When Wait and Watch is all you can do....

I am glad to be back in school, after 8 weeks of government stalemates that resulted in me losing the opportunity to graduate this year. Being a KCSE graduate for the last 7 years I was glad to have to update my CV. Anyway I was back to my old schedule, waking up at 6am and sleeping at 1am. I was still in internal medicine when I first met Steve*. Steve was a 39yr old man from Nyanza, he was living the African dream: he had two wives. Well it was more in theory than it was practical. His first wife had ran away. He came to the hospital in company of his second wife. 


The mass in his belly had gone on for long enough, even after countless trips to the local herbalists and countless massages from his life partner. He had walked in from a hospital in Bungoma, following an abdominal ultrasound, where they decided to send him over for further management.

I pulled out a stool, sat next to the bed and took out my writing pad. He had felt his belly swell up for seven months. At first the pain was mild but now it had become unbearable. He had also developed two masses on his scalp. His children would ask why he was developing horns. I found this curious; never had I encountered such a presentation. After a thorough examination, I noticed that his liver had put out. His eyes had turned yellow over the past few weeks and his liver was full of large firm nodular masses. He was experiencing recurrent nose bleeds and his feet were swollen. My first thought was liver cancer - Hepatocellular carcinoma. The thought of alcohol induced macronodular cirrhosis was knocked off by the fact that he did not take alcohol. I also suspected lymphoma or metastasis from other possible tumors. So I sent blood for labs. the ultrasound result from Bungoma confirmed my suspicions. As with any cancer diagnosis, ‘tissue is the issue’, and one can hardly commit to a diagnosis up until he had examined a biopsy. But Steve’s case was more of a dilemma, if we attempted a get a tissue sample, there was a great chance he would bleed out on the table. The decision was made to turn to tumor markers (this are blood tests used to help point to particular tumors). His unfortunately pointed to hepatocellular carcinoma.

This was bad, the definitive treatment would have involved having a liver transplant, this was not an option in Kenya. His HIV and Hepatitis B tests came back positive. I sat down with the couple and leveled with them taking time to listen to their questions and explain the diagnosis that we had found: it was not easy. However, they were very understanding. We tested his wife and she turned out negative for HIV and Hepatitis B, I advised her to get tested after three months.

Over the next few days, Steve’s condition deteriorated, from a man who could once hold an entire conversation to being bed ridden. He was going through the stages of hepatic encephalopathy, he spent most days asleep with his wife seated by his side. She slept on the floor beside his bed, even after having the knowledge that he was probably never going to make it. A few days earlier, he had a head CT scan that we had scheduled. When I walked into the ward, she handed me the scan with a smile on her face, hoping that it would hold a message of hope. I held up the radiograph: It had a large brain mass that was continuous with the two scalp masses I had seen. It was surprising that he was able to hold a conversation just a few days ago. She read my expression, “Has it gone into his brain?”.  

“Unfortunately, sorry.” Those were the most difficult words I had ever had to say.

She told me that she would stay with him to the very end regardless. However she requested that they be allowed home to be with family. We promised them we would do that the following morning. Unfortunately Steve passed on early that day.