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The amount of blood per day is almost 700-800 ml, and the hemochromatosis is as low as 4 grams!
Uncle Lü's face was miserable, his skin was sallow, and he was curled up on the bed of the ambulance, from Nanchang, Jiangxi to Guangzhou, after 12 hours of bumps, and finally arrived at Zhongshan Sixth Hospital at 8:00 a.m. At this moment, he was urgently sent to the ICU, not only the hemoglobin was very low, the blood pressure was not good, fortunately the consciousness was still quite clear.
The "drip" sound of the life monitor sounded in the ear, and the bright red blood in the upper right blood bag slowly flowed into the body along the tube. Uncle Lu knew in his heart that the blood injected would not stay in his body for too long, and would soon be lost in another form. Sure enough, in less than half an hour, he pulled the bloody stool twice, each time "hula" and discharged as much as 200 ml.
Outside the gate of the ICU ward, Uncle Lu's son Ah Wei (pseudonym) frowned tightly and paced in a square step, wondering if his "impulse" could pull his father back from the ghost gate. While anxiously waiting for the arrival of the consultant, he secretly prayed: he hoped that the doctors in Guangzhou would help his father find the real cause of the bleeding.
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It took more than 100,000 people to find the cause of the disease across provinces for help
Uncle Lü, a 63-year-old from a small county town in Shangrao, Jiangxi Province, has a history of chronic anemia and hypertension.
"My dad started to have bleeding symptoms in 2019, at one point too severe to walk. In the hospital in Zhejiang, he suspected that it was a blood cancer, and although he finally ruled out blood diseases, he did not find a substantial cause. Ah Wei said that after hospitalization, his father's condition improved, and the bleeding was controlled, so there was no further examination, only some blood tonic drugs were prescribed to take home, and his father was not in serious trouble for three years.
Unexpectedly, in November 2021, Uncle Lu suddenly had a heavy bleeding at home, and he blacked his stool for more than 10 consecutive days, and thus had one "shock" and two "first aid". In order to find the cause, he was referred from the local hospital in Shangrao to the hospital in Jiangxi Province, and further investigation and treatment.
Uncle Lu's abdomen is soft and tender, there is no bump, there is no percussion pain in the liver, and there is no edema in both lower limbs, but there are frequent bowel sounds, 4 times per minute.
"After more than twenty days of hospitalization, blood routine, blood biochemistry, full abdominal CT, gastrointestinal endoscopy, small colonoscopy, angiography, and two interventional surgeries, almost all the examination methods for gastrointestinal bleeding have been used over and over again, adding up to more than 100,000 yuan." Doctors suspect that the mesenteric vessel malformations cause bleeding, but the location of bleeding can not be found, and only symptomatic treatment such as hemostasis, acid suppression, and rehydration can be used. Ah Wei helplessly said that if he could not find the cause of the bleeding, he could not effectively stop the bleeding, and watched his father's body deteriorate day by day.
The anxious family inquired around and learned that the Sixth Affiliated Hospital of Sun Yat-sen University had experience in this area. "To go or not to go" has become a difficult problem in front of us.
"There are more than 800 kilometers from Nanchang to Guangzhou, and there are great risks to take on the road, and it is not certain whether the doctors in Guangzhou can find the cause." However, if I hadn't sought a better way, I think my dad would have been 'gone'! With the serious blood loss, Uncle Lu has reached the point where his life is in danger, ah wei decided to give it a try, and chartered a car on the night of December 7 to leave overnight. After a long journey of 120 ambulances, escorted, the next morning at 8:00 a.m. successfully arrived at Zhongshan Sixth Hospital.
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CT of the small intestine found suspicious signals
Gastrointestinal bleeding is a common symptom, long-term repeated inability to find the cause is called unexplained gastrointestinal bleeding, this is relatively rare in the clinic, Zhongshan Sixth Hospital annual admission of cases is only in single digits.
Carefully studying Uncle Lü's medical records, Xie Shangkui, chief physician of the Department of Anorectal Surgery of Zhongshan Sixth Hospital, said that the only thing that can be determined is that the bleeding comes from the digestive tract including the gastrointestinal tract, biliary tract and other systems.
"Because the patient did not have significant stomach pain or jaundice, had no history of cirrhosis, and had earlier CT conditions indicating that liver indicators were basically normal, diseases of the biliary system could be temporarily ruled out." Xie Shangkui combined the large amount of bleeding and the dark redness of blood to speculate that the bleeding point was probably located in the upper part of the digestive tract, but a CT and gastroscopy of the small intestine were required to confirm the diagnosis.
"The checks that should have been done have been done before, and there was no problem, is it necessary to do it again?" Ah Wei did not understand the doctor's proposal to do another examination.
Huang Dandan, attending doctor of the Department of Anorectal Surgery at Zhongshan Sixth Hospital, patiently explained why the two tests had to be repeated. "The accuracy of the examination results is related to the fineness of the equipment and the level of the doctor's reading, and the small intestine CT and gastroscopy can help to determine the location of the bleeding as much as possible, ensuring that the bleeding point is found with a high probability during the operation." If you rush to open the abdomen and can't find the bleeding point, then there are only two ways, either close the abdomen and give up, or cut the small intestine completely, and the loss of the small intestine will seriously affect the quality of life. ”
◎CT of the small intestine found suspicious bleeding in the upper section of the jejunum
Hearing this interpretation, Ah Wei nodded in agreement. Gastroscopy probed deep into the duodenum as requested by Xie Shangkui and found no problems. Success or failure depends on the small intestine CT, radiology Dr. Li Wenru, Dr. Wei Kaikai carefully studied the film, and after about 20 minutes, a new discovery was finally made - Uncle Lu had a suspicious signal in the upper part of the small intestine, but it was not sure whether it was a bleeding lesion.
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"Ancient Methods" Probe
Pull out the "bleeding point" of the needle eye
The digestive tract is still bleeding non-stop, Uncle Lu's condition can not be delayed by half a minute, the only way in front of him is to immediately operate for "intraoperative exploration". Xie Shangkui led the team to prepare, and the operation was performed that night.
"Unfortunately, after opening my stomach, I didn't find any other problems except for the blood in my intestines, and I was a bit 'drumming' in my heart at that time." The chief surgeon Xie Shangkui frowned involuntarily, in the past, he could find the bleeding point by carefully probing after opening the abdomen, but this time it was completely different, it was really tricky, and he fell into a dilemma.
Huang Dandan, who assisted in the operation, also pinched a handful of sweat, and continued the operation may not allow the patient to get off the operating table. So many high-tech equipment can not find the problem, surgical exploration is ineffective, is it really only possible to close the abdomen and declare failure?
"But after all, the small intestine CT examination is suspicious," hesitated for a moment, Xie Shangkui immediately decided to use the most primitive method to find bleeding points, "the small intestine is divided into 4 segments, each segment is first drained of blood, and then clamped the small intestine with forceps to the light for naked observation." The suspicious part of the CT tip to be found is focused on probing. ”
Time passed minute by minute, and after about 30 minutes of investigation, Xie Shangkui suddenly found that there was a small intestine bulging. The "discovery" gave the surgical team great confidence to narrow it down to 40 cm of the small intestine, cut it open and look closely.
"It's here, only to see a small hole the size of a needle eye constantly bleeding out." Xie Shangkui signaled the team to remove this bleeding small intestine, and sure enough, Uncle Lu did not bleed again, and everyone in the operating room was relieved and showed a victorious smile.
◎ Removed bleeding small intestine
"Found it? That's great! Ah Wei, who was guarding the door of the operating room, heard that the doctor had found the bleeding point and excitedly kept thanking him. After the operation, Uncle Lu stopped his hemoglobin decline that night and rose to 6 grams when he rechecked the next morning.
"Director Xie gave a very vivid lesson to our young doctors, and doctors who treat diseases and save people must not be afraid of danger and make accurate judgments." Huang Dandan sighed.
Xie Shangkui said that pincers to detect bleeding points in the small intestine are the basic skills of anorectal surgeons, and no matter how advanced the examination equipment is, it cannot be replaced. Not finding the cause does not mean that it does not exist, and sometimes it takes some risks to treat and save people, which is based on rich experience and evidence to dare to give it a go.
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Bleeding of unknown origin should be investigated for small bowel lesions
Why does Uncle Lu's small intestine have a small hole the size of a needle eye? Huang Dandan explained that the pathological report confirmed that this bleeding point was not an ulcer, but a benign lesion. "It may be that there is a lesion under the mucosa of the small intestine, and most of it is a vascular malformation that causes bleeding. Unlike ordinary bleeding, vascular perforation can be plugged quickly by relying on the coagulation function of the human body, and the deformed blood vessels are difficult to recover on their own, and they will be fine after surgical removal. ”
Xie Shangkui reminded that in addition to Uncle Lu's symptoms such as blood in the stool and diarrhea, it is very typical that the stomach is always grunting, which is an intestinal sound, which is caused by the stimulation of blood accumulation in the intestine. Therefore, if there is gastrointestinal bleeding, gastrointestinal endoscopy can not find out the cause, and accompanied by these symptoms, we must be vigilant against small intestinal lesions, and should be treated in time.
Why have so many previous tests failed to find bleeding spots? Xie Shangkui and Huang Dandan analyzed that there are a variety of objective factors, including examination items and changes in the patient's condition, Uncle Lu only had abdominal CT reports in the hospital at that time, and did not do small intestinal CT, although there was gastrointestinal endoscopy, but the amount of bleeding during the examination may not be large, which will also affect the doctor's judgment.
Many patients only know small colonoscopy, in fact, small bowel CT is also an important means to check for small bowel lesions. Xie Shangkui said that in the past, there were only gastroscopes and colonoscopes, and the examination of the small intestine was greatly limited. Later, there was a small colonoscopy, but because its examination process was more painful, it took a long time, and the popularity was not high. In contrast, ct of the small intestine, which is gradually emerging, is a noninvasive examination that can quickly detect lesions in the small intestine. However, at present, there are very few people who have mastered the technique of CT reading of the small intestine. In addition, methods such as small bowel contrast and nuclide scans can also help to detect disease in the small intestine.
After two days of observation in the ICU, Uncle Lu was transferred to the general ward, and his body recovered quickly, and he could be discharged from the hospital a week after the operation. In particular, he instructed his son to make a pennant to express his gratitude to Xie Shangkui's team. After being discharged from the hospital, Uncle Lu mainly focused on an easily digestible diet in the short term, and did not need to be particularly taboo. If both diet and bowel movements are normal, just review a blood routine.
◎ Group photo of patient Uncle Lü (second from left), son of patient (first from right) and Director Xie Shangkui (second from right).
Uncle Lu's medical experience tells us that any disease should be prevented from microaggressions, do not think that it is okay because the symptoms are controlled, in fact, you have to find the cause to completely treat. In addition, find the right doctor and let the doctor take fewer detours.
(Correspondents: Jian Wenyang and Dai Xi'an Photo: Courtesy of Zhongshan Sixth Hospital)
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