Tuesday, 9 February 2016

Dead bowel

Well, you asked for it.  I mentioned dead bowel (well, the smell of dead bowel, to be precise) in a previous post, and several commenters asked for the stinky story behind the stench.  I haven't yet told that story here for . . . well, the reason is . . . ok, if I'm mentioning the smell of a case, don't you think I'm trying to save you people here?  And you lunatics still want to know about it?  REALLY?

Seriously, you people are messed up in the head.  I'd seek professional help.  No, not from me, dammit.  I don't do crazy.  Fine, if that's the way you feel, then you're about to get what you deserve.  If you really must know then I have no choice but to preface this story with the following completely 100%  totally entirely invented probably illegal legal disclaimer:
I hereby disavow any and all responsibility for keyboards, monitors, iPhones, Galaxy S6s, iPads, Kindles, laptops, iMacs, netbooks, Chromebooks, and/or any and all other media readers that may be temporarily or permanently stained, made inoperable, and/or otherwise ruined by your vomit.
YOU HAVE NOW BEEN WARNED.  THERE WILL REAL PICTURES OF DEAD BOWEL.  Turn back now etc etc.


Good grief, you people are still here?  Ok, but remember - you asked for it.  

I'm sure everyone has heard the phrase that bad things come in threes.  The logical people will naturally and logically argue, "That it isn't true, it's just that human brains seem to enjoy fitting things into patterns, so when bad things happen, we like to lump them in with other bad things that happened in close temporal proximity."  To those logical people, I'd simply like to say "Fuck you!  You obviously have NO idea how the Call Gods work." 

A few years back Intensive Care Doctor (not her real name™) called me in a panic (N.b. when the people who devote their lives to caring for the sickest people are frantic, it's never a good sign).  She had an elderly, frail patient who had been battling a severe Clostridium difficile infection and was circling the drain despite treatment with several different antibiotics and immunoglobulin over the previous few days (these were the days before faecal transplants existed).  Nothing was working, she was about to die, and they wanted me to take out her colon as a measure of last resort.  She was so sick by that point that my two choices at this point were 1) do nothing and let her die, or 2) open her up, remove her entire colon, and then let her die.

Unfortunately her family wanted to give it the old college try, so as I opened her abdomen less than an hour later, the stench of death slapped me in the face like a drunk moron at a bar getting his due from that nice lady he won't stop bothering.  I removed her entire colon and performed an end ileostomy, but the damage to her system was done, and she was dead before I even got to the hospital the next morning.  I don't have a picture of her colon, so you'll just have to trust me that it wasn't just mostly dead, it was all dead.

That was number 1. 

WAIT JUST ONE DAMNED MINUTE!  YOU PROMISED PICTURES OF DEAD THINGS!  THERE ARE NO PICTURES YET, JUST A CARTOON OF AN OPERATION, ASSHOLE!

Oh just you wait, I'm getting there.

Number two came about a week later.  I got a call from Emergency Doctor (not his real name™) who had a patient who was actively dying.  He was in his 50s and came in complaining of severe abdominal pain associated with nausea and intractable vomiting for the past day.  When he described his abdomen as "rigid", my ears pricked up.  "Rigid" is a term used only for the worst-looking abdomens, ones that look as if they could burst a la Alien, and it makes general surgeons extraordinarily nervous.  It usually indicates that something catastrophic has happened in the abdomen, and that bad something will evolve into a fatal something if not addressed immediately.

I got the patient into the operating theatre about 45 minutes later, and upon opening his abdomen I found his entire small intestine dead.

All that black-looking stuff is supposed to be pink-looking stuff.  The man had suffered from chronic mesenteric ischaemia, a condition where the blood supply to the intestine is compromised and results in severe, chronic abdominal pain after eating.  To treat this he had a stent placed into his superior mesenteric artery (which supplies blood to the small intestine), and as I was transecting that artery to remove the specimen I found (and removed) a large clot that had clogged the stent and the artery, killing his intestine:

Since my necromancy skills are still poor, my only options were A) close up and let him die, or B) remove the entire small bowel, leaving him with short bowel syndrome (where you do not have enough surface area to absorb nutrients so you must depend on IV nutrition to live).  Since you've seen the specimen, obviously I went for option B.  Miraculously he survived, and about a year later I sent him to consult with a transplant surgeon about a bowel transplant (yes, those exist).

I thought I had had enough of dead bowels for some time, but the Call Gods (of course) had other plans: number 3.

Barely two weeks after I discharged the previous patient I got a call from a different Emergency Physician (still not his real name™) about a young man with an acute abdomen.  He was 35 and healthy, but his abdomen was rigid and his CT scan "looks funny".  I assumed he didn't mean "funny ha ha" but rather "funny oh shit please help".  But even I have to admit he was right - his scan did look funny - his small bowel looked thickened and sick.  All of it.

Again to the operating theatre, and again I found dead stuff . . . lots of it.  I once again had the choice of letting this young man die or attempting a huge and heroic surgery.  Based on the picture, you can safely assume you know which avenue I chose:

Perhaps it doesn't look as bad as the last one, but it was - there were patches of deadness along his entire small bowel up through and including his ascending colon (which you can see in the top portion of the picture).  But unlike the previous patient, the clot was in his superior mesenteric vein, not the artery.  This had caused progressive congestion of the intestine followed days later by organ death.  I again removed the entire small intestine, leaving the guy with an end jejunostomy and short bowel syndrome.  And again he miraculously survived.  Because the mesenteric vein is an extremely rare site for a blood clot I asked my haematology colleagues to investigate.  After he woke up and had his breathing tube removed several days later, he admitted that he had also had multiple clots in his leg veins in the past but never took his blood thinner.  After an exhaustive search we finally got a hit - Prothrombin 20210 mutation.  After I sent him home (on blood thinners) he was unfortunately lost to follow up, so I have no idea if he took his meds or if he is even alive.

So there you have it - my favourite dead bowel cases.  That isn't by any means all the dead bowel cases I have seen, but I still find it interesting that I had three so closely lumped together.  But with all that dramatic drama, I strongly suspect that the overwhelming response from the readers will be, "That's it, Doc??  SERIOUSLY?  THAT'S IT??  That wasn't so bad!  I want a refund!"  Maybe you're right.  Maybe I blew it way out of proportion.  Maybe it isn't quite as bad as I described it.

But just remember one thing: you couldn't smell it.

54 comments:

  1. Whats worse than the smell of old shit? The smell of something dead. Whats worse than that? Both. At the same time. Doc i think i at least get the picture
    Connor

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  2. I was going to read it.

    Then I saw the words "Pictures of Dead Bowel" and noped out. :I

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    1. If it makes you feel any better, none of them are in situ. All of them are "in the bucket".

      But that was the exact purpose of the multiple disclaimers.

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    2. I tend to be the type to ignore disclaimers. Strong gut. But even I have limits. :P

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    3. I sat down at my computer with avocado toast on my plate. Thanks to the disclaimers I enjoyed my lunch and here I am a couple of hours later.

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  3. I think I might have an idea.

    One summer I left my dorms for a few weeks during break. I was getting a new room mate and the policy was to have a cleaner come in and spruce up the place so new guy could have a clean place to come into. The dorms came with a little mini-kitchen. Cleaner came cleaned my fridge, then turned off the fridge which had a freezer full of meat. And the AC. And closed the windows I had cracked to keep the air fresh. During the height of summer heat that easily got up to 100*F+ every day.

    So I come back from break. The room was sweltering reeked of something foul. I thought I had forgotten to throw away the last of my milk or something before I left. But nothing could prepare me for when I opened the freezer.

    I couldn't even breath as I had to stagger back and out of the room. I don't even think I got the extend of the smell since the plastic wrapping around the Styrofoam was bubbled up from the toxic bacteria and containing some of the smell.

    The building manager couldn't get anyone out to help me out for another 3-4 hours. My mom is hard balls and ended up emptying the freezer while I was trying my best not to dry heave to just get it out of the room. My room became legendary as it literally stank up the entire building.

    TL;DR: Dead things smell and my mom is awesome.

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  4. Totally interesting post DocB, and didn't even gross me out. It did make me a little more concerned for my chronic portal vein thrombosis though. Maybe I am a hypochondriac. :)

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  5. Excellent post! You can really write like hell, doc, respect! The "mostly dead"-link was so funny :D.

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    1. not just mostly dead - go through the pockets and look for change dead.

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  6. Doc, I'm tired of trying to decipher your case presentations so I stopped reading after case example number #1.

    On your first case. What was the actual diagnosis? 1. Inflammatory Bowel Disease. 2. Ulcerative Colitis 3. Crohn's Disease. I'm sure it's not Ulcerative Colitis so it must be other forms of IBD or Crohn's Disease. That's withholding information.

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    1. Well John, I would think that you'd be tired of constantly making yourself look like an idiot, but you apparently aren't.

      See that little part where it says "She had an elderly, frail patient who had been battling a severe Clostridium difficile infection"? I suppose you missed that, didn't you.

      So now the only question is, on a scale of 1 to stupid, how stupid do you feel?

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    2. And you would automatically perform a colectomy/ileostomy for that? She didn't have an underlying condition? C'mon.

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    3. For someone dying of C diff? Yes. Thank you for once again displaying your stunning ignorance of medicine and once again proving that you have no medical knowledge short of whatever comes up on Bing.

      Here let me educate you:
      1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024619/
      "Colectomy for C. difficile colitis has a high mortality but can be life-saving, even in extremely sick patients. Although heavy antibiotic use is a predisposing factor, this is not an obligatory prerequisite in the development of C. difficile. Neither is it a disease of the elderly, making it difficult to predict vulnerable patients. There are large differences in colectomy rates between specialties and we suggest there may be a place for a surgical opinion in all cases of severe C. difficile colitis."

      2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3577611/
      "Subtotal colectomy with ileostomy remains the standard of care when toxic megacolon, perforation, or an acute surgical abdomen is present, but mortality rates are high."

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    4. Doc, C.difficile COLITIS is the answer that I was looking for. Thank you.

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    5. No it isn't, that's just your pathetic attempt at saving face, which no one will buy. I doubt even you believe that.

      Again, thanks for the chuckle. I'm sure everyone else appreciates it too. I'll see you on the next post when you make another ridiculous claim or ask another ridiculous question. I doubt I'll actually let your comment through though. It depends how generous I'm feeling. Toodles, John.

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    6. Our reader reports a symptom of discomfort...

      "I'm tired of trying to decipher your case presentations."

      Though I don't claim to be a medical professional, so trust I won't be accused of practicing medicine without a license, I *can* share an easy remedy for afflictions such as this one. I use it all the time when I come across a blog or zine that I find boring, uninformed, or just plain not worth my time. Just go read something else! :)

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    7. so john can't comprehend what C.diff is if it is not completely spelled out with COLITIS in all caps...

      why, am I not surprised?

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    8. @ Scarab: and here I thought you were going to recommend a rectal craniectomy.

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    9. John, your lack of Actual Medical Knowledge™ Is showing. ANYONE who has spent time learning about C. diff from an actual medical source knows that when someone is septic and circling the drain from said infection, total colectomy is the last ditch, Hail Mary tool in the drawer. If someone is getting one, we know it is REALLY Bad. And you don't have to have a preexisting GI issue to fall victim.
      As for Doc's case narratives, they are more than adequate to describe the case and the issue at hand. It is his prerogative to include whatever information that he feels is necessary. He is not obligated to include every detail of the case. It is not "withholding" information. It is EDITING. For a blog.

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    10. @ Ken..That would be the BEST solution. The problem with cranial rectal inversion syndrome is that those afflicted don't realize they have it, so they're unable to seek or consent to treatment. ;)

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    11. his minders need to do a CRIS intervention.

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    12. WTF is a CRIS intervention? You mean CRISIS!

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    13. @ Anon. 12 Feb. 4:09:

      Cranial
      Rectal
      Inversion
      Syndrome

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    14. Christ almighty John us stupid and i am a newbie to all of this

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  7. "All that black-looking stuff is supposed to be pink-looking stuff. "

    What's the red-looking stuff on the left?

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    1. That's the end of the bowel where I transected it. It is severely congested and not viable.

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    2. better put a latin term for that with part of in in all caps so Johnny boy can comprehend it.

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    3. Good idea, Ken. But some of us didn't study Latin in school, so maybe we could use "pig Latin" instead. We could caption that picture,"Owelbay ransectedtay ongestedcay and eadday."

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    4. Yeah but john would then of course insist on us describing the dialect of pig latin: potbelly or boar? Otherwise he may get confused!
      Connor

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    5. Yeah but john would then of course insist on us describing the dialect of pig latin: potbelly or boar? Otherwise he may get confused!
      Connor

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  8. I have pictures of my placenta that look worse than those :p
    I'm sure it smelt a lot better though (not that I stuck my nose in it lol)

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    1. ....why do you have pictures of placenta??

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    2. Because I wanted to see it. Sounds morbid, but I wanted to see what gave life to my baby for so long. Hubby took pictures of it for me so I could see them when I wasn't so tired :)

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    3. In a recent (quasi) news story, I read Kim Kardashian plans to eat hers, or her baby's. I am not sure who has ownership of placenta. What was odd, I was not surprised.

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  9. Dear John,
    I'll pray for you.
    Jordaen

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  10. In case anyone is curious, there have been several more comments by John that I have not let through. I had thought that showcasing his idiocy for all the world to see would have encouraged him to slink back to the rock he slithered out from under, but it has not.

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    1. Isn't it a shame when stupid people don't realize they're stupid?

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    2. Is it sad that I enjoy reading his posts, and laughing at his inability to show even a modicum of intelligence?
      Though I understand how It gets old really fast for you Doc.

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  11. I'd have to agree with John on C. Diff colitis.

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  12. Advanced neglected cervix Ca's smell just as bad. Jmho.

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  13. What is so hard to decipher, John? I have practically no medical knowledge and I understand what Doc is saying.

    Perhaps the problem leans more towards lack of basic English skills? Doc does have a rather impressive vocabulary compared to most would be hacks...

    I truly can't imagine living off of an IV for nutrients. I would miss too many flavourful foods.

    Oh! Yes, I believe bad things happen in threes. Ive suffered from this phenomenon before. -.-

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    1. the problem leans more towards getting his jollies off disrupting things.

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  14. Yeah, it's hellish all right. At least there's a great deal less to smell when it goes necrotic. Compare and contrast to when a horse has colicked and been stoic about it. Happened to a friend of mine, the mare finally looked miserable, vet was called out and she was hauled away to Leesburg. They opened her up, it was all black, closed her up and euthanized her on the table.

    I CAN imagine the smell that must have hit them and I'm surprised no one vomited in front of the owners. Leesburg has an observation room for owners and others to watch the surgery.

    Wednesday

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    1. took me a second reading to realize you were saying less to smell in comparison to a horse with dead bowel.

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    2. As I mentioned before, my husband is a vet. He has no problem with the plethora of disgusting smells he encounters daily, because he lost most of his sense of smell (taste went as well) many years ago. He has found many of his colleagues also have little or no ability to smell. It is a self-preservation mechanism, I suppose. However, I am tired of him holding out dubious looking items from the back of the fridge and asking me to smell them; it's never good.

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  15. The worst thing i've ever smelled was a male resident admitted on hospice with complete organ failure and cdiff with blood in the stool and the hospital only discovered the organ failure in the middle of leg amputation surgery i guess since when we got the gentleman his leg was amputated but not stitched shut. Simply covered with bandages. I was assisting the nurse with changing the bandages and found it fascinating to get a look at the inner anatomy of the leg.

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  16. Volume can make a difference when it's olfactory assault!

    Horses simply have more volume and it can be overwhelming. I think the fact that the surgical suites are bigger may help a little, but I doubt it.

    Wednesday

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  17. Handy tip: we use to hang large Ioban sheets on IV poles for open/necrotic bowel cases. Not sure if it counteracted or overpowered the smell but worked great either way.

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  18. Thanks for sharing! I was personally hoping for more gore, but that's just me :P
    I thought you might be interested in seeing pictures from a similar surgery on a horse, which I had the pleasure of watching at an equine vets. The photos are in an album here (graphic!!) https://facebook.com/SammiMcSporran/albums/10152167061337439/
    As far as the smell, it was bad, but I have certainly smelled worse from my veterinary work experience!

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  19. Worked in veterinary, chi came in with a horrid pyometera. I can imagine.

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  20. This is a smart blog. I mean it you have so much knowledge about this issue and so much passion. computer-retro |

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  21. I'm a 23year old female. Was relatively healthy. 2 months ago I had a laparoscopic appendectomy. All was fine. Experienced severe pain 10 days later. Went to the ER, cat scan showed fluid in abdomen, but they assumed it was a ruptured ovarian cyst. So I left and went home. 2 weeks later I was in EXCRUTIATING PAIN went to the ER again screaming uncontrollably, and they said ct scan showed nothing, but I insisted they were missing something and kept telling them I was going to die. They discharged me and a few hours later I arrive again at the emergency room, pain got worse but all my vitals looked "perfectly normal" so they assumed I was faking my symptoms and "drug seeking" meanwhile I've never done a drug in my life and they refused to give me pain medicine and told me there's nothing they could do for me, called me a taxi and sent me home. 3 hours later I start throwing up blood, desperately came back to the hospital and begged for help. I couldn't breathe but my oxygen levels was 100%, WBC was normal, blood pressure was a little low but not too concerning, so again they thought I was faking symptoms. Hours go by and I'm still vomiting blood, and all of a sudden my WBC comes to 35.5.... heart rate went up to 150's, and they did another ct scan and found a lot of fluid and inflammation. I had an exploratory laparotomy and surgeon was shocked to find necrotic small bowel. I had 75cm of ileum removed, ileocecal valve & cecum. They still don't know how it happened and think I might have a "blood clotting disorder" so I'm following up with hematologist to do a repeat anticoagulation test. I'm now 6 weeks post op and feel okay. They told me I was one in a million. I've been trying to read cases similar to mine, survival stories... and haven't found many. Kind of concerned for my future.. not sure if I should be worried or not? I'm scared more bowel will become necrotic, and ct scans barely pick it up before it's too late.. not sure what I can do to prevent this from happening again.

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    1. How are you doing now?

      Delete

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