Detailed Treatment Process
Male, 31 years old, admitted to the gastrointestinal surgery ward Discharge summary Admission date: June 20 Discharge date: August 31 Outpatient diagnosis: Intestinal obstruction Admission diagnosis: Intestinal obstruction; septic shock; Crohn’s disease; acute peritonitis Discharge diagnosis: Intestinal obstruction; septic shock; malignant transformation of Crohn’s disease; mild protein-energy malnutrition; delirium Admission condition Six years ago the patient developed recurrent paroxysmal left lower abdominal distending pain without obvious inducement. There was no radiating pain, no diarrhea, and stools occurred once every 2–3 days, yellow and soft in texture. He had no fever, chills, nausea, or vomiting, but had lost 10 kg in weight. He visited our hospital. Intestinal CT reconstruction suggested segmental thickening of the small bowel wall in the mid-lower abdomen, considered inflammatory bowel disease (Crohn’s disease?), with patchy abnormal lesions beside the bowel (local inflammatory encapsulation after intestinal perforation to be ruled out?), multiple enlarged lymph nodes beside the mesentery and retroperitoneum. Colonoscopy (April 11, six years ago) showed erosion and ulcerative lesions at the ileocecal region, with obvious mucosal hyperemia and mild deformity. The scope could not enter further. The remaining colonic mucosa was normal, suggesting ulcerative lesions with deformity at the ileocecal region. Two biopsies were taken from the ileocecal region (pathology report missing, details unknown). Small bowel enteroscopy (April 23, six years ago) revealed multiple ulcers in the middle jejunum, leading to a diagnosis of “small bowel Crohn’s disease.” He was given mesalazine, levofloxacin for anti-infection, and other symptomatic supportive treatment. His condition improved and he was discharged. After discharge he took azathioprine (6 g/day) (as written in the original record, possibly a clerical error) for about half a month before stopping on his own. Half a month later he again developed left lower abdominal distending pain that was more severe than before and often occurred at night. He was diagnosed with Crohn’s disease and received omeprazole for gastric protection, levofloxacin for anti-infection, and other symptomatic anti-infection treatment. Symptoms were relieved. Two months later he was admitted again (details unknown) and given omeprazole and lansoprazole for gastric protection, moxifloxacin and levofloxacin for anti-infection, and ethylprednisolone succinate for correction of anemia (as written in the original). Symptoms improved after treatment and he was discharged. Five years ago he again developed left lower abdominal distending pain that was more severe than before and often occurred at night. He visited our hospital. Small bowel and colon CT (April 13, five years ago) showed local small bowel wall thickening with luminal narrowing in the mid-lower abdomen, disordered structure of local bowel loops in the left mid-upper abdomen, and multiple enlarged lymph nodes in the retroperitoneum and mesenteric area. Colonoscopy (April 11, five years ago) reached the ileocecal region but could not enter the terminal ileum despite effort. The ileocecal valve was normal. A 0.5 × 0.8 cm proliferative lesion was seen in the sigmoid colon 20 cm from the anus. No ulcers, neoplastic growths, or strictures were found in the other segments examined. He successively received moxifloxacin, imipenem-cilastatin sodium, ornidazole, teicoplanin, and norvancomycin for anti-infection. After infection was controlled, intravenous methylprednisolone 40 mg/day was started on April 30, oral azathioprine 25 mg was begun on May 3, along with calcitriol for calcium supplementation, esomeprazole magnesium for gastric protection, and continued cefoperazone sodium-sulbactam sodium for anti-infection. Symptoms were relieved and he was discharged. Three years ago he presented with upper abdominal pain and vomiting after eating and visited our outpatient clinic. Upright abdominal plain film showed intestinal obstruction. He was given fasting, gastrointestinal decompression, drainage, levofloxacin plus metronidazole for anti-infection, peripheral parenteral nutrition, and acid suppression. Abdominal pain was markedly relieved, vomiting stopped, and there was a small amount of flatus and stool from the anus. After admission, further examinations suggested Crohn’s disease with incomplete intestinal obstruction. Gastrointestinal decompression, nutritional support, levofloxacin, metronidazole and other anti-inflammatory treatment, esomeprazole magnesium and lansoprazole for gastric protection, and intravenous methylprednisolone were given. Symptoms improved after treatment and he was discharged. Two weeks ago, without obvious inducement, he developed persistent abdominal distension, no fever or chills, no hematemesis or vomiting, and reduced stool frequency with hard, dark stools. He visited the internal medicine department of our hospital. CT showed segmental small bowel wall thickening in the right lower abdomen, luminal narrowing with upstream small bowel obstruction, multiple lymph nodes beside the bowel, at the mesenteric root, and on the peritoneum, with thickened straight vessels around them. Crohn’s disease? Clinical attention recommended. Enhanced CT was advised. Possible scattered hepatic cysts. Possible pancreatic fat infiltration. Left testicular hydrocele. Symptomatic treatment was given but there was no obvious improvement and symptoms continued to worsen. One hour ago nausea and abdominal distension worsened, with altered consciousness, pale skin and lips, and shortness of breath. No fever, chills, hematemesis, vomiting, diarrhea, or melena. Since onset, he had lost more than 20 jin in weight. He was admitted for further treatment. Since onset, his mental state had been poor, appetite acceptable, bowel movements normal, urination normal, sleep fair, diet unchanged, but weight loss was obvious. Specialist findings: No jaundice of skin or sclera. Abdomen flat, no visible peristalsis or intestinal pattern, no abdominal wall varices, no peristaltic waves. Abdomen soft, with tenderness in the right lower quadrant, no abdominal mass. Liver and spleen not palpable below the costal margin. Liver dullness normal. No shifting dullness. No renal or hepatic percussion tenderness. Bowel sounds normal. No succussion splash. Main laboratory results August 27: [Renal function + eGFR + cystatin C + full lipid panel + liver function (new 2) + electrolytes + total calcium Ca + phosphorus P + magnesium Mg]: Glutamate dehydrogenase 49.30 U/L↑, albumin/globulin ratio 1.10↓, globulin 31.9 g/L↑, prealbumin 135.00 mg/L↓, alanine aminotransferase 117 U/L↑, aspartate aminotransferase 154 U/L↑, gamma-glutamyl transferase 204.00 U/L↑, alkaline phosphatase 545 U/L↑, total bile acids 13.9 μmol/L↑, glycocholic acid 2.84 mg/L↑, cystatin C 1.69 mg/L↑, apolipoprotein A1 0.66 g/L↓, high-density lipoprotein cholesterol 0.48 mmol/L↓, phosphorus 1.79 mmol/L↑; August 27: [Complete blood count (CBC)]: White blood cell count 3.77 × 10⁹/L↓, lymphocyte percentage 18.3%↓, monocyte percentage 11.4%↑, lymphocyte absolute value 0.69 × 10⁹/L↓, red blood cell count 2.52 × 10¹²/L↓, hemoglobin 82 g/L↓, hematocrit 0.249 L/L↓, platelet distribution width 9.4 fl↓; August 18: [Liver function (new 2) + electrolytes]: Glutamate dehydrogenase 41.90 U/L↑, albumin/globulin ratio 0.98↓, globulin 37.1 g/L↑, prealbumin 139.70 mg/L↓, alanine aminotransferase 134 U/L↑, aspartate aminotransferase 151 U/L↑, gamma-glutamyl transferase 373.00 U/L↑, alkaline phosphatase 1049 U/L↑, total bile acids 13.0 μmol/L↑, glycocholic acid 3.31 mg/L↑; Special tests and important consultations: Nutrition department consultation: 1. Continue enteral nutrition support. Advise family members to learn home enteral nutrition under physician guidance. Also guide preparation of homemade food slurry, but suggest adding only after intestinal function stabilizes. Monitor digestive tract symptoms and signs. 2. Encourage family members to perform passive resistance exercises to promote muscle growth. 3. Regularly recheck complete blood count, liver and kidney function, electrolytes, calcium, phosphorus, magnesium, etc. Follow up at nutrition clinic regularly. 4. Strengthen treatment of primary disease. Follow-up by our department. Thanks for the consultation. Neurology and neurosurgery consultation: Suggest vitamin B1 10 mg tid po, mecobalamin 1# tid po, and appropriate folic acid supplementation. If no contraindications, antidepressants may be used: sertraline 0.5# qn po, mirtazapine 0.5# qn po. Hyperbaric oxygen therapy optional. Follow-up by our department. If no improvement, suggest EEG. Partial small bowel: High-grade intraepithelial neoplasia with malignant transformation (1 × 0.5 × 0.2 cm), invading the muscularis mucosae. Both resection margins and lymph nodes in the bowel wall (0/18) negative. Partial small bowel: High-grade intraepithelial neoplasia with malignant transformation. Tumor cells CK7 (+), CK20 (−), Ki-67 (40%), P53 (+++), MLH1 (+), MSH2 (+), MSH6 (+), PMS2 (+). Treatment course On June 20 in the emergency department the patient underwent small bowel resection. Due to hypotension, altered consciousness, and unconsciousness he was transferred to the ICU. In the ICU, septic shock was corrected with fluid resuscitation, anti-infection treatment, and intensified monitoring. The tracheal tube was removed on July 10. On July 13, plain scans of the upper and lower abdomen combined with the patient’s history confirmed pulmonary infection. Antibiotics were given, along with active sputum suction. Free gas was present in the abdomen, raising the possibility of intestinal perforation from Crohn’s disease, but given the patient’s overall condition and history of multiple Crohn’s flares, surgery was not considered for the time being. Continued sputum suction and anti-infection treatment were given. Abdominal gas decreased compared with before. Conservative treatment continued. On July 20 sputum culture indicated Klebsiella pneumoniae infection. Antibiotics were adjusted, replacing sulperazon with levofloxacin combined with amikacin. On July 21, after removal of the central venous catheter, the patient’s temperature dropped, suggesting a high likelihood of catheter-related bloodstream infection. Antibiotics were further adjusted according to sputum culture and sensitivity results. Anti-infection and fluid support treatment continued, with close monitoring of the patient’s condition. Current vital signs: T 36.4°C, BP 104/67 mmHg, HR 82 beats/min, RR 18 breaths/min. Condition relatively stable, adequate urine output. Consciousness gradually recovering, able to make sounds and articulate. Physical examination: Emaciated, cachectic appearance. Consciousness present. Nasal cannula oxygen. Scaphoid abdomen, soft, with no obvious tenderness. No edema in lower limbs. Obvious muscle atrophy in all four limbs. Poor cooperation. All four limbs can move. Pupils equal and round, reactive to light. Nutrition and neurology/neurosurgery consultations were requested: Continue enteral nutrition support, gradually transition to whole-protein formula. Nursing department to guide family in home enteral nutrition and preparation of homemade food slurry, gradually increasing caloric support. Encourage family to perform passive resistance exercises to promote muscle growth. Vitamin B1 10 mg tid po, mecobalamin 1# tid po, and appropriate folic acid supplementation. If no contraindications, antidepressants may be used: sertraline 0.5# qn po, mirtazapine 0.5# qn po. Hyperbaric oxygen therapy may be considered. Management: Agreed with current orders from nutrition, neurology, and neurosurgery departments. Suggested hyperbaric oxygen chamber treatment. Family accepted, so the patient was transferred to Anda Hospital for further treatment. Complications None Condition at discharge Current vital signs: T 36.4°C, BP 104/67 mmHg, HR 82 beats/min, RR 18 breaths/min. Condition relatively stable, adequate urine output. Consciousness gradually recovering, able to make sounds and articulate. Physical examination: Emaciated, cachectic appearance. Consciousness present. Nasal cannula oxygen. Scaphoid abdomen, soft, with no obvious tenderness. No edema in lower limbs. Obvious muscle atrophy in all four limbs. Poor cooperation. All four limbs can move. Pupils equal and round, reactive to light. Abdomen soft, no tenderness or rebound tenderness. Flatus and stool passed from anus. Incision healed well. Post-discharge medications and advice 1. Recommend hyperbaric oxygen chamber treatment and rehabilitation exercises at another hospital. 2. Follow-up in our department and gastroenterology clinic. 3. Seek medical attention promptly if any discomfort occurs. Follow-up plan: None for now Treatment outcome: Improved
Surgical record Surgery date: June 20 Preoperative diagnosis: Intestinal obstruction; Crohn’s disease; septic shock Intraoperative diagnosis: Intestinal obstruction; Crohn’s disease; septic shock Operation name: Small bowel resection Anesthesia: General anesthesia Surgical procedure 1. Brief operative course (including intraoperative findings): The patient was extremely emaciated with severe malnutrition. Exploration revealed obvious stricture of the small bowel 150 cm from the ligament of Treitz, through which intestinal contents could not pass. The area around the stricture showed inflammatory changes. From the ligament of Treitz to this point, the jejunum was markedly dilated, approximately 10 cm in diameter, with obvious congestion and edema of the bowel wall, markedly reduced peristalsis, dark red color, and poor blood supply. The distal small bowel beyond the stricture was empty. Exploration of the entire small bowel revealed multiple inflammatory strictures, but intestinal contents could still pass. The stomach and colon were also markedly dilated. The bladder was full. Intestinal and gastric contents were decompressed, yielding about 3000 ml of dark brown viscous fluid. The obviously strictured segment and dilated small bowel were resected (approximately 150 cm), followed by end-to-side small bowel anastomosis. Two abdominal drainage tubes were placed. 2. Steps: *After successful general anesthesia, disinfection and draping were performed. A midline abdominal incision around the umbilicus was made to enter the abdomen. Exploration as above. *Small bowel was exteriorized. The diseased segment was resected. End-to-side anastomosis of proximal and distal ends was performed, reinforced with sutures. The stump was closed with an 80 mm side-to-side stapler. *Abdominal cavity irrigated with 10000 ml normal saline. Two negative-pressure drainage tubes placed in the pelvis, brought out through stab incisions beside the main incision and secured. *Instruments and gauze counted correctly. Hemostasis completed. Incision closed layer by layer. Operation completed. 3. Postoperative measures: Retained during surgery. Special intraoperative events and management: None
Small bowel resection was performed under general anesthesia. The surgical record was incomplete: neither the circulating nurse nor the scrub nurse signed the operative note. The patient developed altered consciousness and unconsciousness after surgery and was transferred to the ICU. The discharge summary recorded admission on June 20 and surgery on June 20, meaning the operation was performed on the first day of hospitalization. The patient was transferred from surgery to the ICU and other departments within the same hospital for continued treatment. The discharge summary described the patient on August 31 as having gradually recovering consciousness and being able to make sounds and articulate, with physical findings of emaciation, cachexia, and obvious muscle atrophy in all four limbs. The discharge diagnosis included delirium but no explicit diagnosis of stroke. According to the family, the patient has remained in a persistent vegetative state since discharge—unconscious, unable to communicate normally or perform voluntary movements. He was transferred to a hyperbaric oxygen chamber for continued treatment, but consciousness never recovered. The discharge note still described the condition as “consciousness gradually recovering,” which in reality meant consciousness had not fully returned and the patient remained in an unclear state of consciousness.