If you were to hear hoofbeats approaching, what would be the first think you'd think of? Like the vast majority of people, you'd probably think of horses, right? Of course you would, because that what all rational, sane people would do. I think of horses also, but I also think of zebras. Why zebras? A zebra looks like a horse, its hoofbeats sound like a horse, hell it may even smell like a horse, but it is definitely NOT a horse. This is the way surgeons learn to think, because just when we think the diagnosis will be something simple and common (a horse!), it turns out to be something completely unexpected.
The ER doctor called for a young woman in her 20's with abdominal pain. That's certainly common enough - in young people with abdominal pain, my mind automatically goes straight to the horse - the appendix. "Her pain is all over," he continued, "but mainly in the upper abdomen." Ok, the appendix is in the lower right part of the abdomen, so it probably wasn't the appendix. Fine, upper abdominal pain in a woman - it must be her gall bladder. Another horse! I prepared myself to ask about liver function and prior surgeries.
"...and mainly in the left upper abdomen."
Uh...the gall bladder is in the upper right, so that's strike two. There really aren't too many things which cause pain in the left upper abdomen. The spleen is up there somewhere, but splenic pain is very uncommon. Now my mind started thinking about zebras.
The next step was to obtain a CT scan, and as I looked at the images, it became clear that this was definitely NOT a horse. There was something in her stomach that was causing an obstruction. Was it a tumour? Whatever it was, the thing was so big it wasn't allowing the stomach to empty. She needed urgent surgery, so that's exactly what she got.
In the OR, that thing causing the obstruction was not a tumour. It was...a big hairball. Yes, a hairball, one that extended about 30 cm (12 inches) down her GI tract.
After surgery, she was questioned about her, um, eating habits. It turns out that she spent her free time watching TV and eating her wig. Yes, you read that right - eating her wig. And it was also discovered that this wasn't the first time this had happened. Several years before she had had a big ball of cotton removed from her stomach after she had eaten a towel that she had meticulously shredded.
I'm not sure if there is anything more exotic than a zebra that makes the sound of hoofbeats, but I guarantee you if there is, I'll find it. Because whatever that strange creature is, that is what this case was.