1. Clinical data.
The patient was admitted to the hospital on October 27, 2005 with diarrhea for more than 20 years, aggravated for 5 months with nausea and vomiting. 1984, the patient developed diarrhea with no obvious cause, passing purulent and bloody stools, accompanied by abdominal pain, which was obvious in the right lower abdomen, and was relieved after defecation. In 1992, due to the aggravation of symptoms, the patient underwent transverse colon, descending colon and appendectomy in an outside hospital. In May 2005, the patient’s diarrhea worsened and he excreted undigested food, accompanied by abdominal distension, nausea, vomiting of stomach contents after eating, and edema of the extremities. In September of the same year, he developed sclera and skin yellowing and transient disorders of consciousness during his treatment in an outside hospital. He had lost about 7.5 kg of body mass in the last 5 months before admission to the hospital, and his physical examination showed significant wasting and moderate anemia. The sclera and skin were yellowish. The abdomen was flat, no abdominal wall varices, no intestinal pattern and peristaltic waves were seen. There was mild pressure pain in the upper abdomen and left lower abdomen, no rebound pain, no mass was palpated, liver and spleen were not detected under the ribs, Murphy’s sign was negative, abdominal mobile turbid sounds were negative, there was percussion pain in the liver area, no percussion pain in the spleen area, intestinal sounds were about 4~5 times/min, no air over water sound and vascular murmur was heard. The coagulation function showed: prothrombin time (PT) >120 s, prothrombin time (TT) >50 s, partial thromboplastin activation time (APTT) >120 Blood biochemistry showed: direct bilirubin (DBIL) 96.8 μmol/L, indirect bilirubin (IBIL) 20.0 μmol/L, alkaline phosphatase (ALP) 147 U/L, gamma-glutamyl transpeptidase (γ-GT) 128 U/L, albumin (ALB) 28.0 g/L, globulin (GLO) 20.2 g/L, bilirubin (GLO) 20.2 g/L, and fibrinogen (FBG) <50 g/L. The abdominal ultrasound suggested fatty liver and gallbladder atrophy. Barium enema suggested: (1) postoperative changes of descending colon, transverse colon and appendectomy; (2) rectal and sigmoid stenosis; (3) irregular filling defects in the rectum, considering rectal polyps and chronic inflammation; (4) sigmoid-small intestine fistula. The formation of jejuno-colonic fistula was seen at 30 cm from the Treitz ligament on electron small bowel microscopy. Electron colonoscopy showed scattered polyps and ulcers in the rectum and narrowing of the intestinal lumen at 20 cm from the anal opening; mucosal biopsy pathology showed moderate to severe polyp-like acute and chronic inflammation with focal chronic ulcers, which was consistent with Crohn’s disease. The pathology of liver puncture biopsy suggested severe fatty liver and cholestasis. The clinical diagnosis was: (1) colorectal Crohn’s disease; (2) jejuno-sigmoid fistula; (3) severe malnutrition; (4) severe fatty liver; (5) post-operative transverse colon, descending colon and appendectomy. The main symptoms of the patient at the time of admission were the clinical manifestations of malnutrition syndrome in short bowel patients due to Crohn’s disease causing jejuno-sigmoid fistula, such as emaciation, anemia, low protein edema, cholestasis, hepatic impairment, coagulation dysfunction and metabolic disorders. The final treatment of the patient required surgical removal of the endovascular fistula, but the patient was in extremely poor physical condition at the time of admission and was unable to undergo surgery. Therefore, preoperative nutritional support to improve the patient’s nutritional status is the first treatment strategy to be considered, and enteral nutritional support using the distal small intestine of the internal fistula is the most physiologically appropriate and should be the first treatment option. A percutaneous endoscopic jejunostomy (PEJ) was first performed, and a jejunal tube was placed proximal to the endotomy to drain and collect gastric, bile, pancreatic and proximal intestinal fluids. Then a percutaneous endoscopic gastrostomy (PEG) was performed again, and a Fulcrum nasogastric tube was entered through the PEG tube, and the distal end of the Fulcrum nasogastric tube was guided under X-ray with an ultra-slip guidewire into the Fulcrum nasogastric tube, which was confirmed to be located in the jejunum about 30 cm distal to the internal fistula. After 3 months, the patient’s body mass increased by 5 kg compared with that at the time of admission, and the anemia, coagulation function and liver function impairment improved significantly. 2. Discussion. Malnutrition is the most common and prominent complication in patients with Crohn’s disease, which seriously affects their immune function, quality of life and long-term survival rate. This patient was suffering from chronic diarrhea, vomiting and internal fistula formation due to Crohn’s disease, resulting in inadequate intake, malabsorption and excessive loss of nutrients, and finally severe malnutrition. Nutritional support can relieve the clinical symptoms of Crohn’s disease by resting the intestines and reducing the intake of harmful antigens. There are two ways of nutritional support: parenteral and enteral. Enteral nutrition and parenteral nutrition can also make the intestine rest and relieve the symptoms of Crohn’s disease, and enteral nutrition is physiologically consistent, can protect the intestinal mucosal barrier, reduce the displacement of flora, and is simple and inexpensive. The establishment of nutrition channel is an important part of enteral nutrition support. Routine enteral nutrition routes include nasogastric tube, nasoenteric tube, surgical gastrostomy, jejunostomy, PEG and PEJ, direct percutaneous endoscopic jejunostomy (DPEJ), percutaneous endoscopic duodenostomy (PED) and other new technologies. Each of them has its own indications, advantages and disadvantages. However, in this patient, the nasal intestinal tube could not reach the distal jejunum through the fistula because the internal fistula was 30 cm away from the Treitz ligament, and the surgical jejunostomy was too traumatic for the patient to tolerate because of the poor general condition. However, in practice, the problem is that the endoscopic placement of the jejunal tube cannot determine the route of the tube and ensure that it crosses the fistula to reach the location of the distal jejunum where enteral nutrition can be safely administered. Since 1980, the indications for percutaneous endoscopic gastrostomy in clinical application have been expanding. It is characterized by easy, safe and effective operation, which is more easily tolerated by patients than the transnasal nutrition tube, and is less invasive and safer than surgical gastrostomy and jejunostomy, and is suitable for patients undergoing long-term enteral nutrition support. The purpose of placing a gastrostomy tube is to eventually place a jejunal nutrition tube through the gastrostomy tube. In this case, we used a super-slip guidewire guided placement of jejuno-intestinal nutrition tube through the gastrostomy tube under X-ray. Compared with the traditional PEJ procedure, it has the advantage that the route and position of the guidewire and tube can be clearly defined under X-ray fluoroscopy, and the placement of the tube can be confirmed by imaging immediately after completion, ensuring a successful operation. Although the establishment of the above-mentioned channel solves the problem of the way to give enteral nutrition, there is still a large amount of loss of gastric juice, bile, pancreatic juice and proximal intestinal fluid due to the existence of jejuno-sigmoid fistula, which causes the obstruction of hepatic and intestinal circulation of bile acid and the poor digestion and absorption of enteral nutrition preparation. Therefore, a percutaneous endoscopic jejunostomy was performed at the same time, and a jejunal tube was passed through the descending duodenum and placed at the proximal end of the fistula to collect gastric juice, bile, pancreatic juice and proximal intestinal fluid, which was returned to the distal jejunum. At this point, a complete enteral nutrition support channel was established. There is no fixed pattern or method for the establishment of enteral nutrition channel, but it must be based on the patient’s condition and the medical conditions available. However, the general principles are safe use, clear effect, simple operation, low cost and easy care.