Gou is practicing medicine in the clinic

Li Jingsheng sat in Director He's office, pondering over the patient's information.

Various examination reports, as well as medical history, symptoms, changes in the course of the disease, etc.

It is not easy to treat a critically ill patient, especially a patient who has already had an operation and then developed problems.

Only by clarifying the patient's situation can it be possible to find the real problem and come up with a reasonable solution.

"This patient's intestinal obstruction should be confirmed. Whether intestinal necrosis will occur after surgery is still unclear..."

The biggest difficulty with this disease is that the patient's entire small intestine exhibits segmental lesions.

For surgical solution, the patient's entire small intestine needs to be removed.

After the surgery, the patient's future nutrient absorption will be greatly affected.

If the intestines are not cut off, is there any other solution?
Li Jingsheng did not have much experience in general surgery. He racked his brains and could not come up with a particularly good alternative to surgery.

It should also be possible to make a terminal ileostomy without cutting out the small intestine, followed by peritoneal irrigation and drainage.

But there are still many risks in this plan.

Diagnosing the cause of disease is Li Jingsheng's strength.

He still had a lot to learn about surgical solutions.

This patient is still very young, only in his 20s. If the treatment fails and dies, it will be a heavy blow to the entire family.

Not long after, He Qingzhi came back.

"The family agreed to the second surgery."

He told Li Jingsheng excitedly.

Looking at this situation, he should not have been scolded.Letting go of so-called face is definitely a good thing.

Not to mention being open-minded, at least you can search for the real cause of the disease normally and treat the patient down-to-earth.Without a lot of utilitarian concerns, I can practice medicine better.

The reason why the family agreed to the second surgery was basically a helpless move.

My son is being treated in the hospital and refuses to agree to the doctor's treatment plan. He has to take responsibility for himself if something goes wrong.

"Scheduling the surgery overnight?"

Li Jingsheng asked.

"Yes, we are going to arrange surgery for the patient now. I have invited the anesthesiologist to come over for preoperative evaluation, and the operating room is also ready."

He Qingzhi nodded in confirmation.

"Dr. Li, can I ask you to help me with the surgery later?"

"OK."

Li Jingsheng readily agreed.

……

In the operating room, the patient's abdominal cavity was opened again.

It can be seen that the suturing of the wound is very good, the wound is flat, and the incision edge is well aligned.The spacing of the sutures is also very neat, and the knots are firm and close to the skin.

After removing the sutures, Li Jingsheng saw that the wound was in very good shape, both in terms of the position of the knife and its flatness.

Since the suturing had only lasted for more than ten hours, all it took to open the abdomen again was to cut the sutures.

After opening the abdominal cavity, you can see a large amount of dark red fluid inside.

These are bloody exudates.

The temperature inside the abdomen was high, and a faint pungent odor wafted out.

After sucking up the bloody exudate, the measurement was up to 1700 ml.

Such severe exudation is unusual in laparotomy.

Although exudate is not equal to blood, the large amount indicates that the previous laparotomy treatment not only had no effect, but also worsened the condition.

He Qingzhi has his own medical team and a professional surgical team.

As a guest, Li Jingsheng could only stand in the audience and watch with his neck raised.

After draining away the fluid in the abdominal cavity, the condition of the intestines can already be seen.

The color of the jejunum and ileum all turned purple.

Some segments are purple in color.

The tone of the intestines has significantly deteriorated, and the tone of some intestinal segments has even disappeared.

There is no peristalsis in the intestines.

Obvious congestion, thickening of edema, and bleeding and necrosis can be seen in all layers of the intestinal wall, especially the intima.

No intestinal perforation has been found yet.

You can faintly see that the intestinal cavity is filled with dark red liquid.

Mesenteric congestion and edema are equally severe.

The only good thing is that the proximal blood vessel pulsation is still normal.

However, after seeing the condition of the patient's abdominal cavity, Li Jingsheng's heart sank to the bottom.

The patient's condition progressed much faster than expected.

How long does it take for the intestines and mesentery to show obvious signs of imminent necrosis?Just like a big tree is about to die, its leaves will start to turn yellow and fall off.

The condition of the patient's intestines is like a tree with serious problems.

The purpose of this abdominal dissection was threefold.

First, explore the changes in intestinal conditions.

Second, decompress intestinal drainage.

Third, actively search for the real cause and, if possible, formulate a surgical plan and implement it together.

It is certainly not practical to cut off the entire small intestine.

"The vascular pulse at the terminal end has disappeared, and the patient's hope of saving the small intestine is very slim."

Li Jingsheng sighed in his heart.

Even though the patient's intestinal sequence is normal and there is no obvious intestinal volvulus or intussusception, the situation is not optimistic.

There is also a bright side, such as the fact that the color of the patient's colon wall looks normal.It shows that the lesions are mainly concentrated in the small intestine.

"Dr. Li, you have also seen the condition of the patient's abdominal cavity. How about incision and decompression first?"

"Alas! I didn't expect the patient's intestinal condition to become so bad. If you want to incision, drainage and decompression, I suggest you make an incision at the end of the ileum, which is still red. Just release the contents of the intestinal cavity and see the intestinal fluid. The situation inside.”

Li Jingsheng supports incision, drainage and decompression.

He would even support cutting out the small intestine if possible.

Compared with the patient's life, cutting off the small intestine is very harmful, but it can save the patient's life.

"My thoughts are basically the same as Dr. Li's, so let's just do the surgery."

He Qingzhi immediately made an incision at the end of the patient's ileum from that position.

After intestinal contents are discharged, up to 1600 ml.

If you look carefully, you can see flakes of necrotic mucosa in the small intestine in the released intestinal contents, and the rest is blood.

After release, the root of the mesentery was sealed with procaine, and the abdominal cavity was flushed with warm saline.

Basically, you need to use warm saline to flush the more sensitive organs.

Otherwise, the irritation to the patient will be very great.

After He Qingzhi's assistant finished rinsing, he used gauze to apply hot compress to the small intestine wall.

"Wait for about half an hour and then observe the changes in the intestine. I really hope to save this patient's small intestine. He is only 22 years old, which is too young. I felt entangled when I had an abdominal opening last time.

There are too many diseased intestinal segments. If all of them are removed, the patient will basically be disabled in the future.

Moreover, his family situation is not good and he cannot afford the postoperative treatment costs.

Unexpectedly, the last treatment had no effect.

Dr. Li, with your help this time, I must help you make a careful calculation and try to find the most reliable treatment plan. "

He Qingzhi has good intentions.

"Director He, I always feel that this patient's condition is a bit strange. If it is just a simple intestinal obstruction, it should be difficult to develop multi-segment disease in the entire small intestine. It feels to me that there is something wrong with the disease."

Li Jingsheng stared at the patient's abdominal cavity, frowning slightly.

Diagnosing the cause is his forte.

Before opening the abdominal cavity, he thought that the patient's intestinal tube might not be in good condition.

But after really looking at the situation inside the abdomen, he found that it was different from what he had judged before.

The patient's intestinal lesions are not in one place, nor are all the intestinal lesions caused by one obstruction. It is more like lesions in the entire small intestine.

"what do you mean?"

He Qingzhi no longer dared to look down on Li Jingsheng.

Now after listening to his analysis, He Qingzhi immediately attached great importance to it.

"Is it possible that intestinal obstruction is caused by a certain disease? In other words, intestinal obstruction is only a cause that occurs later. Before it, there are other causes that have not been discovered."

Li Jingsheng said.

"This... I really haven't thought about it. The patient had a B-ultrasound when he was admitted to the hospital, and he had biliary ascariasis. Also, there was no vomiting of brown liquid before the operation."

Director He found that this young man's thinking was different from other doctors.

It was a disease within a disease. Before the intestinal infarction, other diseases had already occurred in the intestines. He did not think about it at all.

Including the doctors under his command, they also have no consideration in this regard.

This is not because of their poor level, but because their talents are... not as good as Li Jingsheng.

His way of thinking is not even remotely different from Li Jingsheng's.

"Didn't you just perform incision and drainage? Why not do a pathological biopsy of the intestine?"

Li Jingsheng did not have rich experience in gastrointestinal surgery, so he could not judge what kind of disease existed based on the condition of the intestines.

Not to mention him, even if Director Bi came, it would probably be about the same.

It is a very good choice to make a pathological biopsy of the intestine.

"I'm just afraid that my family won't agree!"

Director He was worried.

"With all due respect to this matter, even if the patient's family does not agree, it must be done. Because it is related to the patient's life safety. His disease is by no means as simple as intestinal obstruction. Under normal circumstances, if intestinal obstruction is not effectively treated, the condition will It progresses very quickly, but rarely progresses to the entire small intestine in a very short period of time. Pathology is very necessary."

Li Jingsheng said firmly.

"Director He, I think Dr. Li's analysis is reasonable. You can worry that doing this intestinal pathological biopsy will lead to the patient's third laparotomy. The patient's condition is progressing very rapidly. Now that it has reached this stage, we can only Prepare for the worst.”

Yisuke supports Li Jingsheng's point of view.

After someone supported him, Director He was afraid of losing face, worried that the patient would have to go to the palace again, which would embarrass him and the team... all these thoughts were thrown away.

"Okay, do it!"

Director He hesitated and agreed to do intestinal pathological biopsy.

"It will take at least three or four days for the results to come out. You can see the patient's condition now. I'm worried that the patient will die before the pathology results come out."

This concern is certainly justified.

The condition of the patient's intestines was quite bad. It had progressed so quickly in just over ten hours. After three days, the intestines would have rotted away from the inside.

"More than 700 ml of dark red bloody fluid leaked out of his abdominal cavity, and there were [-] to [-] ml of blood-red fluid in the intestine. I have reason to suspect that the patient has acute intestinal bleeding. I just used the elimination method to diagnose the cause. It is still not certain that the patient has intestinal necrosis.

Then there is only one possibility left, his disease is probably acute hemorrhagic necrotizing enteritis.

We can perform non-surgical treatment according to certain principles before the results come out.

For example, correcting water and electrolyte disorders, using anti-shock treatment and broad-spectrum antibiotic anti-infection treatment..."

Li Jingsheng played to his own advantages.

With the help of the patient's clues and the results of intraoperative exploration, we used the elimination method to find out the cause of the disease.

It’s just that no one dared to make a diagnosis before the pathology results came out.

There are still variables.

Treating first and diagnosing later violates basic medical procedures, but in special circumstances only this method can save the patient's life. (End of chapter)