A Student Ate Gas Station Sushi For Breakfast. This Is What Happened To His Stomach. TB is a 22 year old man, presenting to the
emergency room with facial swelling, shortness of breath, and hives. He tells the admitting nurse that he had had
severe, right sided, lower abdominal pain for at least the last 3 days. You see, TB was a college student. During his freshman year, he found out the
grocery would toss out their expired food, and he could pick it from the waste bin, to
eat. If it was edible, he took it. The grocery would throw away a bag of apples
if even just one was rotten. But to TB, the other apples were just fine. On the internet, he read that over 1 billion
tons of food every year is thrown away. Clearly, this was bad for the environment,
so picking that disposed food and eating it was doing his part. His reward for saving the earth, was eating
for free. As TB became more experienced in finding his
food, he became more relaxed in what qualified as edible. Instead of tossing the rotten apples, he eventually
just ate around it. If bread was moldy, just cut out the bad part—
it’s fine, he thought. (It’s not fine. DON'T.) This got to the point where he’d pick pizza,
hotdogs and sushi from the back of the gas station, at night. TB’s favorite was Monday because that was
when the gas station threw away their weekend sushi. Yeah it’s a couple days old he thought,
but it’s refrigerated. And sealed. No reason anything could be wrong with it,
he thought. So every Tuesday morning, TB had gas station
sushi for breakfast. He did this for months, and he was fine. One Monday night, TB was heating up a suspicious
gas station pizza for dinner. If you heat it up for a really long time in
the microwave, you clean off the bacteria so then it’s no longer suspicious, he thought. (It’s still suspicious btw) Earlier that morning, he had his normal sushi
breakfast before class and was feeling great. But immediately after finishing his expired
gas station pizza, TB felt like he couldn’t breathe. He could feel his tongue expanding. His stomach started to cramp. His face, started to swell. A sensation rippled through his cheeks, as
he was brought down to the floor. As the hours go by, TB laid down in a bathroom,
with minimal relief. He felt his stomach folding over itself over
the next few days. He woke up every night, sweating. His friends made fun of him saying he clearly
had been getting botox because his lips were so swollen. He couldn’t take it anymore as he brought
himself to the emergency room where we are now. At examination, TB’s abdomen was a little
swollen. There was tenderness in the right lower quadrant. There was nothing suspicious about his stool,
but his blood test was borderline. Counts of his white blood cells were near
the upper limit of normal. Could be a problem. Maybe not. TB told the doctors about his food habits. He had been garbage picking for so long and
had so many successes that he was proud of all the money he saved himself. He told them he was sure that whatever he
picked out the garbage wasn’t rotten, hadn’t come into contact with flies or rats, and
that he always physically examined it himself, visually, and by smell. He told the doctors that the expired gas station
pizza he last ate was suspect. He knew beforehand that it was sketchy. Maybe he didn’t microwave it long enough. But, he also forgot to mention anything about
sushi because he didn’t think anything of it. It was definitely the pizza. Over the next 6 hours, TB was observed and
the physical exam was repeated. Abdominal tenderness, guarding and rebound
tenderness were found in the right lower quadrant. If you look at an anatomical model, this right
lower region of the abdomen is where the appendix is. A CT scan showed inflammation in the area
and other features pointing to appendicitis. TB was sent in for appendectomy, the removal
of his appendix. Appendicitis is caused by a blockage of the
appendiceal lumen, or hole. The blockage could be from undigested food,
from some inflammation, or maybe that twisting and turning he felt in his stomach was actually
his appendix, doing just that. But the reality was, after it was removed,
TB’s appendix didn’t really look that inflamed. It was kind of normal and unremarkable. The region around it also looked ok. The surgeon told TB afterwards that they had
seen worse. The doctors advised TB to stop scavenging
his food. To just get a meal plan from the cafeteria,
or something that didn’t involve garbage. TB argued back that cafeteria food was the
real garbage as he was wheeled off. And his surgical recovery was uncomplicated. At the end, he felt, a little better. At home now, TB started picking expired food
again, but this time, no more pizza. In a few weeks after his surgery, he started
creeping back to his old foods. During this period, TB would start to experience
crampy abdominal pain. Sometimes, he’d sit in the bathroom and
struggle for a movement. Every day, he’d feel exhausted, and tired. (Students, what are you thinking here? Crohn's? IBD? Why/why not UC?) The next day, TB went to the gas station. For the first time, he bought the sushi that
he had been picking from the garbage all these months. He was going to have a legitimate breakfast
this time. Immediately after finishing this raw fish,
a rash quickly developed all over TB’s body. His face started swelling, and he became short
of breath. His stomach started cramping. As he got down to the floor, his roommates
called for an ambulance, and he’s brought to the emergency room, again. On examination this time, TB’s blood pressure
was 60/30. He was in anaphylactic shock. Epinephrine, also known as adrenaline was
administered to him with fluid resuscitation, to increase his blood pressure. This is so that oxygen can get to his organs. Over the next several hours, TB was managed
as he was admitted into the hospital. This sudden onset abdominal pain and nausea
with a history of constipation could mean something is blocking his intestines, and
TB would likely need surgery, again. An abdominal radiograph showed markedly dilated
loops of bowel, strongly suggesting that there is some kind of blockage going on. A blood test revealed a high count of white
blood cells, meaning TB might have some sort of infection. This was confirmed because at surgery, parts
of his intestines by where his appendix used to be were removed. The finding showed that the inside walls of
those removed parts were thickened, and accompanied by inflammation, meaning white blood cells
swelled up the region with fluid, causing the blockage. But why would those white cells be there? Looking at samples of that tissue under a
microscope, clumps of immune cells were gathered all around multiple worm-like larva that had
embedded in the tissue, meaning that a parasite, had been living and crawling around this whole
time. In the recovery room, doctors asked TB what
his last meal was, and when he answered gas station sushi, they confirmed, this nematode
parasite is named Anisakis Simplex, a common roundworm found in raw fish. The problem with a parasite found in raw fish
sushi, that causes severe illness, is that it may be more common than you might think. In Japan, at a wholesale fish market, 98%
of its mackerel and 94% of its cod, was found to carry Anisakis simplex. (Hochberg NS, et. al. See description for references) 40% of fish sold at a market in Spain were
also found to contain the worms. And in the United States, one study found
a 1 in 13 chance of consuming an anisakis larva in salmon sushi, meaning if you’ve
ever had that delicious fish, it’s likely you’ve had contact in some form, with the
parasite. (Adams AA, et. al.) This isn’t by chance. Almost all of us have been warned at some
point in time about eating raw fish, and this parasite’s lifecycle tells us everything
about its prevalence. The Anisakis parasite’s primary hosts are
whales and dolphins, animals called cetaceans. Primary host, meaning that Anisakis lives
as adults in the stomach of these animals. This is important because during the Anisakis
adult life, they lays eggs in their hosts’ stomach. The host then passes these eggs in their feces,
which spread all over the sea. Those eggs develop into embryos in water,
as they hatch into larvae, where they’re eaten by crustaceans like krill. Inside the krill, the larva mature. Krill can then be eaten by larger fish and
squid, who accumulate the parasite. Anisakis grows into an adult inside fish,
and as fish eat other fish, the parasite gets passed on to one another, as the big ones
accumulate a lot of these nematodes. Normally, a whale, or porpoise will eat those
fish and complete the Anisakis lifecycle. But somewhere in this pathway, humans come
in to play. Humans that eat infected uncooked fish that
hasn’t been previously frozen. Me included. Anisakis enters our GI tract. It’s not supposed to be there. It’s not meant to be in an environment like
a human stomach, so it tries to burrow into the mucosa, or the inner lining, where it
wreaks havoc as it damages tissue by digging deeper, to get out. The immune system immediately reacts by sending
huge amounts of white blood cells, and inducing what looks like an allergic reaction, just
like in TB. The story isn’t over for him. After recovering from the surgery, he still
had epigastric pain and nausea. A CT scan showed thickened stomach mucosa. He was sent in for endoscopy, and another
set of roundworms, Anisakis again, was found and extracted, meaning TB was probably exposed
to it, more than once. The normal appearing appendix after appendectomy
meant that he probably didn’t have appendicitis but instead already had Anisakis around the
ileocecal region right by it. The unnecessary operation was suspected by
the first surgeon, but it wasn’t clear at that time what was going on because TB never
told anyone about eating raw fish. They didn’t know what they were looking
for. Anisakidosis is a rare infection, and can
be mistaken for Crohn’s disease, appendicitis, and many others. And without him mentioning eating raw fish,
the doctors missed that possibility altogether. The leftover pizza that TB kept talking about
at that first hospital admission COULD have caused food poisoning. But abdominal pain in the right lower quadrant,
of his severity, is not typically something you’d get from spoiled pizza. It was only at the second hospital admission
that an Anisakis larva was found in the walls of his intestine. His immune system had been reacting to this
by sending an inflammatory response and white blood cells to the region causing it to swell
and form a structure that eventually obstructed his bowels. Anisakis can’t live inside human stomachs
or intestines for very long, but in some rare cases, they can be absorbed into the liver,
the pancreas, and cause massive damage there that would look like tumors on radiographic
imaging. These parasitic lesions have been mistaken
for metastatic carcinomas in literature. TB’s second infection came after he bought
his gas station sushi. In this case, the Anisakis larva stopped short
in his GI tract and burrowed into the lining of his stomach, causing acute abdominal pain,
and nausea. The rash and swollen face looked like an allergic
reaction and was again, a response by the immune system to a foreign pathogen, as his
body detected something damaging his stomach. All of this from raw fish sushi that was likely
not handled well, because while Anisakis is relatively prevalent in fish, we have measures
to prevent this from happening. Do you remember that 1 in 13 chance of eating
anisakis in salmon sushi? Well, the study specified that those larva
weren’t alive when found. Anisakis needs to be living to cause problems,
because it causes that damage by burrowing into mucosa, and it can’t do that if it’s
not alive. And in the United States, most salmon served
raw is frozen first, which would kill the nematode, but also mean that you would still
have eaten a deceased worm anyways. That 8% is kind of unsettling if you think
about it. There’s really no way to prevent what happened
to TB, other than to just not eat any raw fish at all, cause unless you do it yourself,
you may never know who prepared the food, or how it was prepared. It’s no surprise that of all the anisakis
cases reported, majority of them come from coastal Japan. Although there’s been an increase of reports
from coastal regions of Europe, notably Spain and Italy, as well as from South America. If you’re in the United States, eating sushi
from a well known restaurant, that has a good track record is probably going to be ok. But for sushi packaged from an unknown place,
and put on a shelf, where it’s left for a couple of days, and then discarded because
it’s past its sell by date, well I hope you’re now aware of the risks if you’re
thinking of eating that. Having learned a valuable lesson in food caution,
through permanently losing parts of his GI tract, TB was able to make a recovery. Please don’t let this video make you be
scared of sushi. I still eat it once a week. That study that said 1 in 13, well they were
all dead larva, and this study was written in 1990. I would at least hope it’s a little better
today. But I can’t say for sure. So if you have any medical friends who refuse
to eat sushi, it’s because they’ve heard of cases like this one. It’s still a rare occurrence here in the
US because we’re pretty good at handling our food. Just be careful of what you eat. Take care of yourself. And be well!
