Wu Mou, male, 21 years old, 4th college student.
Taking advantage of the summer vacation, he plucked up the courage to go to the hospital to end a major event in life.
After everything was prepared, the mixed hemorrhoid stripping surgery was done in the morning of the third day. As the name suggests, the basic process of this operation is to peel off the hemorrhoid blood vessels, ligate the blood vessels, and cut off the hemorrhoid core. After the operation, you will feel a lot more comfortable, because without the hemorrhoid nucleus that is a few centimeters large in the anus, there will be no repeated blood in the stool.
The operation went well. But for the first two days after the operation, Wu still felt quite uncomfortable. Especially after anesthesia, there will still be obvious pain in the buttocks and eyes, and I want to cry without tears. But when I think that after these few days, I will feel comfortable in the future, and I will no longer complain.
Pushed into the operating room the next morning. It was a laparotomy. According to the colonoscopy, the hemangioma was in the sigmoid colon. So as soon as it entered the abdominal cavity, the surgeon began to examine the sigmoid colon. It was really found that there was a lump in the sigmoid colon. During the operation, I checked it with a colonoscope again. Yes, the lump found by the surgeon was the location of the hemangioma seen under the colonoscope. After confirming that it was correct, the surgeon cut the intestinal tube before and after the hemangioma, which was almost 3 cm in length. After the cut, the intestine was re-anastomosed to restore the continuity of the intestine. Then check the other intestines and organs again to confirm that there are no problems, and then close the abdomen.
We cut off the hemangioma, and usually there will be no more bleeding. After the intestinal tube is anastomosed, fasting for a period of time, it will grow better later, there is no problem. The surgeon told the family. The family members also thanked the doctor a thousand words. Who will let his child be in bad luck? If something goes wrong, he must ask the doctor for help. Although tossing, as long as he bleeds no longer, it is fine. Blood is too precious, and if it continues like this, the child can bear it.
If it is confirmed that it is bleeding from the anastomosis, it means that the intestines in the anastomosis can no longer be used, because there is edema, and the reluctance to continue the suture will only cause more serious bleeding. I had to cut a small part of the intestines in the anastomosis of the hard-failed child, and then stitch the new ends together.
This is called retreat.
This time the director of surgery carefully checked, and he was confident that he did not continue to bleed, and the stitches were beautiful, so he closed his abdomen confidently.
Everyone was relieved and finally escaped.
Unexpectedly, one night two days later, the patient was on the verge of death again.
On this day, the patient had just walked on the ground for a few minutes, and suddenly felt a swelling sensation in the anus. This familiar feeling made him very scared, because it meant that it might be bleeding again. And soon the patient appeared flustered, pale, and clammy limbs. That's right, the patient recovered hundreds of milliliters of blood.
The family members were mad, and the doctor on duty was also worried.
This is obviously the rhythm of hemorrhagic shock, which means that the patient's bleeding rate is very fast and the amount is very large, otherwise it will not be shocked all at once. You must know that the patient has been receiving blood transfusion in the past two days. Hemorrhagic shock will also occur in the case of, showing how fierce the bleeding is.
There is no other way, and there is no way to hesitate for a moment.
The surgeon's face was cold, and he said that he should be sent to the operating room immediately, and he will be examined by laparotomy to stop the bleeding. The family members’ lips trembled, and there was no other way except signing.
So he was sent to the operating room while having a blood transfusion. Before entering the operating room, the patient's blood pressure was as low as 90/60mmHg. This is hemorrhagic shock caused by heavy bleeding. A check of hemoglobin showed only 65g/L.
The director of surgery calmly ligated the bleeding spot, and then filled some oil gauze (with a drainage tube inside) into the compression to stop bleeding.
I look forward to no more bleeding this time. In fact, the patient's shock was corrected.
Oil gauze can compress surrounding wounds and play a hemostatic effect. But oppression alone is not enough, it has to be drained. why? In case there is bleeding or accumulation of blood above the oil gauze, your gauze has blocked the blood flow, so you can't see blood in the stool. You think there is no bleeding, but it is not. Therefore, a drainage tube must be wrapped in the middle of the oil yarn, and the opening of the drainage tube is just above the oil yarn. In this way, if there is still bleeding, the blood can be discharged from the body along the drainage tube. The surgeon can see at a glance whether there is still bleeding inside.
They hope that the drainage tube is clean.
The patient's parents also opened the drainage tube more than a dozen times in an hour, and it would be very nervous if there was a little disturbance. The child is too bitter, and the operation is all done in one go. He has done it 4-5 times now, and he can't stand it anymore. The whole person also lost a few laps, and his face was sallow.
Parents don’t feel bad.
But the matter is far from over.
A few hours after the operation, there was a steady flow of blood from the drainage tube. Although it was not much, it did not seem to stop.
It was judged that there was still bleeding. But because repeated local hemostasis was not effective, I had to contact the interventional department. See if the effect of interventional hemostasis works.
The effect of interventional hemostasis is generally good. I have also repeatedly introduced to you the principles of interventional hemostasis. To put it simply, the interventionalist puts a catheter into the patient's blood vessel, and then injects the contrast agent into the blood vessel. If a blood vessel leaks, the contrast agent will also leak out in that place. The doctor takes X You can see the leaking contrast agent and infer which blood vessel ruptured and bleeds.
As long as you find the leaking blood vessel, also called the blood vessel that caused the accident, it will be easier. The doctor then pushes some embolization and hemostasis coils to the anterior part of the blood vessel in question through the guide wire, and releases it to block the blood vessel. There is no blood flow in the blood vessel and naturally there will be no more bleeding.
This is called a precise attack, finding the murderer, and then starving to death or shooting to death.
I thought it would stop the bleeding after intervention.
Everyone thinks so, because in many cases, interventional hemostasis is very effective and is the last straw.
But fate is so teasing.
On the second day after interventional hemostasis, the patient shed 200ml of stool again.
The surgeon was almost crying.
What went wrong? The patient's coagulation index was checked several times to see if there was any coagulation dysfunction. The director of surgery was angry. He was not angry with others or patients, but he was angry.
The coagulation indicators are all normal. The set of coagulation indicators checked are basically normal. Some indicators are a little higher, but considering that it is caused by bleeding, it is not particularly meaningful.
The head is big.
All blood coagulation indicators must be perfected to see if it is bleeding caused by coagulopathy. How can there be such a reason? The operation is so well done and bleeding is still happening. The director of surgery is about to pat the table.
Will there be hemophilia. Some young doctors weakly put forward a view.
Several directors did not speak, and no one could deny this statement. But everyone can't agree with this statement. It's not that they have never seen hemophilia. Patients with hemophilia are prone to bleeding. Usually, patients will bleed if they bump and bump, and they will live well into their twenties.
Under normal circumstances, a surgical patient only checks several commonly used indicators such as prothrombin time and activated partial thrombin time when querying coagulation function. These indicators are a combination of coagulation factors. Generally speaking, these indicators mean that coagulation is basic. is normal. No one will directly check the value of each specific coagulation factor, which is troublesome and of little significance.
But the patient has repeated bleeding, which is of great significance. Just check it by hemophilia. The director of surgery said blankly, and everyone hurriedly checked the information to see if there were other diseases related to coagulation disorders. Also, quickly ask the Department of Hematology to come over for a consultation and see if you can find any clues.
When looking for a hematology consultation, on the one hand, I really hope that others can give me instructions. After all, there is a specialty in surgery. On the other hand, of course it is also for sharing responsibilities. In the unlikely event that something goes wrong with the patient, they will find it out and say that you can’t solve the problem by yourself and don’t ask other departments for help. Isn’t this just a matter of life.
After the blood physician came, he carefully evaluated the condition. I also have some interest in the hemophilia question raised by the tube bed doctor. But they repeatedly asked, the patient did not have a history of easy bumping and bleeding, really unlike hemophilia. The typical hemophilia is easier to bleed, bumps will cause ecchymosis, and even dental bleeding cannot stop. The blood physician said that occasionally there are patients with hemophilia in their department, so the impression is quite deep.
However, in order to rule out the diagnosis, the hemophilia test must be improved.
Under the guidance of the hematologist, the tube bed doctor took blood to check the coagulation factors. At the same time, explain to family members to improve genetic testing. Because hemophilia is a genetically inherited disease, if genetic testing can find abnormalities, it will be a stone hammer.
At the same time of the examination, Wu must be given continuous blood transfusion, fluid replacement, hemostasis and other treatments. Fortunately, the bleeding did not continue in the past 2 days, otherwise I really don’t know what to do.
On this day, the clotting factor results came back.
When the surgeon took a look, he quickly called the hematologist to come and see it together. Oh my God! The patient is really hemophilia! The hematologist exclaimed. He is a hemophilia type A.
Going around, the patient really has congenital coagulopathy.
What’s more dramatic is that the usual coagulation indicators cannot assess the presence of false hemophilia. To determine whether there is hemophilia, only coagulation factor tests or genetic tests can be done, but these tests are generally not done before surgery. After all, hemophilia is not common.
No matter what, a diagnosis is a good thing.
This is the case. Hemophilia is a kind of congenital genetic deficiency of certain coagulation factors. According to the type of the lacking factor, it can be divided into hemophilia A, hemophilia B, and hemophilia C.
In this patient, the lack of clotting factor is FVIII. So it is hemophilia type A. General fresh frozen plasma, cryoprecipitate, etc. contain some coagulation factors, which can be used to treat hemophilia, but due to the stress of blood use, the patient does not use fresh plasma every time, but uses ordinary plasma, so supplement The blood coagulation factor is not enough, and it happens that the patient has hemophilia again, and he has repeated bleeding.
Family members heard that their child had hemophilia, but they couldn't believe it. Both of us are very good, how can we pass it on to our children.
This is the case. Surgery did his homework in advance, so he explained to the family that this hemophilia is a genetic disease, and it does not mean that all children will have it. Your son has hemophilia. We speculate that the mother of the child is concealed and the father is normal. You can improve this inspection later.
This sentence made the patient's parents more hesitating.
But no matter what, finding the problem is better than anything. Later, the patient was treated with targeted coagulation factors, some fresh plasma, cryoprecipitate, etc. were also supplemented, and other treatments were added, and the patient finally stopped bleeding.
Actually paid medical expenses. Although he was reluctant, he was discharged from the hospital through the normal process.
There is still a question, why the patient is obviously hemophilia, but he usually does not bleed. The surgeon wondered. The hematologist said that from the index point of view, the patient belongs to relatively mild hemophilia, and it may only return to the situation such as surgical trauma and cause the bleeding, and the bumps in daily life will not cause harm.
It turned out to be so.
The patient really escaped this time. The director of surgery said, we must also be alert to ourselves, and we must also escape!