The protagonist of this case is a 45-year-old female patient with the surname Zhang.
1 day ago, Ms. Zhang suddenly had abdominal pain, the degree was more intense, and the pain was so severe that she could not work. At first, it was left upper quadrant pain, and there was nausea, vomiting, at first I thought it was stomach disease, because Ms. Zhang had previously done gastrososcopy, there was superficial gastritis, and it was left upper quadrant pain, there was reason to suspect that it was a stomach disease attack.
Rushed to the hospital emergency department.
When I arrived at the hospital, the abdominal pain worsened, manifesting as pain throughout the abdomen, no longer confined to the left upper quadrant, and vomiting frequently, and all the food I ate in the morning was vomited out. The nurse took the temperature, 38.0 ° C, and had a fever.
In addition to abdominal pain, bloating also became severe.
When dr. Ma of the emergency department looked at it, he didn't have to think about it, it must be a problem with the abdomen. Ms. Zhang was examined in her abdomen and found that the abdominal pressure was obvious, and as soon as her fingers touched, with a little force, she was in pain to tears. Abdominal tenderness and rebound pain are obvious. As soon as the stethoscope listens, the bowel sounds are hardly audible. Murphy's sign (judged to be cholecystitis) appears to be positive, there is no obvious percussion in the renal area of both backs, and tenderness at the Mysite point (right lower quadrant appendix area) is also present, but in fact, there is tenderness throughout the abdomen, and these tests are not necessarily accurate.
The problem is definitely in the abdomen, most likely acute pancreatitis, acute cholecystitis, acute intestinal obstruction, etc. And it is likely to be a disease that requires surgery.
Don't hesitate, just pull over and do the abdominal CT.
Before doing CT, the nurse also came to draw blood, routine all checks, blood routine, blood glucose, liver and kidney function, electrolytes, coagulation indicators, pancreatitis two items (blood amylase, lipase), troponin and so on.
The results came out quickly, and the old horse's guess was correct.
The patient is pancreatitis, and it is a severe pancreatitis. Inflammation of the pancreas is pronounced and there is.
The family is very confused, how can the good end have severe pancreatitis. Later, Ms. Zhang told Lao Ma that she had drunk some wine and eaten some roast meat the day before yesterday.
Judging from the treatments currently available, there is a relationship. The onset of pancreatitis is related to gallbladder bile duct stones, alcohol, and pancreatic duct obstruction. You do not have gallbladder stones, but drink alcohol, do not necessarily have to overeat, ordinary drinking wine and eating meat (individual differences) may cause pancreatic problems, alcohol can promote pancreatic juice secretion, when the pancreatic duct outflow tract can not adequately drain a large amount of pancreatic juice, then these digestive juices can only digest the pancreas itself.
Soon the results of the blood test also came out, the white blood cell count was high, the blood amylase was significantly elevated, and it was further confirmed that it was acute pancreatitis and a severe pancreatitis because the pancreas had necrosis. Mild pancreatitis generally does not kill people, but severe pancreatitis is likely to be fatal, and the mortality rate will go to 20%. Lao Ma gave the patient a critical illness notice.
To be hospitalized, live in the gastroenterology department for active treatment. And from now on, you can't eat anything, and you can't eat anything hungry. Food stimulates the secretion of pancreatic juice, and once the secretion increases, the disease will worsen. The old horse is a thousand times.
Immediate admission.
After admission, the doctor gave fasting, oxygen inhalation, inhibition of pancreatic enzyme secretion, inhibition of gastric acid secretion, anti-infection, anti-inflammatory, correction of water and electrolyte disorders and other treatments.
But Ms. Zhang's abdominal pain was still not relieved, and she screamed in pain. The doctor on duty explained that most patients can relieve pain after giving somatostatin (drugs that inhibit pancreatic enzyme secretion), and can wait.
But after waiting for an hour, the situation did not improve. The doctor on duty had to give a painkiller injection, a piperidine injection, which is a very strong painkiller, but weaker than morphine. Although morphine is strong, it cannot be used in such patients. Interested friends can consult the information further.
After the use of piperidine, the abdominal pain was relieved. Ms. Zhang was comfortable for a day.
The doctor told her that the treatment time of severe pancreatitis is relatively long, and it is necessary to be patient, slowly adjust, slowly recover, and it seems that the situation has been initially contained, and there is still a great chance that it will gradually improve.
Do I need surgery? Ms. Zhang asked, I heard that pancreatitis is to remove the pancreas, right?
The doctor explained that surgery is generally not used, and we only have one pancreas, the pancreas is a very important digestive organ, cut it off, how to digest food in the future, can not be cut, can not be cut. Keep it up and let it recover slowly.
Hope it goes well.
But it didn't go well.
By the 10th day of hospitalization, the patient was still bloated and more pronounced. In addition to bloating, there are also chills and difficulty breathing. The family members were nervous when they saw it and went to the doctor.
Blood pressure was measured, and it was bad, and the blood pressure was also low, only 80/40mmHg.
This is shock.
The inflammation of severe pancreatitis may spread to other organs at any time, the most prone to problems are the lungs, cardiovascular, kidneys, and now the patient suddenly has breathing difficulties aggravated, low blood pressure, feel the lungs and circulation suddenly collapsed.
How can this be? The family asked, and the doctor was looking for a reason. Bedside chest x-ray was taken, the patient did not have pneumothorax, no atelectasis, but the pneumonia worsened, which may not be pure pneumonia, it may be ARDS (Acute Respiratory Distress Syndrome), it is ironclad evidence that inflammation has spread to the lungs. Many patients with severe pancreatitis begin with the lungs.
The doctors were nervous, and the families were even more nervous.
This condition can not continue to stay in the gastroenterology treatment, have to go to the ICU, may need to be on a ventilator, the condition is very serious, may face death at any time. The doctor issued another critical illness notice.
At this time, Ms. Zhang was lying on the hospital bed, weak, and everything was subject to the arrangements of her husband and doctor.
The ICU doctor came, assessed the condition, it is indeed a severe pancreatitis, and multi-organ failure has occurred, what can be seen at present is that the respiratory system is not good (lack of oxygen, dyspnea), the cardiovascular system is not good (hypotension, septic shock is likely), the kidneys are also problematic (there is basically no urine in recent hours), and there will be more organs falling down.
After explanation, agreed to enter the ICU.
As soon as he entered the ICU, the patient's breathing difficulties became even worse, and his blood oxygen saturation went crazy. The disease progressed too quickly. The ICU doctor did not hesitate too much, directly intulated the patient's trachea, and put on the ventilator.
As soon as the ventilator is on, the patient's blood pressure is lower. Immediately, the fluid was fully replenished and expanded, and norepinephrine (a drug that constricts blood vessels can raise blood pressure) was used to initially stabilize the patient's blood pressure.
No, this is too heavy, you have to go to the blood purification treatment. The ICU doctor said. Patients with severe pancreatitis will have many inflammatory mediators in the body, and blood purification treatment, similar to dialysis, can more or less remove the inflammatory mediators, which is conducive to the disease. At the same time, the patient's kidneys are not very good, there is less urine, the blood creatinine is high in the re-examination, and it is also necessary to do blood purification treatment in advance.
Do it, do it, agree. Do what you can save your life.
Declare in advance that all the treatments are to help her, but they may not be able to save her life. The ICU doctor said bluntly, don't think that if you do expensive treatment, you will definitely survive, no. We just try our best.
It was said as if shirking responsibility. But it seems like that's really the case. It doesn't sound good, but that's the truth.
The gastroenterologist came, the respiratory physician also came, the cardiology department also came, everyone sat together to discuss, plan, how to better stabilize. Including whether to support enteral nutrition, everyone gave advice.
After treatment adjustment, the patient's bloating is still not significantly relieved, the stomach is bloated like a ball, checked, ascites is not much, are gas, flatulence is obvious.
Patients with such high abdominal pressure must be alert to abdominal compartment syndrome. Simply put, due to the strong flatulence in the patient's abdominal cavity, the pressure is very high, and such a high pressure has a significant compressive effect on the organ tissues in the intestine, which will cause a series of dysfunctions.
Why is that? There are many reasons, severe pancreatitis itself will, before low blood pressure to make up a lot of fluids, which will also lead to increased intra-abdominal pressure.
So what? You can't let your stomach be so bloated all the time.
Continue to decompress the gastrointestinal tract and enema to see if you can accelerate the discharge of gas and relieve bloating. At the same time, I consulted with Chinese medicine and used some Traditional Chinese medicine enemas. I also made an abdominal puncture drainage tube, and I used all the methods I could think of. Regardless of the black cat or the white cat, the one who can catch the mouse is the good cat.
The doctor communicated with the family again, saying that this is not easy to do, and we must prepare for the worst.
The family was most afraid of the doctor saying this and almost collapsed.
After a few days, the abdominal condition has improved, and under the comprehensive treatment of continuous gastrointestinal decompression, traditional Chinese medicine enema, abdominal drainage tube, stable circulatory breathing, nutritional support, adjustment of water-electrolyte balance, etc., the patient's abdominal condition is not so bad. The stomach is slightly flattened, no longer worry about the risk of swelling and bursting, to know that when the patient's stomach pressure is the highest, the visual impact effect is very large.
But it's still a long way from being transferred out of the ICU.
At least the patient can not get rid of the ventilator ah, pneumonia is still serious, and the patient's ability to cough up sputum on their own is poor. I have been using the ventilator for 2 weeks, and it is estimated that I may not be able to get rid of the ventilator for 2 weeks.
We're going to do a tracheotomy for her. The ICU doctor told the family.
The family did not understand what a tracheotomy was, but they were very scared when they heard the name. Cut open the trachea, can people still live? Why cut open? Will it be able to grow back in the future?
The ICU doctor explained that the patient is in a critical condition, there is no way to get out of the ventilator in the short term, and it is expected that there will be a period of time to use the ventilator and cut the trachea, in order to make her better cough up sputum, suction sputum, better respiratory care, and to be able to more easily take off the ventilator in the future.
When her condition improved, she took off the ventilator, the pneumonia was alleviated, the phlegm was less, and her ability to cough up sputum was restored, and then she pulled out the tracheostomy tube, sealed the incision, and she could grow back on her own. In the future, those who can eat, breathe, and talk will not have much impact.
Since it was for the purpose of curing the disease, the family could only agree.
A severe pancreatitis has suffered too much sin. There are six or seven large and small puncture drainage tubes on the patient's body, and the antenna ground wire is really full.
Fortunately, after various efforts, the patient's intra-abdominal pressure gradually decreased, and the stomach was further reduced.
The pneumonia situation also began to improve, and it was gradually possible to get rid of the ventilator.
Blood pressure also stabilized.
The amount of urine is also increasing. The doctor repeatedly confirmed that the patient did have an excessive amount of urine, rather than using diuretics. A critically ill patient, who originally had less urine, now the amount of urine has begun to increase, often indicating an overall improvement in the condition. If the human body is likened to a battlefield, and the brain and heart are the commanders, then the kidneys are the border guards. When life is in danger, the kidneys are often sacrificed initially, there is less urine, and the kidneys fail. When the body begins to recover, the kidneys will respond more quickly and the amount of urine will gradually increase.
That's a good thing.
After more than 1 week, the ventilator was removed, the tracheostomy was unplugged, and the tracheostomy opening was closed.
The patient really came alive.
Lost 20 pounds.
True case adaptation, non-Dr. Li case, posted only for wake-up call.
Popular Science Small Class:
Severe acute pancreatitis is acute pancreatitis with systemic and local complications, which belongs to the special type of acute pancreatitis, which is a kind of acute abdomen with sinister disease, many complications and high case fatality, accounting for 10% to 20% of the entire acute pancreatitis. The overall mortality rate remains as high as around 17 per cent.
70% to 80% of severe acute pancreatitis is caused by biliary tract disease, alcoholism, and overeating.