainage (Progressive liver
damage)
- Surgical Resection: Partial resection of the right liver lobe (Only possible if the
disease is localized)
- Fundamental Transplantation: Total liver replacement (Ending Caroli disease
completely)
"Seo-yoon, we have three
options. The first is conservative management. We continue as we are—coming to
the ER whenever you’re in pain, getting antibiotics, and draining the abscess.
But your liver will continue to deteriorate. The second is surgical resection;
if the lesion is confined to the right lobe, we can remove that entire
problematic segment. And the final, third path is…"
I paused and looked between
Seo-yoon and her mother. The heavy word slipped through my lips:
"Liver Transplantation,
where we replace the entire liver with a new one."
A suffocating silence filled
the room. Only the rhythmic, artificial beeping of the patient monitor from
behind the next curtain broke the stillness.
The Heaviest Word
"Liver… transplant? Am I
in a state where I have to receive someone else’s liver just to survive?"
Seo-yoon rolled the word
'transplant' around in her mouth, as if in disbelief. To someone in their
mid-twenties, 'transplant' doesn't just feel like a medical treatment. It is
the heaviest and most colossal declaration in the world—a requirement to sever
the trajectory of her ordinary life and walk into a fate of an entirely
different dimension.
The Patient’s Eyes
"Professor… please tell
me honestly. Will I… be able to get married like others, have a job, and live a
long life? If I can live, I’ll do anything."
Her gaze was trembling, yet a
fierce, burning attachment to life—a desire not to be wretchedly defeated by
this disease—was blossoming like a flame. I looked directly into her eyes,
refusing to look away, and answered with the strongest conviction I could
muster.
"Yes, Seo-yoon. You can
live. And you can live a long, healthy life, enjoying all the daily routines
that others take for granted. Modern liver transplantation outcomes are far
better than you can imagine. But to achieve that, you must cast aside your
vague fears and make a courageous 'choice.'"
The Guardian’s Resolve
Her mother, who had been
listening to my explanation in silence, finally wiped away the tears she had
been holding back and spoke in a firm tone.
"Doctor, can I give my
liver to Seo-yoon? If my organs are a match for my daughter, you can cut me
open as much as you need. Please, proceed with the transplant
immediately."
"Mother, fortunately,
Caroli disease is a good indication for transplantation, as it removes the
structural cause entirely, allowing us to expect a cure. However, this is not
an emergency that requires you to be on the operating table tomorrow morning.
We will let the inflammation subside completely with the current drainage tube,
recover your daughter's strength, and then judge the donor compatibility
through precise testing to find the safest possible timing."
A Doctor’s Honesty
I did not indulge in
unconditional optimism or unfounded hope for the patient and her guardian. It
is also one of a doctor’s most important roles to show the harsh reality of the
disease as it is, and to ensure they accurately recognize the size of the enemy
they must fight.
"However, you must keep
this in mind: as time passes and infections recur, liver function will decline,
and the difficulty and risks of the transplant surgery will rise in proportion.
In other words, the necessity and urgency of the transplant will only become
clearer over time."
The Patient’s Choice
Three days later, during
morning rounds, Seo-yoon sat upright in bed, cradling the drainage tube at her
side protectively. Her expression was much calmer and firmer than it had been
three days prior.
"Professor… I cried all
night with my mom, and I thought a lot."
She exhaled deeply and looked
into my eyes.
"I… I won’t avoid it.
I’ll prepare for the transplant surgery. It’s scary, but I don’t want to live
the rest of my life bouncing between emergency rooms, carrying a ticking bomb
in my stomach. I want to fix my life with my own hands and start over."
Her choice was more than just
a decision to undergo surgery; it was a grand declaration of life—an act of
reclaiming the autonomy of her life, which had previously been under the
dominion of disease. I nodded, feeling a deep, burning sense of respect rising
from within.
A New Battle
Of course, a liver transplant
does not immediately guarantee a perfect 'happily ever after' for her struggle.
It is merely the beginning of another massive, fierce war on a different
dimension.
The potential for acute or
chronic rejection after surgery, the immunosuppressants that must be taken at
precise times every morning and night for the rest of her life, and the
physical limitations that make her more susceptible to infection. Yet, compared
to the terror of sepsis that had forced her to risk her life in the ER every
month, this was clearly a 'beautiful opportunity'—within the realm of the
manageable and the predictable.
A Doctor’s Record
I returned to the ward
station, closed Seo-yoon’s digital chart, and was overcome with deep emotion.
Three months ago, the fragile
twenty-four-year-old girl who had lightly knocked on my office door,
complaining of epigastric pain without knowing why, was gone. She had grown
into one of the toughest fighters in the world, capable of staring directly at
the reality of the massive tragedy that had befallen her body and rolling the
dice of a giant choice for her own survival. And I, the doctor who had watched this
process in real-time, felt the soul of a clinician facing disease becoming
firmer and more profound as well.
[Medical Insight]
The Calm Before the Storm
The ward, where the sun was
slowly setting, was eerily quiet and peaceful. The torrential rain had long
since stopped, and through the washed-clean window, the vibrant red glow of the
sunset was warmly illuminating Seo-yoon’s bedside.
Seo-yoon was quietly gazing at
the sunset outside. I walked over and stood quietly by her bed.
"Seo-yoon, are you very
scared?"
At my low question, she turned
to look at me and gave a faint, yet the most beautiful smile in the world.
"Yes… I really am scared,
Professor. Honestly, I can’t sleep well at night. But… I really want to live a
long, ordinary life like everyone else. I want to live to attend the job
interviews I’ve dreamed of, and I want to buy my mom lots of delicious
food."
In that short sentence—her
fragile cry, "I want to live"—the pain of the struggle we had both
walked through and all the answers to the massive surgery ahead were clearly
dissolved. I nodded silently and held her hand tightly.
[Medical Suggestions-Part III]
I closed the ward door and
stepped into the hallway, pulling my coat collar tight against the cold. The
massive story of a twenty-four-year-old human named Kim Seo-yoon and her
collision with disease had reached its most intense climax—the crossroads of
life and death. Yet, this was by no means a tragic end. It was simply the
beginning of a brilliant survival, taking the first great step to break the
chains of disease and begin a completely new, second trajectory of life. The
evening breeze blowing down the corridor felt all the more refreshing.
This story is a web novel adapted from the content at: https://leesangbock.blogspot.com/2026/06/caroli-disease-mri-central-dot-sign-radiology-guide.html |
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