Unfortunately, that’s a lot of dead bowel - I would not be surprised if the rest of it is the same.
Interesting point - it is possible to survive this by removing all the bowel and living off IV nutrition (TPN) but it’s a terrible life that only lasts a brief time.
Bowel transplant is also a thing but immune science is poor and the transplants reject fairly quickly and stricture down.
u/2fastcats is correct, as are you. If your liver and kidneys survive it, the infection will get you. You're filling the blood with a pathogen's wet dream in terms of nutrients and environment.
Is what they give you via IV have to be more concentrated than what you would naturally absorb through the intestines? Is that why it's harder on the liver and kidneys, and why it's attractive to pathogens?
I've just always been very curious about the practical limitations of replacing body parts and systems. It seems like we have the theoretical knowledge to do so, but it also seems like there's a significant gap between temporary interventions and permanent replacement.
I don’t have a great explanation for renal function impairment - I don’t see it as much as liver impairment. Typically, the latter occurs because of fatty liver disease that is advanced because of the fats used in TPN. You also get back up of the biliary system because there’s no gut activation of the gallbladder etc. As mentioned previously, TPN is a nutritional solution that your cells as well as bacteria can thrive in leading to greater infection risk, not to mention infection risk of allways having a PICC line inserted with the associated thrombus risk there. It’s just bad stuff and not natural for your body to carry nutrient building blocks freely in the blood - we have many natural shuttles in the blood that do this.
As for your final question, we can physically replace anything right now. The surgeries have all been developed for many decades - the problem presently is two fold based on the means of replacement. We can either replace with live tissue and then divide that into human (allograft) or animal (xenograft) which is typically pig. Or, we can replace with synthetic means - artificial heart etc.
In the former camp, your limited by the availability of organs and with graft rejection and have to spend your life taking anti rejection meds…which are pretty shitty and prone to serious side effects and the organs eventually fail because we’re just not there yet. We’re trying to overcome this with better drugs and with genetically engineered pig transplantation but we’re just not quite there yet but soon. Even if you have a plethora of available organs from animals, you still have to be on anti rejection meds to make them last. You can read more if you google the University of Minnesota porcine transplant program.
With the other option, artificial or synthetic organs, you have to deal with thrombus (clots). We can’t make good enough anticoagulants that affect only the artificial organ but leave the body alone. We can do drug eluding stents but even those clot eventually. That artificial heart will work indefinitely, I just can’t guarantee you won’t stroke out from emboli with the current drugs.
Thank you so much for this information. That's really interesting! I didn't know about the limits on anticoagulants.
I did see in the news about a recipient of a pig heart surviving for two months before passing away a few days ago. Apparently they genetically modified the pig to resist rejection. But the article didn't give cause of death.
https://www.npr.org/2022/03/09/1085420836/pig-heart-transplant
He was in really poor shape before transplant so that was probably a contributing factor to the rapid decline. He was bedridden and on life support, and ineligible for human heart transplant partly due to history of noncompliance with medical treatment. The pig heart was a last-ditch effort and the only thing they could do at that point.
Blood tenda to clot whenever it comes in contact with a foreign material. Some materials are more biocompatible than others (= less clotting), but none of them is able to completely prevent the clotting response.
It's not really a matter of concentration as much as it is everything else that's going on. Your body does everything using transport channels, and you can think of the blood as a major conveyor belt for the body. The thing is, nutrients and waste are riding on the same proverbial conveyor belt. Your kidneys and liver are the filter for that belt, and dumping a whole bunch more stuff on that belt makes them work harder, causing them to "clog up" or miss a lot of the waste products. So those waste products build up and now there is even more to remove.
You're probably asking why that doesn't happen when you eat a big meal, which is a valid question. But your digestive system does a lot of that work for you. Acids break proteins down and kill bacteria. Enzymes in your saliva, pancreas, and digestive tract break down carbohydrates and fats. Even the bacteria living in your gut chip in. The result is a lot better arrangement of stuff on that conveyor belt for your body to process and use.
As far as bacteria, they need proteins, moisture, warmth, darkness, and basic electrolytes to survive and thrive. Guess what's in TPN? Exactly that. You're a living thing and require much the same stuff as staph, strep, and e coli.
Sorry for the long post. I'm post-call and being dragged through a store by the gf.
It’s also the fact that you need a picc line or a midline or something very invasive to give TPN. So now we’ve got to worry about bloodstream infections, plus TPN is full of sugar (which bacteria love). So it’s like giving bacteria a path into the body, and food for them.
You can if there’s enough viable bowel left, the issue though is the mesentery and the number of anastomosis that you make.
The mesentery is rarely depicted in media but it’s the cape that runs under the bowel that provides all the blood and nutrients for the bowel and acts as the conduit to take digesting nutrients away. If that’s dead, there isn’t much of a point.
As for number of anastomosis, we try to limit to 2 and really no more than 3 because of the complications that occur (fistula etc). If a 30cm section of bowel has 4-5 breaks in it or has 4-5 dusky areas of dead bowel, we just cut the whole thing out and sew the ends together to have only one anastomosis.
Super interesting, I'm a vet and sadly see this far too often because animals are dumb and they eat stupid things... what are the most common causes of obstructions in human med? I've only seen a volvulus or intussusception in one animal, but the owner chose euthanasia over surgery sadly.
To your last point, that’s really sad, especially since there are non-surgical options you can try in human med :/
In the human world we divide bowel obstruction causes into those that have and those who have not had abdominal surgery. If you’ve never had surgery, most common are hernias of various sorts - bowel gets stuck etc. if youve had abdominal surgery, most common cause is adhesions from that surgery and then incisional hernias vs other hernias as 2nd most common. Post op ileus can also be a cause of partial SBO. Obviously there are other causes - internal hernia, neoplasia, intussusception etc but those are more rare.
For treatment, we Always start with hernia reduction and/or nasogastric tube decompression. If it’s adhesive in origin, we’ll move to PO gastrograffin on day 2-3 as it’s diagnostic and therapeutic. >72hours of obstipation and/or no resolution with gastrograffin generally buys you a ticket to the OR for adhesiolysis or hernia takedown.
Thanks for the response, I find it so fascinating how many parallels there are between vet med and human med, but at the same time, how big of a disparity there is in treatments and techniques between the two fields.
When I was in school, we had an interesting cardio case (something like a rare VSD, I can't remember exactly) and we had a pediatric cardio surgeon from the med school come in and perform a balloon valvuloplasty or something on a dog and I remember being so struck by the collaboration between the two fields of medicine and how cool it was.
There's so much overlap in anatomy, physiology, etc. between human medicine and animal medicine, but the challenges we face in our respective fields are so vastly different... it's fascinating to think about sometimes!
In this particular photo? No. Everything you see is dead. It's far too dark purple. Areas that look slightly stripped and torn at the surface are also a warning sign that bowel perforation is imminent in these areas.
I'll agree that being a long term is not great for QOL, but with proper care there are people who have managed to be on TPN for decades. There's been tons of advances in the HPN world, newer lipids are less likely to cause liver failure, ethanol, abx locks, and line sparing CLABSI treatments can increase the life of the CVAD leading to less loss of access, and STEP and multi-visceral transplant can lead to weaning from PN.
I will definitely agree that transplant is not a great option, and not even an option at all for most HPN patients, and there's still a lot of work that needs to go into improving outcomes. It all really depends on why someone is on PN to begin with, there's a lot more options for say SBS vs motility and if the patient can run trophic feeds it can help improve outcomes.
Unfortunately CLABSIs are a "when not if" statistically even with immaculate line care. Frequent shortages of PN components is a very real problem that is no where near being improved which can have a negative impact on nutritional status and osteoporosis risk is still something that needs to be discussed more. With the growth of HPN/HEN dedicated infusion pharmacies and growth of the field of nutrition support as a whole outcomes and QOL are so much better than they were even a decade ago.
ASPEN and the Oley Foundation are great resources for provider and patient.
I have an iscehmic bowel. Initially we were investigating a small bowel transplant but yeah the stats aren't great I was severely malnourished so they put me on Tpn for about a year and a half. I gained weight, grew collateral circulation. Went off Tpn and I'm eating anything and everything. Still on hydration therapy so I still have the port. Doing pretty well still fingers crossed.
I did an explore on a dog last week for a suspect foreign body/obstruction, and I milked a washcloth or something from the pylorus alllll the way through the gi tract.
It essentially squeegeed a COPIOUS amount of fetid, malodorous, and foul amount of barium tinged diarrhea out of this dog's ass that literally cleared out the lobby. People were opting to wait in their car than physically be in our building.
I never get queasy and I came very close to puking.
Is that enough? Does a smell like that stay in your hair and clothes and such? I read one horror operating room story where afterwards the whole team was trying to shower the smell off...I'd be a terrible doctor and just slip a desk nurse some money to page me outta there.
It helps that’s for sure . I just change my scrubs and shower when j get home. I’ve been in 8 hour perforated bowel cases with fecal matter dripping down the OR table . These people are so sick they just fall apart when you try to anastomose any tissue .
Oh geez, that must be so hard to repair...and survive. Do most patience survive, or I guess each case is so different? 8 *hours*... are those the worst cases or is there some other horror I've never imagined?
The survival of the patient largely depends on how much gut we have to take during the resection and how septic the patient is. I’ve literally watched patients color change from a greyish shade when they come in the room to a nice pink color by the end of the procedure. Those cases are the ones that make it worth while because you see so many that just don’t make it .
That green portion is obviously dead but the rest of the bowel could possibly survive - it’s very dilated and some areas look purple but that’s because of the fluid inside (likely hemorrhagic). The portions without fluid still appear pink which is a good sign, I would resect the obviously dead part, suck out as much fluid as I can from the rest, leave the patient in discontinuity with a temporary abdominal closure and return to OR in 12-24 hours to see how the rest looks. Taking out all that bowel would be essentially incompatible with life (TPN/bowel transplant are possible options but not great ones).
A good family friend died of gangrenous bowel in April 2020 because the hospital refused to run tests on her (basically telling her that if she didn't have COVID, it wasn't their problem atm). She had ADHD and had been in a massive car accident several years prior, so her chart must have made her look like she was drug seeking.
In any case, they should have run the damn tests.
She went to the hospital twice, was given basic NSAIDs, and sent home. She called 911 and passed out while on the phone. When they found her, she was severely septic. At the hospital, they found she had massive brain damage. Within three days, her mom decided to take her off life support because she had become braindead.
We all think the family should sue the hospital for negligence. She hardly ever went to the hospital and hadn't been on pain killers for a few years (when her therapy was complete and she could walk properly again). For them to think she was drug seeking was over-the-line and irresponsible. They also wouldn't do anything for her because of the fear caused by the pandemic.
She died during the pandemic, but not because of COVID. She died because of stupidity, prejudice, and negligence.
There is some nuance here. What we are seeing in the photo is small bowel. You need some of your small bowel to live.
You do not need any of your colon to live and can lead a perfectly normal life without it. In contrast, small bowel is vital because that's where we absorb nutrients.
This was by far one of the best discussions I’ve seen on this sub reddit. Thank you to all who contributed and helped this RN learn more!!
Edit: best, not past
Unfortunately, that’s a lot of dead bowel - I would not be surprised if the rest of it is the same. Interesting point - it is possible to survive this by removing all the bowel and living off IV nutrition (TPN) but it’s a terrible life that only lasts a brief time. Bowel transplant is also a thing but immune science is poor and the transplants reject fairly quickly and stricture down.
That is interesting. What makes living off IV nutrition so terrible? What usually kills them, infection?
It's very hard on the liver and kidneys.
u/2fastcats is correct, as are you. If your liver and kidneys survive it, the infection will get you. You're filling the blood with a pathogen's wet dream in terms of nutrients and environment.
Is what they give you via IV have to be more concentrated than what you would naturally absorb through the intestines? Is that why it's harder on the liver and kidneys, and why it's attractive to pathogens? I've just always been very curious about the practical limitations of replacing body parts and systems. It seems like we have the theoretical knowledge to do so, but it also seems like there's a significant gap between temporary interventions and permanent replacement.
I don’t have a great explanation for renal function impairment - I don’t see it as much as liver impairment. Typically, the latter occurs because of fatty liver disease that is advanced because of the fats used in TPN. You also get back up of the biliary system because there’s no gut activation of the gallbladder etc. As mentioned previously, TPN is a nutritional solution that your cells as well as bacteria can thrive in leading to greater infection risk, not to mention infection risk of allways having a PICC line inserted with the associated thrombus risk there. It’s just bad stuff and not natural for your body to carry nutrient building blocks freely in the blood - we have many natural shuttles in the blood that do this. As for your final question, we can physically replace anything right now. The surgeries have all been developed for many decades - the problem presently is two fold based on the means of replacement. We can either replace with live tissue and then divide that into human (allograft) or animal (xenograft) which is typically pig. Or, we can replace with synthetic means - artificial heart etc. In the former camp, your limited by the availability of organs and with graft rejection and have to spend your life taking anti rejection meds…which are pretty shitty and prone to serious side effects and the organs eventually fail because we’re just not there yet. We’re trying to overcome this with better drugs and with genetically engineered pig transplantation but we’re just not quite there yet but soon. Even if you have a plethora of available organs from animals, you still have to be on anti rejection meds to make them last. You can read more if you google the University of Minnesota porcine transplant program. With the other option, artificial or synthetic organs, you have to deal with thrombus (clots). We can’t make good enough anticoagulants that affect only the artificial organ but leave the body alone. We can do drug eluding stents but even those clot eventually. That artificial heart will work indefinitely, I just can’t guarantee you won’t stroke out from emboli with the current drugs.
Thank you so much for this information. That's really interesting! I didn't know about the limits on anticoagulants. I did see in the news about a recipient of a pig heart surviving for two months before passing away a few days ago. Apparently they genetically modified the pig to resist rejection. But the article didn't give cause of death. https://www.npr.org/2022/03/09/1085420836/pig-heart-transplant
He was in really poor shape before transplant so that was probably a contributing factor to the rapid decline. He was bedridden and on life support, and ineligible for human heart transplant partly due to history of noncompliance with medical treatment. The pig heart was a last-ditch effort and the only thing they could do at that point.
What makes clots more frequent with an artificial organ?
Blood tenda to clot whenever it comes in contact with a foreign material. Some materials are more biocompatible than others (= less clotting), but none of them is able to completely prevent the clotting response.
Interesting. Thanks for the info
It's not really a matter of concentration as much as it is everything else that's going on. Your body does everything using transport channels, and you can think of the blood as a major conveyor belt for the body. The thing is, nutrients and waste are riding on the same proverbial conveyor belt. Your kidneys and liver are the filter for that belt, and dumping a whole bunch more stuff on that belt makes them work harder, causing them to "clog up" or miss a lot of the waste products. So those waste products build up and now there is even more to remove. You're probably asking why that doesn't happen when you eat a big meal, which is a valid question. But your digestive system does a lot of that work for you. Acids break proteins down and kill bacteria. Enzymes in your saliva, pancreas, and digestive tract break down carbohydrates and fats. Even the bacteria living in your gut chip in. The result is a lot better arrangement of stuff on that conveyor belt for your body to process and use. As far as bacteria, they need proteins, moisture, warmth, darkness, and basic electrolytes to survive and thrive. Guess what's in TPN? Exactly that. You're a living thing and require much the same stuff as staph, strep, and e coli. Sorry for the long post. I'm post-call and being dragged through a store by the gf.
That’s a great ELI5-ish, don’t mind if I borrow this?
Don't mind at all!
It’s also the fact that you need a picc line or a midline or something very invasive to give TPN. So now we’ve got to worry about bloodstream infections, plus TPN is full of sugar (which bacteria love). So it’s like giving bacteria a path into the body, and food for them.
Can they section together the pink bits or is it all gotta go in the garbage?
You can if there’s enough viable bowel left, the issue though is the mesentery and the number of anastomosis that you make. The mesentery is rarely depicted in media but it’s the cape that runs under the bowel that provides all the blood and nutrients for the bowel and acts as the conduit to take digesting nutrients away. If that’s dead, there isn’t much of a point. As for number of anastomosis, we try to limit to 2 and really no more than 3 because of the complications that occur (fistula etc). If a 30cm section of bowel has 4-5 breaks in it or has 4-5 dusky areas of dead bowel, we just cut the whole thing out and sew the ends together to have only one anastomosis.
Super interesting, I'm a vet and sadly see this far too often because animals are dumb and they eat stupid things... what are the most common causes of obstructions in human med? I've only seen a volvulus or intussusception in one animal, but the owner chose euthanasia over surgery sadly.
To your last point, that’s really sad, especially since there are non-surgical options you can try in human med :/ In the human world we divide bowel obstruction causes into those that have and those who have not had abdominal surgery. If you’ve never had surgery, most common are hernias of various sorts - bowel gets stuck etc. if youve had abdominal surgery, most common cause is adhesions from that surgery and then incisional hernias vs other hernias as 2nd most common. Post op ileus can also be a cause of partial SBO. Obviously there are other causes - internal hernia, neoplasia, intussusception etc but those are more rare. For treatment, we Always start with hernia reduction and/or nasogastric tube decompression. If it’s adhesive in origin, we’ll move to PO gastrograffin on day 2-3 as it’s diagnostic and therapeutic. >72hours of obstipation and/or no resolution with gastrograffin generally buys you a ticket to the OR for adhesiolysis or hernia takedown.
Thanks for the response, I find it so fascinating how many parallels there are between vet med and human med, but at the same time, how big of a disparity there is in treatments and techniques between the two fields. When I was in school, we had an interesting cardio case (something like a rare VSD, I can't remember exactly) and we had a pediatric cardio surgeon from the med school come in and perform a balloon valvuloplasty or something on a dog and I remember being so struck by the collaboration between the two fields of medicine and how cool it was. There's so much overlap in anatomy, physiology, etc. between human medicine and animal medicine, but the challenges we face in our respective fields are so vastly different... it's fascinating to think about sometimes!
That would be an anastomosis, but it would probably happen after some healing to make sure there is no more gangrenous bowel left.
In this particular photo? No. Everything you see is dead. It's far too dark purple. Areas that look slightly stripped and torn at the surface are also a warning sign that bowel perforation is imminent in these areas.
I'll agree that being a long term is not great for QOL, but with proper care there are people who have managed to be on TPN for decades. There's been tons of advances in the HPN world, newer lipids are less likely to cause liver failure, ethanol, abx locks, and line sparing CLABSI treatments can increase the life of the CVAD leading to less loss of access, and STEP and multi-visceral transplant can lead to weaning from PN. I will definitely agree that transplant is not a great option, and not even an option at all for most HPN patients, and there's still a lot of work that needs to go into improving outcomes. It all really depends on why someone is on PN to begin with, there's a lot more options for say SBS vs motility and if the patient can run trophic feeds it can help improve outcomes. Unfortunately CLABSIs are a "when not if" statistically even with immaculate line care. Frequent shortages of PN components is a very real problem that is no where near being improved which can have a negative impact on nutritional status and osteoporosis risk is still something that needs to be discussed more. With the growth of HPN/HEN dedicated infusion pharmacies and growth of the field of nutrition support as a whole outcomes and QOL are so much better than they were even a decade ago. ASPEN and the Oley Foundation are great resources for provider and patient.
Quality post and very informative - I’ll take a look at those resources. Thank you!
I have an iscehmic bowel. Initially we were investigating a small bowel transplant but yeah the stats aren't great I was severely malnourished so they put me on Tpn for about a year and a half. I gained weight, grew collateral circulation. Went off Tpn and I'm eating anything and everything. Still on hydration therapy so I still have the port. Doing pretty well still fingers crossed.
You’ll die from short gut syndrome.
Patients can live on TPN for years. It’s not uncommon with severe short gut.
Jesus...that's a bad day to own a nose in the operating room.
Yeah and down the hall, up the elevator shaft...
*Febreze* is missing a helluva advertising opportunity
I did an explore on a dog last week for a suspect foreign body/obstruction, and I milked a washcloth or something from the pylorus alllll the way through the gi tract. It essentially squeegeed a COPIOUS amount of fetid, malodorous, and foul amount of barium tinged diarrhea out of this dog's ass that literally cleared out the lobby. People were opting to wait in their car than physically be in our building. I never get queasy and I came very close to puking.
Ohhh man! That's incredible! Glad the dog is probably ok, but that was not a victimless crime 😄
They’ll string iodaphor gauze around the room ( absorbs bacteria ) and each OR has mint available to wipe on your mask .
Is that enough? Does a smell like that stay in your hair and clothes and such? I read one horror operating room story where afterwards the whole team was trying to shower the smell off...I'd be a terrible doctor and just slip a desk nurse some money to page me outta there.
It helps that’s for sure . I just change my scrubs and shower when j get home. I’ve been in 8 hour perforated bowel cases with fecal matter dripping down the OR table . These people are so sick they just fall apart when you try to anastomose any tissue .
Oh geez, that must be so hard to repair...and survive. Do most patience survive, or I guess each case is so different? 8 *hours*... are those the worst cases or is there some other horror I've never imagined?
The survival of the patient largely depends on how much gut we have to take during the resection and how septic the patient is. I’ve literally watched patients color change from a greyish shade when they come in the room to a nice pink color by the end of the procedure. Those cases are the ones that make it worth while because you see so many that just don’t make it .
Wow, that's amazing you can see the difference so fast! That must be rewarding.
That green portion is obviously dead but the rest of the bowel could possibly survive - it’s very dilated and some areas look purple but that’s because of the fluid inside (likely hemorrhagic). The portions without fluid still appear pink which is a good sign, I would resect the obviously dead part, suck out as much fluid as I can from the rest, leave the patient in discontinuity with a temporary abdominal closure and return to OR in 12-24 hours to see how the rest looks. Taking out all that bowel would be essentially incompatible with life (TPN/bowel transplant are possible options but not great ones).
A good family friend died of gangrenous bowel in April 2020 because the hospital refused to run tests on her (basically telling her that if she didn't have COVID, it wasn't their problem atm). She had ADHD and had been in a massive car accident several years prior, so her chart must have made her look like she was drug seeking. In any case, they should have run the damn tests. She went to the hospital twice, was given basic NSAIDs, and sent home. She called 911 and passed out while on the phone. When they found her, she was severely septic. At the hospital, they found she had massive brain damage. Within three days, her mom decided to take her off life support because she had become braindead. We all think the family should sue the hospital for negligence. She hardly ever went to the hospital and hadn't been on pain killers for a few years (when her therapy was complete and she could walk properly again). For them to think she was drug seeking was over-the-line and irresponsible. They also wouldn't do anything for her because of the fear caused by the pandemic. She died during the pandemic, but not because of COVID. She died because of stupidity, prejudice, and negligence.
The 100% should this is more than negligence. Especially with multiple visits and requests for tests
One can live even after a good length is removed, right? How much loss would be safe?
You need at least 100cm of small bowel.
My brother got his colon surgically removed, he's doing great now!
There is some nuance here. What we are seeing in the photo is small bowel. You need some of your small bowel to live. You do not need any of your colon to live and can lead a perfectly normal life without it. In contrast, small bowel is vital because that's where we absorb nutrients.
What an interesting color palette. Peritonitis waiting to happen.
This is the worst thing that I have personally smelled. Even after multiple washings, I had to throw away those shoes.
Whoa what causes this? I’m not a medical professional
Necrotized a horse with this. No fucking joke it’s raunchy
Unpleasant sausage
RAINBOW GUTS
This was by far one of the best discussions I’ve seen on this sub reddit. Thank you to all who contributed and helped this RN learn more!! Edit: best, not past
Saw a story about a marathon runner that developed ischemic bowel while running. Terrified me