Chapter 908 - 449: All Blood, Treat First, Diagnose Later

Chapter 908: Chapter 449: All Blood, Treat First, Diagnose Later

Li Jingsheng sat in Director He’s office, repeatedly pondering the patient’s information.

Various examination reports, as well as medical history, symptoms, changes in the disease course, etc.

Trying to save a critically ill patient, especially one who has already undergone surgery and then developed complications, is no easy task.

Only by thoroughly understanding the patient’s situation can the real problem be identified, and a reasonable solution be devised.

"This patient likely has intestinal obstruction, but whether there is postoperative intestinal necrosis is still unclear..."

The greatest challenge lies in the segmental lesions present in the patient’s entire small intestine.

To resolve the issue surgically, the patient’s entire small intestine would need to be removed.

After removal, the patient’s future nutrient absorption would be greatly impacted.

If the intestine isn’t removed, is there another way to resolve the issue?

Li Jingsheng is not very experienced in General Surgery, and he racks his brain but can’t come up with particularly good alternative surgical solutions.

Not removing the small intestine but creating an end ileostomy followed by abdominal lavage and drainage should also be feasible.

However, this plan still carries many risks.

Diagnosing the cause is Li Jingsheng’s strong point.

He has much to learn in terms of surgical solutions.

This patient is very young, only in his twenties; ineffective treatment leading to death would be a heavy blow to the entire family.

Soon, He Qingzhi returned.

"The family has agreed to a second surgery."

He excitedly told Li Jingsheng.

Judging by the situation, he probably didn’t get reprimanded. Setting aside pride is definitely a good thing.

Not to mention the humility, at least the genuine cause can be sought out normally, and treatment can be grounded in reality for the patient. With fewer self-serving concerns, one can practice medicine better.

The family’s agreement to a second surgery is basically out of helplessness.

If the son is treated in the hospital and the doctor’s treatment plan isn’t agreed upon, any mishap would be their own responsibility.

"Are you planning to arrange the surgery overnight?"

Li Jingsheng asked.

"Yes, we’re preparing to arrange the surgery for the patient now. I’ve already asked the anesthesiologist to come over for preoperative evaluation, and the operating room is ready."

He Qingzhi nodded to confirm.

"Dr. Li, can I ask you to assist with the surgery later?"

"OK."

Li Jingsheng readily agreed.

...

Inside the operating room, the patient’s abdominal cavity was reopened.

The suture of the incision can be seen as quite excellent, with the incision being smooth and the margins well-aligned. The spacing of the stitches is very orderly, the knots are secure, and they are close to the skin.

After removing the stitches, Li Jingsheng saw that both the knife position and the smoothness of the incision were very good.

Since it has only been a dozen hours since the suturing, reopening only requires cutting the sutures.

Upon opening the abdominal cavity, a large amount of dark red fluid can be seen inside.

These are blood-stained exudates.

The internal temperature of the abdomen is relatively high, with a faint irritating odor wafting out.

After suctioning away those blood-stained exudates, the quantity totaled up to 1700 milliliters.

Such severe exudate is quite uncommon in abdominal surgeries.

Although exudate isn’t equivalent to blood, reaching such a large quantity indicates that the previous open surgery not only had no effect but actually worsened the condition.

He Qingzhi has his own medical team with a professional surgical team.

As a guest, Li Jingsheng can only stand below, craning his neck to watch.

After suctioning out the fluid in the abdominal cavity, the condition of the intestines can already be seen.

The color of the jejunum and ileum has turned entirely purple.

Some segments appear cyanotic.

The tension in the intestines has worsened noticeably, and some segments have even lost tension.

There is no peristalsis in the intestines.

All layers of the intestinal wall show clear congestion, edema thickening, and there is bleeding and necrosis, particularly severe in the inner membrane.

No perforation of the intestines has been found yet.

The intestinal cavity can faintly be seen filled with dark red fluid.

Mesenteric congestion and edema are equally severe.

The only consolation is that the proximal vascular pulsation is still considered normal.

However, after seeing the patient’s abdominal situation, Li Jingsheng’s heart sank directly to the bottom.

The progression of the patient’s condition is faster than expected.

The intestine and mesentery are already showing clear signs of impending necrosis. Like a tree that is about to wither, its leaves start to turn yellow and fall off.

The condition of the patient’s intestines is akin to a tree experiencing serious problems.

This time, the purpose of reopening the abdomen is threefold.

First, to investigate changes in the condition of the intestines.

Second, to provide drainage and decompression for the intestines.

Third, to actively search for the true cause, and if a surgical plan can be devised, implement it.

Removing the entire small intestine is definitely unrealistic.

"The terminal vascular pulsation has disappeared, the hopes of saving the patient’s small intestine are very slim."

Li Jingsheng sighed inwardly.

Although the patient’s intestinal sequence looks normal, with no obvious intestinal torsion or intussusception, the situation is far from optimistic.

There is also an optimistic side, such as the patient’s colon wall appears normal in color.

This indicates that the lesions are mainly concentrated in the small intestine.

"Dr. Li, you’ve seen the condition of the patient’s abdominal cavity. How about we first perform an incision for decompression?"

"Alas! I didn’t expect the patient’s intestinal condition to become so bad. If you want to perform incision drainage and decompression, then I suggest cutting at the still somewhat rosy end of the ileum. This would release the contents of the intestinal cavity and allow us to see the condition within the intestinal fluid."

Li Jingsheng supports the incision drainage and decompression.

If possible, he even supports the removal of the small intestine.

Compared to the patient’s life, the harm of removing the small intestine is significant, but it can save the life.

"My idea is basically consistent with Dr. Li’s, so let’s just proceed with the incision,"

He Qingzhi immediately made an incision at that location on the patient’s ileum end.

After the intestinal contents were released, as much as 1600 ml was discharged.

Upon careful examination, necrotic mucosal patches from the small intestine can be seen in the discharged intestinal contents, the rest being bloody water.

After discharge, procaine was used to block the mesenteric root, and warm saline was used to irrigate the abdominal cavity.

Generally, when irrigating sensitive viscera, warm saline is required.

Otherwise, the stimulation to the patient would be immense.

He Qingzhi’s assistant completed the irrigation and then applied heat using gauze to the small intestine wall.

"Wait for about half an hour and observe changes in the intestines. I sincerely hope that this patient’s small intestine can be saved; he is just twenty-two years old, far too young. When we last performed abdominal surgery, I felt conflicted.

The diseased intestinal segments are really too extensive; if we wanted to remove them all, the patient would essentially be incapacitated for life.

Also, his family’s financial situation is not good, and they cannot afford postoperative treatment costs.

I didn’t expect that the last treatment didn’t yield any effect.

Dr. Li, with your help this time, we must really think it through and strive to find the most reliable treatment plan."

He Qingzhi is indeed trying his best.

"Director He, I feel there’s something peculiar about this patient’s condition. If it were merely an intestinal obstruction, it would be difficult for it to lead to multiple-segment lesions of the entire small intestine. To me, it seems like there is an underlying disease."

Li Jingsheng frowned slightly as he stared at the patient’s abdomen.

Diagnosing the cause of the disease is his strength.

Before opening the abdomen, he had considered the possibility that the patient’s intestinal condition might be bad.

But after actually seeing the situation inside the abdomen, he realized it was slightly different from his previous judgment.

The patient’s intestinal lesions weren’t localized, nor caused by obstruction leading to overall intestinal problems; instead, it seemed as if the entire segment of the small intestine was affected.

"What do you mean?"

He Qingzhi no longer dares to underestimate Li Jingsheng.

Now, after hearing his analysis, He Qingzhi immediately pays close attention.

"Is it possible that some disease caused the intestinal obstruction? Which means the intestinal obstruction is just a subsequent symptom, with other undiscovered causes preceding it."

Li Jingsheng said.

"This... I really haven’t thought about it. The patient underwent a B-ultrasound when admitted, indicating the presence of bile duct ascariasis. Also, no vomiting of coffee-colored liquid occurred before surgery."

Director He found this young fellow’s thinking to be distinct from other doctors.

The disease within a disease, occurring before the obstruction, meant the intestines already had other diseases; he had never considered this angle before.

Including his team of doctors, none of them had thought about this aspect.

It’s not that their level is lacking, but their talent... falls short of Li Jingsheng.

The way of thinking differs by more than just a bit from Li Jingsheng.

"Didn’t we just perform incision drainage? Why not prepare an intestinal pathology biopsy?"

Li Jingsheng lacks extensive experience in gastrointestinal surgery, thus cannot judge further diseases based solely on intestinal conditions.

Even Director Bi, if he were here, might struggle similarly.

Conducting an intestinal pathology biopsy is a very good option.

"It’s just that the family might not agree!"

Director He has some concerns.

"I mean no disrespect, but even if the patient’s family disagrees, it must be done. Because this concerns the patient’s life safety. His condition is not just a simple intestinal obstruction. Generally, if an intestinal obstruction doesn’t receive effective treatment, the disease progresses quickly, but rarely does the entire segment of the small intestine deteriorate within such a short time. Performing a pathology test is very important."

Li Jingsheng stated firmly.

"Director He, I think Dr. Li’s analysis is reasonable. You’re worried that performing an intestinal pathology biopsy will lead to a third abdominal surgery for the patient. The disease progression is extremely rapid; since things have reached this point, we can only prepare for the worst."

The first assistant supports Li Jingsheng’s point of view.

With support, Director He fears losing face or the patient needing another surgery, bringing shame to him and his team... these thoughts are all cast aside.

"Alright, let’s proceed!"

Director He resolutely agrees to conduct the intestinal pathology biopsy.

"But the results will take at least three to four days, and you can see the patient’s condition now. I worry the pathology results will not be ready before the patient deteriorates."

This concern is indeed valid.

The patient’s intestinal situation is extremely bad, having deteriorated so quickly in just a little over ten hours; waiting three days could mean the intestines rot from the inside.

"The intraperitoneal dark red hemorrhagic fluid is as high as 1700 milliliters, and there are another 1500 to 1600 milliliters of blood-red fluid inside the intestines. I suspect the patient may have acute intestinal hemorrhage. I used the exclusion method to diagnose the cause earlier, and still cannot confirm intestinal necrosis in the patient.

So it leaves only one possibility: his disease might be acute hemorrhagic necrotizing enteritis.

We can, before the results come out, administer non-surgical treatment according to certain principles.

For example, correcting the imbalance of electrolytes, using anti-shock treatment, and broad-spectrum antibiotics for infection..."

Li Jingsheng showcases his strengths.

Using the patient’s hints and intraoperative findings, he managed to deduce the cause using the exclusion method.

But before the pathology results are out, nobody can confidently diagnose.

There is still room for error.

Treat first and diagnose later, violating basic medical procedure, but only through this method can the patient’s life be saved.