Page 149 Guide to Pain Management in Low-Resource Settings

Chapter 18

Abdominal Cancer, Constipation, and Anorexia

Andreas Kopf

Case report fl ammation,” said he just needed some rest, and gave him
diclofenac (75 mg t.i.d.) as a painkiller.
Yohannes Kassete, 52 years old, and married with Taking diclofenac regularly in an adequate dose
four children (12, 15, 21, and 23 years old), is a cook instead of irregular 500-mg doses of aspirin actually re-
born in Addis Ababa, who has found work in the rail- lieved most of the pain for some time, so that Mr. Kassete
way restaurant of Nazret. About four times a year he could resume his job in Nazret. Being a cook, he was a
travels on the Djibouti-Addis Ababa railway to see his little overweight, so he did not mind that he was losing
family at home. weight over the next 3 months, since he did not feel like
When he fi rst experienced stomach pain, he sus- eating. When he started to have some nausea, he also
pected that he did not tolerate food as well as when he reduced his fl uid intake. Unfortunately, he then started
was younger. Also, he attributed it to his increasing sor- to experience increasing diffi culty relieving himself. Pa-
rows because business was deteriorating. Common aids paya seeds, he knew, would help, but that did not relieve
such as aspirin and an occasional smoke of “bhanghi” him of the abdominal pain, which he attributed solely to
did relieve some of the symptoms, but not all. Th e next constipation. With decreasing weight, increasing upper
time he was traveling to Addis Ababa he felt almost re- abdominal pain, and recurrent nausea, he was seen at
stored, but when he was with his family, he was struck the local health station. Since the pain was radiating to
with the most intense pain he had ever felt in his life. his back, they suspected some spinal problem due to his
When the pain did not go away the next day, his brother, constant standing and bending in the kitchen, and a x-
who works at the Ambassador Bar, which caters lunch ray of the spine was taken, which showed no spinal prob-
for the doctors of the Tikur Ambessa Hospital across lem. Nevertheless, codeine 50 mg p.r.n. was prescribed.
Churchill Avenue, made an “unoffi cial” appointment Mr. Kassete felt weaker and weaker, and when the pain
with a doctor of internal medicine. increased, he increased his dose of codeine. Since he was
Although Yohannes was reluctant to see the doc- worried, he used his next trip to his family in Addis Aba-
tor, his brother pushed him until he agreed. On physical ba for another visit to the doctor his brother knew.
examination, the doctor suspected a “mass” in the upper When this doctor was not available, he was seen
left abdomen and scheduled an abdominal sonography. by another colleague from the internal medicine depart-
Th e results were devastating; cancer of the head of the ment, who admitted him immediately when seeing him:
pancreas was most likely. Th e doctor did not dare to re- he had a maximally extended abdomen, with no bowel
veal the diagnosis to Mr. Kassete and talked of “some in- movements on auscultation. Rectal examination revealed

Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 137
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
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