Crohn's Disease\Small Bowel Resection\Persistent Vegetative State

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 status Six years ago the patient developed recurrent paroxysmal left lower abdominal distending pain without obvious triggers. There was no radiation of pain, no diarrhea, and bowel movements occurred every 2–3 days with yellow, soft stools. He had no fever, chills, nausea, or vomiting, but had lost 10 kg in weight. He presented to our hospital, where CT enterography showed segmental thickening of the small bowel wall in the mid-lower abdomen suggestive of inflammatory bowel disease (Crohn’s disease?), a patchy abnormal lesion adjacent to the bowel (possible localized inflammatory encapsulation after intestinal perforation?), and multiple enlarged lymph nodes adjacent to the mesentery and retroperitoneum. Colonoscopy (April 11, six years ago) revealed erosions and ulcerative lesions in the ileocecal region with marked mucosal congestion and mild deformity; the scope could not be advanced further. The remaining colonic mucosa appeared normal, indicating ileocecal ulceration with deformity. Two biopsies were taken from the ileocecal region (pathology report unavailable, details unknown). Small bowel enteroscopy (April 23, six years ago) showed multiple ulcers in the mid-jejunum. The diagnosis was “small bowel Crohn’s disease.” He received mesalazine, levofloxacin for infection, and supportive treatment. Symptoms improved and he was discharged. After discharge he took azathioprine (6 g/day) (as written, possible 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 treated with omeprazole for gastric protection, levofloxacin for infection, and other symptomatic measures. Symptoms eased. Two months later he was readmitted (details unclear) and received omeprazole and lansoprazole for gastric protection, moxifloxacin and levofloxacin for infection, and ethylprednisolone succinate for anemia correction (as written). Symptoms improved and he was discharged. Five years ago he again developed left lower abdominal distending pain that was worse than before and often occurred at night. He presented to our hospital. Small bowel and colon CT (April 13, five years ago) showed localized small bowel wall thickening with luminal narrowing in the mid-lower abdomen, disordered structure of a local intestinal segment in the left mid-upper abdomen, and multiple enlarged lymph nodes in the retroperitoneum and mesentery. Colonoscopy (April 11, five years ago) reached the ileocecal region but could not enter the terminal ileum. 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, new growths, or strictures were seen in the remaining examined segments. He received successive courses of moxifloxacin, imipenem-cilastatin sodium, ornidazole, teicoplanin, and norvancomycin for infection. After infection control, 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 and esomeprazole magnesium for gastric protection. He continued cefoperazone sodium-sulbactam sodium for infection. Symptoms improved and he was discharged. Three years ago he presented to our outpatient clinic with upper abdominal pain and vomiting after eating. An upright abdominal plain film showed intestinal obstruction. He received fasting, gastrointestinal decompression, drainage, levofloxacin plus metronidazole for infection, peripheral parenteral nutrition, and acid suppression. Abdominal pain eased significantly, vomiting stopped, and there was a small amount of flatus and stool per anus. After admission, further evaluation led to a diagnosis of 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 and he was discharged. Two weeks ago, without obvious trigger, he developed persistent abdominal distension, no fever or chills, no hematemesis or vomiting, and reduced, hard, dark stools. He presented to the internal medicine department of our hospital. CT showed segmental small bowel wall thickening in the right lower abdomen with luminal narrowing and upstream small bowel obstruction, multiple lymph nodes adjacent to the bowel, at the mesenteric root and peritoneum, and dilated straight vessels around the area—Crohn’s disease? Clinical correlation advised; enhanced CT recommended. Scattered hepatic cysts possible. Pancreatic fat infiltration possible. 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 intensified, consciousness became impaired, skin and lips turned pale, and breathing became rapid. There was no fever, chills, hematemesis, vomiting, diarrhea, or melena. Since onset he had lost more than 20 jin (about 10 kg) in weight. He was admitted for further treatment. Since onset his mental state had been poor, appetite fair, bowel and bladder function normal, sleep fair, diet unchanged except for marked weight loss. Specialist examination: No jaundice of skin or sclera. Abdomen flat, no visible peristalsis or intestinal pattern, no abdominal wall venous distension, no gastric or intestinal peristaltic waves. Abdomen soft with tenderness in the right lower quadrant, no palpable masses. Liver and spleen not palpable below the costal margin. Liver dullness normal. No shifting dullness. No renal or hepatic angle tenderness. Bowel sounds normal. No succussion splash. Main laboratory results August 27: [Renal function + eGFR + cystatin C + full lipid profile + liver function (new 2) + electrolytes + total calcium + phosphorus + magnesium]: 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 count 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 medical guidance and prepare homemade food slurries, but only after intestinal function stabilizes. Monitor gastrointestinal symptoms and signs. 2. Encourage passive resistance exercises by family members to help maintain muscle mass. 3. Regularly recheck complete blood count, liver and kidney function, electrolytes, calcium, phosphorus, magnesium, etc., and follow up at nutrition clinic. 4. Strengthen treatment of the primary disease. Follow-up by our department. Thank you for the consultation. Neurology and neurosurgery consultation: Suggest vitamin B1 10 mg three times daily orally, mecobalamin 1 tablet three times daily orally, and appropriate folic acid supplementation. If no contraindications, consider antidepressants: sertraline 0.5 tablet at night orally, mirtazapine 0.5 tablet at night orally. Hyperbaric oxygen therapy optional. Follow-up by our department. If no improvement, consider 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 (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. Because of hypotension, impaired consciousness, and unresponsiveness he was transferred to the ICU. In the ICU he received treatment for septic shock, fluid resuscitation, antibiotics, and close monitoring. The endotracheal tube was removed on July 10. On July 13 plain scans of the upper and lower abdomen, together with the patient’s history, confirmed pulmonary infection. Antibiotic treatment and active sputum suction were given. 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 recurrent Crohn’s flares, surgery was not undertaken at that time. Conservative management continued with sputum suction and antibiotics. Abdominal gas decreased. On July 20 sputum culture showed Klebsiella pneumoniae. Antibiotics were adjusted from sulperazon to levofloxacin combined with amikacin. On July 21, after removal of the central venous catheter, temperature decreased, suggesting probable catheter-related bloodstream infection. Antibiotics were further adjusted according to culture and sensitivity results. Anti-infective therapy and fluid support continued with close monitoring. At present temperature 36.4℃, BP 104/67 mmHg, HR 82/min, RR 18/min. Condition relatively stable, adequate urine output. Consciousness gradually improving; patient can make sounds and articulate. Physical examination: cachectic and wasted appearance, consciousness present, nasal cannula oxygen, scaphoid abdomen, soft, minimal tenderness, no lower limb edema, obvious muscle wasting in all four limbs. Poor contact, limbs can move, pupils equal and reactive to light. Nutrition, neurology, and neurosurgery consultations obtained: continue enteral nutrition with gradual transition to whole-protein formula. Nursing staff can guide family in home enteral nutrition and homemade food slurries, gradually increasing caloric support. Encourage passive resistance exercises by family to help maintain muscle. Vitamin B1 10 mg three times daily orally, mecobalamin 1 tablet three times daily orally, appropriate folic acid. If no contraindications, sertraline 0.5 tablet at night orally, mirtazapine 0.5 tablet at night orally. Consider hyperbaric oxygen. Management: agree with current orders from nutrition, neurology, and neurosurgery. Recommend hyperbaric oxygen therapy. Family agreed, so patient transferred to Anda Hospital for further treatment. Comorbidities None Condition at discharge Temperature 36.4℃, BP 104/67 mmHg, HR 82/min, RR 18/min. Condition relatively stable, adequate urine output. Consciousness gradually improving; patient can make sounds and articulate. Physical examination: cachectic and wasted appearance, consciousness present, nasal cannula oxygen, scaphoid abdomen, soft, minimal tenderness, no lower limb edema, obvious muscle wasting in all four limbs. Good contact, limbs can move, pupils equal and reactive to light. Abdomen soft, no tenderness or rebound. Flatus and stool passed per anus. Wound healed well. Post-discharge medications and advice 1. Recommend hyperbaric oxygen therapy and rehabilitation exercises at another hospital. 2. Follow-up with our department and gastroenterology. 3. Seek medical attention promptly if any discomfort develops. Follow-up plan: None at present 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 Procedure: Small bowel resection Anesthesia: General anesthesia Surgical course 1. Brief operative findings: The patient was extremely thin with severe malnutrition. Exploration revealed obvious narrowing of the small bowel 150 cm from the ligament of Treitz; intestinal contents could not pass. Inflammatory changes surrounded the stricture. Proximal jejunum from the ligament of Treitz was markedly dilated (diameter about 10 cm) with congested, edematous wall, markedly reduced peristalsis, dark-red color, and poor blood supply. Distal small bowel beyond the stricture was empty. Exploration of the entire small bowel showed multiple inflammatory strictures, though contents could still pass. Stomach and colon were markedly dilated; bladder full. Intestinal and gastric decompression was performed, yielding about 3000 ml of dark-brown viscous fluid. The markedly narrowed segment and dilated proximal bowel (total about 150 cm) were resected. Side-to-end small bowel anastomosis was performed. Two abdominal drains were placed. 2. Steps: • After successful general anesthesia, skin preparation and draping. Midline incision around the umbilicus to enter the abdomen. Exploration as above. • Small bowel delivered. Diseased segment resected. Proximal-to-distal side-to-end anastomosis performed with reinforcement sutures. 80 mm side-to-side stapler used to close the stump. • Abdomen irrigated with 10 000 ml normal saline. Two negative-pressure drains placed in the pelvis and brought out through separate stab incisions and secured. • Instruments and sponges counted correctly. Hemostasis secured. Wound closed in layers. Procedure completed. 3. Intraoperative measures: Drains left in place. Special intraoperative events and management: None

Small bowel resection performed under general anesthesia. The surgical record is incomplete; neither the circulating nurse nor the scrub nurse signed the operative note. After surgery the patient developed impaired consciousness and unresponsiveness and was transferred to the ICU. The discharge summary records admission on June 20 and surgery on June 20, meaning the operation occurred on the first day of hospitalization. The patient was transferred within the same hospital from surgery to the ICU and other departments for continued care. At discharge on August 31 the summary described consciousness as “gradually recovering” with ability to make sounds and articulate. Physical findings included cachexia and marked muscle wasting in the limbs. The discharge diagnosis included delirium but no clear diagnosis of stroke. According to the family, after discharge the patient remained in a persistent vegetative state—unconscious, unable to communicate normally or perform voluntary movements. He received hyperbaric oxygen therapy afterward, but consciousness never recovered. The discharge description of “gradually recovering” consciousness actually indicated that full recovery had not occurred and the patient remained in an altered mental state.