Sunday, October 18, 2015

9 1/2 Weeks


I met Alice almost by accident. Sunday morning rounds were nearly completed when I passed Dr. T. in the hallway. We exchanged pleasantries and then walked on in opposite directions. But, seemingly as an afterthought, he called out.
“”Do you think you can go by and see a patient for me? Her name is Alice. She’s in room 402. She’s in the hospital with constipation and she’s pretty distended. I plan a colonoscopy tomorrow, but, maybe, just give her a quick look. She had a CT that just showed constipation.”
“Sure,” I replied, “I’m going in that direction anyway.”
Alice was petite, weighing in at 98 pounds and she certainly was distended, almost like she was about to deliver twins. She was 46, had always had “bowel trouble,” had previous back surgery and was on chronic pain medication, taking Percocet several times a day. She had not had previous abdominal surgery.
“Does your abdomen hurt?” I began.
“All over, but the Dilaudid helps,” she replied.
“When did the pain start?”
“About three weeks ago, but it got worse three days ago.”
“When’s the last time you had a bowel movement?”
“Nine weeks before I came into the hospital.”
I had to stop for a moment to completely absorb this statement.
I think this is a record.
“Did you say nine weeks?” I asked again.
“Yes, nine weeks.”
“…and you’ve been here three days, so it’s been nine and half weeks since you had a BM? Is that unusual for you?”
“Normally I go every three or four days. I did start to panic after a week, but I didn’t know what to do.”
“Are you able to pass gas?”
“I’m not sure.”
“Let me check your abdomen.”
She was extremely distended and had diffuse tenderness, and some signs of peritonitis, particularly tenderness to light percussion on the right side of her abdomen.
“I’m going to look at your CAT Scan and then I’ll be back.”
So much for getting rounds done at a reasonable time.
The CT Scan done the day before revealed just what one would expect in patient who had been constipated for nine and half weeks. The colon was dilated, filled with stool, but not much air. The cecum, the first part measured ten centimeters, approaching the diameter where blowout becomes a concern. The dilated colon stopped in the mid sigmoid colon, which is just above the rectum. There was no definite tumor or mass, but there was a definite transition point from dilated to collapsed colon.
I checked her labs next. Her white Blood Cell Count had been slightly elevated at 12,000 the day before, but today it had jumped up to 35,000. Her bicarbonate level was 14, which is low, normal being around 25. Low Bicarbonate suggests metabolic acidosis, a sign of severe metabolic derangement and sepsis.

Taking everything together there was no question. She needed surgery. She either had perforated her colon or she had dead or dying colon. Either way it was a life threatening surgical emergency.
Of course, Sunday is not the best day to get anything done quickly. There were a series of Orthopedic cases scheduled already.
“I need to do this lady soon,” I explained to the crew.
“It looks like you’re in luck. Dr. R. just cancelled his last two cases and we are finishing up with him now,” the OR nurse reported.
I explained my findings and concerns to Alice and her family, put her orders in the computer and waited for the OR crew.
Maybe just a colostomy will suffice. But, it would be better to eliminate the cause of the obstruction. Quick and simple will be best for her.
After about 25 minutes Alice was wheeled into OR room ten and was asleep a few minutes later.
A midline incision through the taut abdominal wall brought me into her abdomen which was filled with a few hundred cc’s of slightly cloudy yellowish fluid. I could see that the sigmoid colon was massively dilated, but it was not gangrenous. There was a faint, pungent odor.
Looks like I should be able to remove the offending portion of colon.
I could see where the colon transitioned to normal caliber just above the pelvis. I began to mobilize the colon by dividing the peritoneal attachments that tethered the sigmoid and left colon.
“Feels like there’s a hard mass in the colon causing the obstruction,” I observed out loud to no one in particular, my assistant nodding her head,
 I should be able to get this colon free and then…
Before I could finish this thought the dam busted and I was suddenly up to my elbows in thick, liquid stool.
“Shit…” Literally.
“Suction, lap, more laps, more suction.”
The suction became plugged with stool. I squeezed the colon closed with my hand and it fell apart. Like The Blob from the 1950’s or the river of slime from “Ghostbusters” liquid stool took over.
“I need an intestinal clamp, something atraumatic,” I said loudly.
The circulator scurried out of the room and came back with the GI instruments. In the meantime I had managed to isolate the source, rather the sources of the river of stool and began to get at least a semblance of control.
          The evil culprit rears its ugly head.
“There’s a big rock of poop causing the obstruction,” I noted.
Indeed, this “fecaloma” had completely blocked the sigmoid colon and eroded into the wall of the bowel, setting a trap for me as I mobilized the colon. As soon as the colon was free it exploded, releasing its noxious contents. The resultant inundation left poop everywhere, on every loop of bowel and filled the pelvis.
With the proper intestinal clamp in hand I stemmed the flow and went on with the resection. I had to make two passes with the GIA to divided the dilated bowel while there was no difficulty dividing the distal colon, stapling it closed with the RL60 stapler.
Home free.
I finished resecting the sigmoid colon and examined it on a separate table.
This colon is as strong as soggy Kleenex.
“Uh, Dr. Gelber, I think there’s a problem here.”
Liquid stool was filling up the abdomen again.
I hurried back to the cesspool which was Alice’s open belly and valiantly struggled to stem the flow again. The staples had not held the friable colon together. Once again, we went to work, sponging and suctioning until I could see enough to mobilize the colon away from its usual position on the left side of the abdomen, find the hole and carefully put a clamp across it.
This time it held, at least enough to allow me to get my bearings and assess the situation in a calmer, more orderly manner. I made a closer inspection of the remaining bowel.
The right side of the colon didn’t look very good either. Muscle fibers in the cecum were split under the tension caused by massive dilation, the ascending colon had patches of frank gangrene as did the splenic flexure.
It all needs to come out.
Back to work. I began by dividing the attachments to the cecum and was then able to liberate the hepatic flexure with minimal fuss and the remainder of the colon followed until everything was free. I zipped through the mesentery with the Ligasure and before long the colon was resting in a large basin on the back table. At this point we all changed gowns and gloves and tried to put banish the pungent odor from our nostrils. Even with benzoin (a fragrant compound often used in surgery) on our masks and repeated washing of hands I knew that the fine aroma of stool and dead bowel would linger with me for the rest of the day.
This nasty beast has been far too much trouble. Time to finish this case.
We spent the next twenty minutes washing, washing and more washing. Liter upon liter of warm saline was poured, sprayed, percolated and pumped into every nook and cranny of her abdomen. We squirted irrigation fluid into the pelvis, above the liver, around the spleen and between every loop of bowel until the fluid came out as clean as it went in.
Finally, I brought the end of the small bowel out as an ileostomy, took one more look around her belly and closed her up. Ensconced safely in the ICU, I washed my hands one more time, wrote orders, dictated the op note and, last of all, told her family the sordid tale of her surgery.
I called Alice’s Attending physician and consulted one of the Pulmonary docs, checked on Alice one more time and finally left the hospital for the day.
Alice was kept on the ventilator, she was very slow to wake up from anesthesia and her blood pressure hovered in the 80’s; occasionally dipping into the 70’s. A massive volume of IV fluid and support with Levophed and Vasopressin were necessary to maintain an acceptable blood pressure. (These two medications help maintain vascular tone, which helps maintain blood pressure in patients with septic shock). Her kidneys started to shut down, but timely adjustment of her fluids and medications by a Renal consultant turned this around.
The following day she looked a little better, more awake, good urine output, but still requiring pressor support with Levophed and Vasopressin. She continued to smolder along over the next 48 hours, neither improving nor deteriorating. I became a little concerned about her abdomen at this time as it became more distended and the ileostomy stoma looked dark purple instead of pink. Her lactic acid level rose to a very high 14, a sign of worsening acidosis, which indicated seriously poor perfusion of something and worsening sepsis. Although she maintained adequate blood pressure and kidney function, it became clear that something was amiss or amuck or afoul.
Alice was taken back to surgery.
The previous wound was opened and a couple of liters of clear fluid was drained.
That explains the abdominal distention.
In the lower abdomen there was some cloudy, foul smelling fluid. As I gently freed up the small bowel and delivered it out of the abdomen I discovered the new source of Alice’s woes. The distal small bowel was dead, not completely, but patches had frank gangrene. I resected about 25 centimeters of terminal ileum and redid her ileostomy.
She also had a portion of abdominal wall which was dying and this also was excised. I put her back together as well as I could and delivered her to the ICU and hoped for the best.
The next twenty four hours brought hope as she required less support with the pressors. However, she didn’t wake up.
The following day came with new events which proved to be too much. She began to have cardiac arrhythmias, frequent Premature Ventricular Contractions (PVC’s) and runs of, Atrial flutter and Ventricular Tachycardia. The Cardiology consultant added his words of wisdom to the already exhaustive list of consultants.
“Acute MI,” he said with a solemn expression on his face. “Ejection fraction is only 30%,” he said shaking his head.
She’s not going to make it.
Alice continued along for a couple of more days, but she didn’t wake up, her kidney function gradually declined and her family wisely withdrew support, allowing her to pass away.
I wish I could report that timely surgery had rescued Alice. I don’t know how many similar patients I’ve taken care of, how many times I’ve told families “We’ve eliminated the source of infection; the perforation, the blockage, the gangrene, the abscess; now it’s time to heal.”
Very often it’s this healing phase which proves to be too much. Organ systems which have suffered the supreme shock of serious systemic infection are unable to recover and gradually shut down. The initial sepsis leads to what is called multi organ system dysfunction which progresses to multi organ failure which often leads to death.
After I finish operations such as Alice’s I’ve learned not to say: “Alice (or Andy or Mabel or anyone) will be better now.”
I’ve learned that the human body often does not suffer lightly intrusions by combinations of bile, blood, GI contents or urine mixed with microorganisms which thrive in such an environment. The body does its best to fight such invasions and may be successful. But, sometimes as the battle is fought and the war looks like it will be won, the body dies.
And, nine and a half week’s worth of poop is more than most of us could handle.