Tuesday, December 13, 2005


I looked at Patient M who lay still and quiet on the gurney. A sharp and trim 90 year old woman complaining of 2 days of abdominal pain, she lay clutching her abdomen, eyes closed tightly from the pain.

I had stopped my work up prematurely because midway through, it was plainly obvious that she had either perforated her bowel, or that she would perforate her bowel in the next several hours. To continue with my workup at this point would offer no further diagnostic information but only delay what she needed, which was an operation to remove her dying intestines. I didn't have a definitive diagnosis, but I knew that without an operation, this lady wouldn't live long enough to make it through the night.

From what I could gather, a loop of her small intestine had become trapped in her abdominal hernia. As the tissue became inflamed and edematous from the trauma of being incarcerated, the swelling of the intestinal walls began to close off the thin walled veins and lympatic channels in the wall of the intestine itself. In addition, as the movement of the bowel contents in this loop of intestine stopped moving, the bacteria started to grow rapidly in this stagnant solution. As the bacteria grew, it released toxic enzymes and byproducts, which further irritated the bowel wall, causing it to become further inflamed creating a positive feedback loop. The venous congestion due to the blocked veins along with the inflammation and continued arterial inflow has now caused so much edema within the bowel wall that the arteries within the bowel wall were beginning to become compressed. And now without an oxygen source, the loop of bowel began to die. Finally as the bowel wall became ischemic and necrotic, one part of the intestinal wall tore and the enteric contents began to spill into the abdominal cavity, spreading bacteria and its toxins throughout the belly.

It was only a matter of time before the bacterial load would exceed the capabilities of her immune system. She didn't have long. I needed to take her to the operating room, remove this dead piece of bowel, clean her intraabdominal contents, and save her life. I explained her grim condition and the risks inherit in her procedure and for someone of her age group.

She listened intently to every word I said, asked intelligent and relevant questions, and then followed up by saying, "Doctor, I've been around a long time. I have lived a blessed 90 years. And if the good Lord is calling for me, then I must go." She paused to take a breath and then continued with a slight twinkle in her eye, "But if you want to try operating on me, I wouldn't mind sticking around for a few more years."