[MHS: Episode-75] Part II: The Moment of Diagnosis
[MHS: Medical Human Story]-Episode 75
Prologue | Part 1 | Part 2 | Part 3 | Part 4 & Epilogue
Part II: The Moment of Diagnosis
"The images said nothing. Yet they contained every answer."
"A great radiologist is not someone who merely looks at images. A
great radiologist is someone who can hear the silent truths hidden within
them."
The Emergency Room at 2:17 A.M. and an Exhausted Face
The analog clock hanging on the wall of the emergency department
physicians' station showed 2:17 A.M.
Min-jun lay on the emergency room bed, still trapped in an endless cycle
of vomiting.
Hours had already passed.
There was no food left inside his stomach—not even a small fragment of
something he had eaten earlier.
And yet his body continued to forcefully expel something.
Gastric acid.
Bitter yellow bile.
Only empty retching remained, rising painfully from deep within his
abdomen and burning his throat.
The emergency department nurse quickly inserted a large-bore intravenous
line to prevent severe dehydration and electrolyte imbalance.
Normal saline and intravenous fluids began flowing rapidly.
The on-call surgeon approached and carefully examined his distended
abdomen, repeatedly checking for tenderness and rebound tenderness.
Emergency blood tests were drawn immediately.
Fortunately, the initial laboratory results remained relatively stable.
His white blood cell count and inflammatory markers had not yet shown a
dramatic elevation.
There was no obvious laboratory evidence of an advanced inflammatory
catastrophe.
But the patient's own body was telling a far more desperate story than any
cold numerical value on a laboratory report.
His face revealed something beyond the appearance of someone simply
experiencing physical discomfort.
It was the exhausted expression of a person who had spent decades fighting
an invisible enemy.
A person whose body and soul had both been worn down by years of
unexplained suffering.
The Weight of a Single CT Scan and the Call from
PACS
"Beginning contrast injection. Please hold your breath for a
moment."
Inside the CT suite, the mechanical hum of the scanner filled the room.
High-concentration iodinated contrast material began traveling through
Min-jun's veins, rapidly spreading throughout his body.
A portal venous phase contrast-enhanced CT scan was completed,
capturing detailed cross-sectional images of his abdominal organs and vascular
structures.
Then, hundreds of high-resolution images were rapidly transmitted to the
hospital's PACS (Picture Archiving and Communication System).
The dataset included:
- Axial images
- Coronal reformations
- Sagittal reconstructions
Together, they created a complete three-dimensional representation of his
internal anatomy.
I opened the first image file in the quiet darkness of the reading room.
At first, I approached the study as I would any other emergency abdominal
CT.
I expected to evaluate possible inflammation.
A simple obstruction.
Perhaps an upper gastrointestinal abnormality.
Nothing more.
But only a few images into the examination...
my hand stopped.
Under the blue glow of the monitor, my pupils subtly widened.
Something was wrong.
Very wrong.
The First Clue: Massive Dilatation of the Stomach
and Duodenum
The first abnormality that caught my attention was the stomach.
It was enormously enlarged.
The stomach was filled with a large amount of retained fluid and air,
expanded far beyond normal expectations.
But that was not all.
The proximal duodenum, directly connected to the stomach, was also
significantly dilated.
The degree of expansion exceeded what would normally be expected.
If a trainee radiologist or a physician unfamiliar with complex abdominal
anatomy had focused only on this isolated finding, it would have been easy to
misinterpret it as:
- Gastric
outlet obstruction
- Chronic inflammatory narrowing
of the duodenum
- A simple mechanical
blockage
Many clinicians might have stopped their investigation at this point.
But radiology does not work by examining isolated fragments.
The human body is not a collection of disconnected images.
It is a continuous anatomical story.
"In radiology, focusing on only one small region inevitably causes us
to miss the larger disease process. The entire pathway of the gastrointestinal
tract must always be followed from beginning to end."
I moved the mouse wheel slowly.
I began tracing the entire abdominal anatomy.
The position of each organ.
The pathway of the bowel.
The relationship between structures.
The Second Clue: The Intestines That Defied
Anatomical Rules
When I reconstructed the images in the coronal plane and examined the
position of the small intestine, an unsettling anatomical contradiction
emerged.
Under normal human anatomy:
The jejunum and ileum are generally located in the central and lower
abdomen, with a strong predominance toward the left side.
The colon, on the other hand, forms a framework around the abdominal
cavity.
It begins in the right lower abdomen with the ascending colon, continues
across the abdomen as the transverse colon, and descends along the left side.
That is the normal anatomical arrangement.
But Min-jun's CT showed something completely different.
His small intestine occupied much of the right side of the abdomen.
I stared at the image.
"The small bowel... why is it on the right?"
To a non-specialist, this might have appeared insignificant.
A minor anatomical variation.
Something easy to ignore.
But to a radiologist who had reviewed thousands upon thousands of normal
abdominal scans, this was not a small difference.
It was a warning signal.
A major one.
I shifted my attention to the colon.
The entire large intestine was displaced abnormally toward the left
side of the abdomen.
The arrangement was almost a mirror image of normal anatomy.
Not simply unusual.
Not merely variant.
Completely disrupted.
At that moment, a rare diagnosis flashed through my mind.
Like lightning illuminating a dark room.
Adult Intestinal Malrotation.
The Third Clue: The High-Riding Cecum and Twisted
Duodenal Course
With growing suspicion, I immediately began examining the finer anatomical
landmarks.
The first structure I focused on was the cecum.
Normally, the cecum is located low in the right lower quadrant near the
pelvic region, where the large intestine begins.
But on Min-jun's CT scan, the cecum was located far higher than expected.
It had migrated deep into the right upper abdomen, beneath the liver.
A classic finding known as:
High-riding cecum.
To many clinicians reviewing routine abdominal CT examinations, this might
appear to be a minor incidental abnormality.
But in the world of rare congenital gastrointestinal disorders, these
subtle anatomical clues are often the strongest evidence revealing the hidden
truth.
I manipulated the images and followed the course of the third portion of
the duodenum (D3) using three-dimensional reconstruction.
Again, the abnormality became clear.
The duodenum had failed to follow its normal retroperitoneal course.
Instead of passing smoothly behind the pancreas and crossing the midline,
it deviated upward in an abnormal direction.
Every scattered piece of the puzzle was beginning to form one complete
picture.
The Fourth Clue: A Subtle Whirlpool of the
Mesenteric Vessels
The next structure I examined was the most vital pathway within the
abdomen:
the major mesenteric vessels.
The lifelines of the intestine.
I carefully analyzed axial images and vascular contrast-enhanced sequences
to evaluate the relative positions and courses of the superior mesenteric
artery (SMA) and the superior mesenteric vein (SMV).
The two vessels showed a subtle abnormal relationship.
They appeared to partially twist around each other.
It was not the classic and dramatic "whirlpool sign" seen
in acute volvulus, where the bowel twists tightly around its mesenteric axis
like a rope, threatening immediate vascular compromise.
There was no complete intestinal torsion.
No catastrophic vascular obstruction.
But it was also far from normal.
The vascular arrangement was clearly abnormal.
"This is not an acute obstructing volvulus at this moment. However,
it is clear evidence that the bowel and mesentery have been experiencing
chronic, intermittent twisting around the mesenteric axis for many years."
The images remained completely silent.
They made no sound.
They offered no explanation.
Yet hidden within those silent pixels was a serious warning.
A warning that this man's intestine had been living on the edge of danger
for decades.
A warning that, at any moment, a complete torsion could occur and threaten
the survival of the bowel itself.
The Fifth Clue: The Ladd's Band That Was Invisible
Yet Undeniable
There was still one final structure that connected all of these anatomical
contradictions into a single explanation.
The key.
The missing link.
The Ladd's band.
During fetal development, the intestine undergoes a complex process of
rotation and fixation inside the mother's womb.
When this process becomes abnormal, fibrous peritoneal bands may form.
These congenital fibrous bands extend from the abnormally positioned cecum
toward the right abdominal wall and can cross over the duodenum, producing
external compression.
This structure is called:
Ladd's band.
Unfortunately, Ladd's bands themselves are usually difficult to directly
visualize on routine CT images.
Because they are composed of soft tissue with a density similar to
surrounding structures, they often remain hidden.
They do not appear as a clearly visible mass.
They do not announce themselves.
They hide.
However, the indirect evidence spread throughout the CT images was overwhelming.
The CT findings were accusing the hidden structure with remarkable
clarity.
- A massively dilated
stomach
- Narrowing and obstruction
of the distal duodenum caused by external compression
- Completely abnormal
intestinal positioning
- Surrounding anatomical
distortion suggesting chronic partial obstruction
The actual band was invisible.
But the damage it had created was unmistakable.
The invisible culprit had left behind a very visible signature.
What AI Saw in the Images and What a Human Radiologist
Understood
At that moment, the hospital's advanced AI-based medical imaging
analysis system, which was undergoing pilot operation on the central
server, automatically activated.
A diagnostic assistance window appeared on my workstation.
Within only a few seconds, the AI algorithm rapidly performed automated
segmentation of the abdominal organs.
It reconstructed the bowel loops in three-dimensional space.
It tracked the subtle pathways of the mesenteric vessels.
It analyzed the spatial coordinates of the intestinal structures.
Then, in the upper-right corner of the monitor, the system displayed its
findings in a cold, precise text box.
AI Analysis Results
- "High
probability of abnormal bowel loop arrangement detected."
- "Suspected
obstruction involving the third to fourth portion of the duodenum."
- "Recommend
further clinical evaluation and surgical consultation."
The speed and pattern-recognition capability of the AI system were
extraordinary.
It identified anatomical abnormalities within seconds.
It detected relationships that could easily escape human attention.
The algorithm was precise.
Powerful.
Efficient.
But beneath those cold lines of computer-generated analysis, the final
diagnostic conclusion still belonged to me.
Because rare diseases are not solved by recognizing patterns alone.
A machine can identify shapes.
It can measure distances.
It can calculate probabilities.
But diagnosis requires something more.
A true diagnosis requires connecting:
the cold numerical pixels displayed on a monitor,
the young man lying exhausted on an emergency room bed,
the years of vomiting that had stolen his youth,
and the invisible suffering he had carried for 32 years.
Only when those elements are woven together does the complete truth
emerge.
AI rapidly processes enormous amounts of information.
It detects possibilities.
It highlights abnormalities.
It supports clinical decision-making.
But understanding the human story hidden behind the images—
the fear,
the frustration,
the years of being misunderstood,
and the meaning behind a patient's suffering—
remains the responsibility of the physician.
The future of advanced medicine does not belong to humans alone.
Nor does it belong to artificial intelligence alone.
The greatest healing power emerges when these two forces work together:
a cold, precise artificial intelligence system,
and a warm, insightful human expert.
Together, they transform medical images from simple data into a pathway
toward healing.
[🩺 Medical Insight]
Part I: The Beginning of the Disease☜ Previous Chapter
Next Chapter ☞Part III: The Crossroads Between Life and Death
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