Patient’s family: My father had a stent put in his heart three years ago and was taking enteric aspirin for a long time. On May 5 of this year, he suddenly had blood in his stool, 3 times an hour. Gastroscopy did not find any abnormality, but because the intestine was full of blood, the colonoscopy was unsuccessful. On May 9, the doctor found a brightly colored blood clot in the right hemicolectomy and removed it, and two drains were placed in the abdominal cavity. Three days after the operation, blood in the stool was again seen, along with abdominal distension, and the exudate from the incision turned green and was accompanied by a high fever of 40 degrees. On May 17, a second surgery was performed. Postoperatively, an anastomotic fistula and a small intestinal fistula were found. After the second operation, he was admitted to the intensive care unit, and the hospital gave a critical care notice, stating: Current diagnosis: 1 post-intestinal resection, intestinal anastomosis, and enterostomy 2 shock Hemorrhagic shock? Infectious shock? 3 Gastrointestinal bleeding 4 Coronary artery disease Post coronary stent placement. After the second surgery, the condition tended to deteriorate, the drainage tube had a blood flow condition, only daily blood transfusion, unconsciousness, talking nonsense, more serious is the doctor found the second surgery small intestinal fistula at the leak again, because the infection is serious brain poisoning, only the third surgery. On May 24, the third surgery was performed. The hospital again issued a critical care notice with the following diagnoses: 1, after dissection, jejunostomy, ileostomy, transverse colon descending colectomy, and abdominal drainage 2, abdominal infection 3, sepsis, septic shock 4, multiple organ insufficiency (pulmonary function, cardiac function, liver function, renal function, coagulation function) 5, coronary artery stent placement after coronary artery disease, and 6, jejunostomy, after abdominal flushing and drainage. The current treatment is anti-infection and supplemental nutrition. On the night of June 3, around 22:00, my father had a high fever of more than 39 degrees, and the CT revealed a large gallbladder, which was suspected to be inflamed. The transaminases were also high. Q: What is the key to treatment in the current situation? 1.I can understand your eagerness. 2.From your detailed account, you can see that the consultation is with a strong general hospital. They have not given up and are doing hard work. 3, the special nature of the disease, it is difficult to do in the treatment, each and every smooth. 4.It should be said that the most dangerous stage has passed, at present, although not completely out of danger, but hope is going to grow. 5.The core problem of the current treatment is how to use the present intestinal tract for enteral nutrition. 6, If you can take yogurt, water, nutrition solution orally, you can also add chicken soup, fish soup, juice, etc., collect intestinal fluid from the jejunostomy, and then instill it from the distal end of the jejunostomy to make full use of the ileum to absorb nutrition. 7 If the amount of oral intake is small, you can also directly input Bepril (an enteral nutrition solution) from the distal end of the jejunostomy with a pump 8. If the enteral nutrition is good, liver function (transaminases) problems, large gallbladder problems, and infection problems, will improve. Patient’s family: Thank you for your affirmation of my father’s hospital visit and for your detailed advice. You know how valuable they are to my father’s current situation and how encouraging they are to us. My father’s upper left abdominal stoma intestine did not grow and his sutures were open. The main reason why the stoma in the upper left abdomen did not grow and the sutures opened is because the incision was split and infected due to malnutrition, which is very common in patients with enterocutaneous fistulas. The patient will be saved if the enteral nutrition is improved, the liver function (transaminases), the large gallbladder, the infection, and the incision will be improved. Patient’s family: My father started to feel pain in his incision yesterday, is this a good sign that his incision is starting to grow, because he felt a wooden wound all the time before. Also, he said he has been having pain near his rib cage, what could be the cause? Also, are there any basic principles and contraindications when administering medications to patients with abdominal infections like my father? For example, can you tell me about the usage of anti-inflammatory drugs? Can you recommend a few books and materials for me? 1, to trust the doctors in their hospitals, especially the chief surgeon, they have experienced the whole treatment process, from your account, I see no major principle errors in the treatment. 2, can be a practicing doctor, especially to do the main surgeon, usually after more than ten years of systematic training, not just read a few books or information. For example: your father’s abdominal infection, it seems to be mainly in the anti-inflammatory drug usage, in fact, the core problem is a serious stress metabolism after the malnutrition problem and immune deficiency problem, I believe his main surgeon will start from enteral nutrition to solve this problem. 3, the difference between doctors and non-doctors is the ability to see the essence through the phenomenon. For example: your father started to feel the pain of the incision yesterday, you think it is a good sign that his incision started to grow, because he felt the wound woody for some time before. There is also constant pain near the rib cage, and the doctor will go to analyze whether there is a localized abscess or fluid in the abdominal cavity, which needs to be treated with ultrasound or CT confirmation. Patient’s family: I am quite disappointed with this hospital and with the attending doctor because my father has already had three surgeries. You said something about collecting the upper half of the intestinal fluid and instilling it back into the intestine to make full use of the intestine to absorb nutrients, and the doctors here have never heard of this treatment. In the current situation, would you recommend my father to be transferred to another hospital? 1. The question of transfer. As far as the condition is concerned, transferring to another hospital is not supported. There are some risks involved in transferring to another hospital. Is there a bed in the new hospital? The doctors at the new hospital have a process of understanding the condition. In terms of losing trust in the primary care physician, the transfer is supported. I am a doctor and I know that after losing trust, it is difficult to have the cooperation of the patient and his family in the treatment, and the treatment will be difficult and less likely to be successful. 2. Collecting jejunal fluid and instilling it back into the ileum to make full use of the intestinal tract to absorb nutrients is something that is done. It’s easy to say, but doctors who are not treating intestinal fistulas will not have a smooth ride doing it. Patient’s family: My father started on June 10, he was more agitated and felt less strong than the previous two days. I saw the large wound on my father’s abdomen today, more than 20 centimeters long, and I was very disturbed that the lower half of his incision was not growing, which means he now has a hole in his stomach. I don’t know what to do when I look at my father’s shortness of breath and the doctor starts telling me that my father’s condition may recur. I was about to collapse. In terms of treatment, the doctor put a tube in the lower half of my father’s small intestine and started dripping saline today. In the afternoon, the doctor said to me that I should filter the stuff from the upper half of the small intestine and pour it into the lower half, which should be the intestinal fluid refill you mentioned. Question 1: Is there anything that needs special attention in the work of reperfusion? 2.My father has had a fever for the past two days, what is the main cause? What is the solution? The condition is very critical, with the possibility of heart failure, respiratory failure, and immune failure. It is life-threatening. 1, intestinal fluid re-infusion requires filtering the intestinal fluid through a layer of gauze to remove substances that can easily block the tube. The collected intestinal fluid should not be left for too long, and it is best to re-infuse every 6 hours of collection. It is also possible to input Pepcid directly from the reperfusion intestinal fluid. 2. Severe infection after intestinal fistula depletes the nutritional state and immune function in the body, and fever is mainly caused by infection. Patient’s family: Is there any hope? Is there any hope? 1. do a good job of enteral nutrition support 2. flush and drain the infected foci 3. maintain the function of important organs, there is still hope! Patient’s family: The blood test results came out today, my dad’s white blood cells are 3000, neutrophils are not high, and hematocrit is also dropping, so we started blood transfusion and human albumin this afternoon. The most difficult time has come, the white blood cells are down, the neutrophils are not high, and the immune function is depleted. The disease is critical. To say still: 1, good enteral nutrition support 2, infected foci flushing and drainage 3, maintain the function of important organs patient’s family: upload to you two photos of my father’s abdominal incision. I am eager to hear your opinion and look forward to hearing from you. 1.My father had two drains removed yesterday, and currently he has one drain on the top left and one on the top right of his abdomen. 2. Today the doctor proposed to remove the remaining drainage tube, but I proposed to keep it for two more days. Is it too early to remove the drains? 3.In the blood test results yesterday, my father’s protein was only 23, and yesterday he started taking 10 grams of human albumin. Is this okay? 4. Is it appropriate for him to receive 750 ml of albumin drip per day through the tube placed in the lower part of his intestine and about 2000 ml of intravenous nutrition fluid almost per day in the deep vein? 5.My father has a popping pain in his left lower abdomen, what do you consider could be the problem and how to solve it? There is no obvious liquid dark area in the CT some time ago, what can this mean? 6.Escherichia coli was found in my father’s abdominal drainage fluid culture and sputum culture, what do you suggest about antibiotics and is there a better way? 7.My father’s temperature is still over 38 degrees recently and he has a constant fever. It has been physically cooled and the doctor currently has my father nebulized 6 times a day to make him cough up sputum. It has been 5 days since the nebulization, do you think it is necessary to continue? 8. I decided to ask them to put my father under a gastric tube nasal feeding, is that okay? Thank you for your trust in me. So many specific questions have been raised. What does it mean to be a clinician? It is the doctor who comes to the (clinical) bedside and, by carefully questioning and examining the condition, then, makes a diagnosis and treatment adjustments. No matter how brilliant a doctor is, he or she can only talk about theories and principles apart from the clinic, otherwise, it is a blind command. The modern network cannot replace, and will never replace, coming to the (clinical) bedside. Patient’s family: My father had a bleeding stomach mucosa, which stopped in two days. Did you encounter any patients with intestinal fistulas with a situation similar to my father’s? Patients with intestinal fistulas often have combined bleeding, including: internal bleeding in the GI tract and external (intra-abdominal) bleeding, which is severe and dangerous. It is good that your father’s bleeding was small and was stopped in time. Patient’s family: How far did my father have to recover to be discharged? The doctor here said to sew up my father’s stomach again and then sent my father home to recuperate, saying that he would be discharged home after another week of hospitalization. Will your father be able to live completely on oral food now? The answer is yes, he cannot. At the jejunostomy, how can the large amount of intestinal fluid lost every day be handled and replenished at home? The answer is yes, there is no way. When the doctor says discharge, I see it as encouraging you, giving you hope and confidence to overcome the disease, which also means that recovery is not far away.