A Tale of Two IBD’s – I

bowelAsk any general or gastro-entero surgeon, what’s his failing! More often than not you’ll get a universal answer, ISCHAEMIC BOWEL DISEASE.

An ischaemic bowel disease is similar to a heart attack, the only difference being that it occurs in the intestines. The blood supply to the intestines is cut off and can lead to a spectrum of diseases ranging from abdominal angina (yes, angina the term most commonly used for heart diseases) to a full blown blockade, leading to an Intestine Attack (similar to a heart attack but in the intestines). While the heart has numerous nerves which refer the pain caused by an decreased blood flow to various parts of the upper half of the body (jaw, chin, shoulder, inner arm etc.), the intestines are less equipped to do so. Which makes this condition ominous, as it is not only difficult to diagnose, but once diagnosed it is usually in a very advanced stage. The intestines contain a large number of bacteria within their walls, but while they are beneficial in health, in disease they pour out into the blood to cause a picture of full blown sepsis in the body.

The First Case:

It was a busy day in the emergency ward. We had already finished 12 minor cases, 3 major ones and we had 6 major cases wait-listed. And it was only midnight. 8 more hours for the emergency shift to get over, but several more hours till the cases were operated upon. This was going to be one heck of an emergency duty!

At around 4 am, while my colleague and seniors were operating in the emergency OR attached to the emergency ward, a 30 something, portly man (one Mr.Arun) came in with severe pain in the abdomen and a file of the various doctors he’d been to for all sorts of treatment. My initial impression after examining the patient was that he had a perforated bowel (a hole in the bowel, which could be due to various causes). I followed the routine protocols for resuscitation as the patient appeared extremely dehydrated and sent him for an abdominal X-ray, once it was deemed fit. To my surprise, there was no evidence of perforation in the X-ray. What else could it be? An obstruction? A tumor?

An ultrasound wouldn’t reveal much, so we decided to go in for a CT scan directly. However, even the CT findings were unremarkable. At this point in time, my seniors came out of the OR having completed the surgeries. I presented the patient to them, with history, examination findings and investigations. They were flummoxed too. The patient however had very little relief in pain during this time and had started developing a fever. A decision was taken to operate.

The clock struck 8 and the emergency duty had just ended. As was the norm, one of us would stay back with the Lecturer to finish the backlog of cases, the other would round off the ward patients, which was no mean task! It was my turn to go back to the ward. I finished my work, we rounded off patients with the consultants, the pending decisions were made and the CT’s of the various admitted patients were reviewed. All this while, I wondered what happened to that 30 something man who was going to be operated upon!

2 pm the following day and I was finally done with all the work. It was time to break for lunch. A quick trip to the emergency OR would do no harm, I thought to myself. Leaning in to the OR, I saw my colleague scrubbed in, closing the abdomen of the patient (the final part of the surgery).

What did it turn out to be! Ischaemic Bowel Disease!

Retrospectively, the long duration of pain signified it was an abdominal angina, the paucity of findings on investigations out of proportion to the clinical findings pointed towards an ischaemic bowel disease. Yes! but in a 30-something. This is a disease of 60-somethings. Strange things happen in the human body! There’s always so much to appreciate and learn. If the decision wasn’t taken to operate, we would have lost the patient without a diagnosis. It was a bold decision nonetheless, one that would’ve been severely scrutinised had we not returned with any findings. Kudos to the Lecturers.

The patient underwent surgery. Almost all of his small bowel and a part of his large bowel were removed, as it was gangrenous and infected, leaving behind 100 cm of the upper part of the small bowel (thats very little considering the entire small bowel ranges from 600-1000 cm). His remaining bowel was brought out onto his abdominal wall as an opening (stoma) at both the ends. The small bowel plays a vital role in the absorption of nutrients, vitamins and minerals into the circulation, which are all necessary for holistic growth. Loss of this function meant the patient would be a nutritional cripple all his life. The large bowel, on the other hand has a limited role in the absorption of nutrients, but a greater role in absorbing water and minerals.

Our patient, Arun, had practically lost all of his small bowel with his large bowel intact, both the ends being open on the abdominal wall, at the tender age of 35. While the surgery went off well and the post operative recovery was good too, the main problem would be nutritional rehabilitation.

The patient was put on a regime of parenteral nutrition (injecting nutrients in a concentrated form straight to the heart) and re-feeding. To prevent the patient from losing his body fluids to the exterior, we collected all the fluid coming out through the opening on his abdominal wall, put it through a sieve and fed it to his large bowel also opened on his abdominal wall (re-feeding).

On our morning rounds, two weeks post-op, the patient and his relatives came to us with complaints of burning pain around the abdominal wall opening (stoma). We examined him only to notice severe excoriation of the skin. Due to the highly toxic and vicious nature of the billiary fluids coming out through his abdominal wall, the patient developed excoriation of the skin. While, this could be considered negligence for any other type of stoma, this was just an expected complication for this one. The skin surrounding the opening was red, thick and excoriated. We tried all the available methods but to no avail.

It was then, that the experts came to our help. A reputed company which manufactured bags to place around the stomas, provided us a bag with a special design (concave) which prevented the excoriation. We tried it. It worked. The skin healed and the stoma contents were manageable.

Arun, was ably supported by his family, un-educated but always willing to learn. His mother was his biggest support, his father always using all available resources to provide him with the best care and his extended family always chipped in with some money. Ours, being a public hospital, the costs were heavily subsidised. Even then, we didn’t have everything available and the patients often had to purchase some prescription articles, using their own money.

All said, we did have our own problems with his relatives. Not that we really complained about them. It seemed that one of his relatives was affiliated to a Member of the legislative assembly. They regularly got letters signed by the administrators asking us to take good care of the patient (as if we weren’t already!). They also went to the extent of lodging a complaint against my colleague and myself for rude behaviour (a totally baseless charge, which was later withdrawn at the behest of the patient himself). Yes, there were arguments, there were disagreements regarding the best course of action, at times there was arrogance (from the patients relatives), but there was never rude behaviour involved, nor was there ever admonishment for belonging to a certain class of society(another baseless charge levelled against my colleague and myself). We were chided, asked to mend our ways, be polite and courteous, but never appreciated for the work we put into getting the patient this far! It’s at times like this when u feel like you shouldn’t go out of your way to help patients recover, stay within the limits of whats right and do the bare minimum. It wasn’t the patients fault though, so we continued with our work in a professional manner, knowing that the uproar would die down, sooner rather than later.

4 weeks post-op and Arun had lost weight, 20 kg’s to be precise. His muscle mass had reduced and his cheeks had become hollow (a sure shot sign of malnutrition). His nutritional rehab regime was failing and we had no idea what to do. My colleague and I came up with an idea. Reading about patients in the ward was always advisable, but none of us followed through with that, considering the lack of time. But Arun was an exception. Both of us wanted him to be fit and healthy, ready to go home. After all, we had spent so many sleepless nights monitoring him to make sure he was ok. We came across the role of medium chain triglycerides in such patients and decided to try them. We also started him on oral feeds, reducing his need for parenteral nutrition. Slowly and surely, he started gaining weight, to our surprise he was even weaned off the parenteral nutrition and could resume all his feeds orally, the only rider being he had to empty his bag 4 times in a day and reefed the contents into the other opening.

With a promise that he would be taken care of well at home, we started planning a discharge. The discharge summary took my colleague and myself 2 days to write out. After all, Arun had been with us for 6 weeks now and had gone through numerous ups and downs. We captured every moment of his stay in the hospital in the discharge summary, got the mistakes rectified by our Seniors and finally sent it to the nurse to follow through with the discharge. The whole process took the nurse 2 hours, segregating his multiple files and reports.

Arun was finally ready to go home! 6 weeks, 2 surgeries and countless troughs later, he was all packed up. His family was in tears, of joy or sorrow, we couldn’t say. They had come to grow very fond of us, the hospital and the surroundings and treated it as their home. Going out of our way to help him stay afloat and eventually survive and rehabilitate was an enriching experience. I learnt more from this one patient, than I had so far in my surgical residency (8 months down). It was because of times like this, that I threw my previous notions out of the window (doing the bare minimum) and felt proud of the effort we had put in.

Arun was placed on a strict follow up schedule. We saw him twice in the OPD every month after that, measured his weight, got his lab reports, kept a tab on his stoma function and made sure he was never dehydrated. He followed up in the OPD for the following 2 months. After which he disappeared.

No phone calls, no visits for consults, no news of him! It had been a month since Arun had showed up and my colleague and I were getting a little worried. We recovered his contact number from the old patients list and contacted him. It was his mother who greeted us over the phone. We exchanged pleasantries. We asked about Arun. HE WAS DEAD! His mother told us that he had collapsed suddenly while resting one evening only to be declared dead on arrival to the local hospital.

Such is the nature of this disease! If it won’t kill you, it’ll make sure some other system is affected. In the long run, that will kill you. We tried and even succeeded partially, but failed in the long run. Arun lived for only 4 months after his surgery, but he taught my colleague, Dr. Devayani and myself more than what any book could ever teach us.

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