From Mastication to Defecation: The True Story of One Kernel of Corns Rebellion

Turned 40 a few weeks ago. Over a month ago, I guess. I mean, basically I may as well be 50. At that point retirement is looming. Golden years. 

Do you know many 40 year olds who still have two grandparents around? Well, I do. Both of my maternal grandparents are alive, but this past week almost saw that number halved. 

My grandmother had another small bowel obstruction, and from what I've heard from my Mother, there was a suspicion of volvulus -- a twisting of the bowel on its axis. Imagine a tootsie roll, how the ends are twisted, it's like this.

You may think, well, big deal, so what if the guts twist around? The blood supply is cut off when this happens. When blood supply is cut off, death is close behind. Gett'n ahead of ourselves, though. 

This, the sixth edition of Doctor, Doctor, Give Me The News will address something near and dear to my heart, and that is small bowel obstruction (SBO.) 

We'll use this for a jumping off point to discuss how to manage patients who are older and relatively frail, with multiple comorbidities. In other words, when a sick, old person comes to the ED, what kind of special considerations should be made?

Small bowel obstructions are common. 

What do you think is the most common reason for someone to have a SBO?

Interestingly, it is having a previous abdominal surgery. Even an appendectomy decades prior can leave one the host of a surprise SBO party. 

It should be noted that the relative recent implementation of laparoscopic techniques will decrease the correlation somewhat in the future, but it very well remain the number one reason. 

Guts. 

They live in the peritoneal cavity. 

Let’s start at the beginning. You stuff some goodies down your gullet. Already the saliva, which has amylase, an enzyme that breaks down carbohydrates, is starting to digest the that “energy bar” which has more sugar than a snickers bar. 

Mechanical digestion — smacking those pearly whites up and down. While I know of no specific studies, it does make sense that smaller chunks will be beneficial in the digestive process. 

Brief detour: I still encounter open-mouthed-masticators who make my misophonia monumentally malignant on a regular basis. With the broadcasting of all the juicy sounds, their chewing turns into an experience meant for them, and them alone, into a “chew-along.” I never liked “sing-alongs” growing up and I like “chew-alongs” even less. Just like gaining consent before sexual activity has become an established thing, so should getting consent if you’re gonna force me into your hellish chew-along. I’m tempted to say that OMMs of the world are at a higher risk for SBO if it meant decreasing their ranks, but the data is inconclusive right now, and I don’t want to lose my medical license only a few months after earning it. 

I digress as I will do . 

Back to the chyme, which is what we’re gonna call the recent food, soon to be poopoo stuff that is now being milked down the esophagus. As it reaches the first sphincter among many, it knocks on the door, and if the secret handshake and password are up to snuff it monies on into the stomach. Into the acid furnace. 

It really is amazing that inside of us is a pouch lined with cells that produce acid so caustic it would burn right through our skin. A pH of 1.5 is pretty low. Meaning it is a strong acid. As a refresher, 7.0 on the pH scale is neutral. Low numbers are acidic, and higher numbers are alkaline, or basic. There can be substances that exceed a 14, and that are less than 0. For all tenths and tortoises, the 0 to 14 scale is a vestigial element embedded in acid base theory and practice. I beleaguer the point only because many people think that an acid or a base must be between 0 and 14 and that is just patently false.  

But also begin to ponder the nature of a logarithmic scale. I remember some mathematician quoted as saying something along the lines of that humans inability to understand and use the power of logarithms. A brief google search didn't yield any results of where it came from and I'm pretty sure I read it in a textbook. 

We now return to our main feature: From the Food Chewer to the Poop Shooter: The True Story of One Corn Kernels Rebellion. 

The stomach is where the bulk of the chemical breakdown occurs. One must really appreciate and dig the craziness of the hydrochloric acid world that lives in all of us. This acid is really strong. It breaks down stuff into base molecules and unlocking minerals and other nutrients. A base understanding of the stomach and its capabilities would drive the MLM and junk science industry out of business -- alkaline diets, water and other supplements all go through the acid bath of the tummy. 

The chyme churns in the stomach. eventually pushed out through the next sphincter and into the duodenum, which is the first part of the small intestine. There are three parts of the small intestine, and in total it measures somewhere around 20 feet. That’s a lot of slimy tube in our belly. 

I didn’t have a great understanding for before I took part in abdominal surgeries that the small intestines are slimy and they move around and slip slide around constantly. The beginning of the small intestine, where we left our chyme, is attached permanently, and the end of the small intestine is attached to the sphincter that allows access to the large bowel. But all those feet in between just move around like a squirming pile of maggots, or worms, or, maybe albino snakes. 

Would you like to have a sphincter named after you? Well, if this has been a burning desire I imagine you are familiar with Ruggero Oddi, an Italian anatomist and physiologist for whom the sphincter that opens up into the duodenum is named for. The biliary tree which includes fun juices from the pancreas and liver (and by extension, the gallbladder) which help normalize the super acidic food chunks. 

As last night's hospital food leftovers make their way through the 20 feet of small intestine -- first the duodenum, then the jejunum and then the ileum -- various nutrients are taken up through the walls of the intestines and into the bloodstream. The microscopic villi of the small intestine provide an astonishing surface area of 323 square feet, on average. This surface are trick is used perpetually in biology -- truly fascinating the kind of power that manipulating three dimensional structures can harness.   

By the time the captain's log start to form in the large intestines, the major work left is reabsorbing water and other chemicals in what amounts to a recycling program for the body. The large intestine begins in the right lower quadrant of the abdomen. This is where the ileocecal valve, or sphincter sits. Often times people associate right lower quadrant abdominal pain with appendicitis, and for good reason. The appendix is a relatively tiny structure that comes off of the very beginning of the large intestine. From the right lower area it comes upwards, than across the top of our belly and then shoots down on the left side as it prepares for the final act performed before the porcelain throne. 

The sordid details and the intimate details of the final sphincter we'll leave to the imagination. 

Circling back around to SBOs, and in doing so a brief exploration of abdominal pain is warranted. 

Pain of the abdomen is a very common complaint, both in the outpatient, urgent care and emergency department settings. 

The intestines themselves only have pain receptors that are wired to detect distension, meaning they can feel stretching -- and nothing else. However, if one is having abdominal pain, this does not mean that the only source of pain can be from a stretching of the intestine. Infection, third spacing, infarctions, ulcerations, and so much more can cause a person to seek medical care secondary to abdominal pain. 

In general, especially in the ED, the main priority is to rule out the things that can kill a person. All to frequently there is no identifiable reason for abdominal pain -- which is frustrating for the patient as well as the physician. 

In the patient who is suffering from an SBO, they will usually complain of nausea, vomiting, cramping with abdominal pain and lack of putsies and bowel movements. 

The degree of intensity of the symptoms, in conjunction with physical exam and often imaging will dictate the immediacy of intervention. 

A patient who is in the unfortunate position of playing host to an SBO can expect a nasogastric tube to be placed. Yup -- the infamous NG tube which often is very helpful in preventing emergent situations from occuring, or from backing off from needing emergency surgery. 

Patients hate this and will fight against having it placed. 

I get it. 

I don't want a tube down my nose either. 

This is the unfortunate nature of SBOs: patients who are at risk for them, often get them repeatedly. 

Frequently the patient is very much aware of the impending NG tube and is already dreading it and fight against it. 

I take my time explaining the benefits of such a negative experience. Skimping on discussion and explanation before putting in orders that will cause pain and or suffering for the patient is not advised. There are people who will not listen to reason, but everyone is owed a chance to at least hear the reason. 

A rookie patient often asks why this happened. I list the most common reasons, and usually they have had one of these things happen in their past:

• Prior abdominal or pelvic surgery
• Abdominal wall or groin hernia
• Intestinal inflammation
• History of or increased risk for neoplasm (cancer or growth of some kind)
• Prior radiation
• History of foreign body ingestion

This list is in order of association with SBO. 

All of the above things can serve to make the small intestines stick together. 

Scar tissue is not like the tissue it replaces, or grows in place of after a trauma. 

Intestinal inflammation, which is listed above is about as vague as it gets. 

Intestinal inflammation to varying degrees, is something that every single one of us has experienced. Chronic inflammation, such as with crohn's disease or ulcerative colitis really puts on at risk. Sometimes the inflammation gets so bad that ulcerations form. The tissue that grows back is less functional as the original. 

This is a supreme simplification of a complex process but this is true for most of the body. The liver can regenerate with an ease enviable of all the other organs and systems of the body. Skin can too, but I'm sure we all can point to a scar on our skin from childhood. That scar is a monument to the incident which saw the insult to our previously unblemished skin. 

In fact, it feels like a good life lesson can be had from knowing that our bodies can heal, yes, but after they have been injured they will never be the same. Yes, function may return to 100% pragmatically, there will always be evidence of damage done. 

Relationships be like this, too, yo. 

If there is concern of the the poop-tube popping or of it dying, it becomes the surgeon's time to shine. 

My grandmother, who has been a part of my life since day one had to undergo surgery as there was concern for the bowel dying due to blood supply being squeezed off by twisting over on itself. Thankfully, as far as I know they did not have to remove any necrotic bowel. 

I've been first assist in a number of surgeries with patients who are in relatively poor health. There are times where it comes down to this. Option A: patient undergoes immediate surgery with a solid chance of dying on the surgical table. Option B: No surgery and all efforts to be made comfortable and pain free is made according to the patient's wishes and death will come in the next hours to day. We think. 

Both options are okay.  

For one thing, imaging doesn't tell us everything and doctor's don't know everything and we can't predict the future. We rely on the past cumulative experience of medical science in partnership with our own anecdotal experience to guide decision making and arriving at prognosis statements and treatment plans.

There are a lot of stories out there where somebody "proved the doctors wrong" by being regaining the ability to walk again, or whatever. 

What people don't know is that there is a physician gambling line created automatically by the AMA everytime a doctor gives a prognosis. In fact just the other day I got a check for $50 because I got the over on Johnny still being wheelchair bound after his rollerblading accident in 2015. 

I still feel strongly that there should be a font created specifically for sarcasm or, satire, so that the naive amongst us can reduce their outrage levels. While I fear I must outright state that the AMA gambling side hustle is just a "joke" lest we not forget that some of the best kept secrets are right in front of our face. 

Logarithms. 

Look, I know many of us, me included, kind of go blank when faced with equations like these. 

Just forget they're there. 

Just look at the different lines. 

The green one is a straight line.  Whatever it might be measuring could be called a linear progression. If the horizontal line were measuring time, say days, and the vertical black line were measuring the number of f-words I had to give, then for every day in the positive, I would have one extra f-word to give. The blue and red ones do not have this same relationship.

For every one of whatever, you may get way more, or way less of the other unit measure, which is dependent upon what the first value is. In other words the blue and red lines have a variable rate of change.

What does this have to do with taking care of patients and how to figure out who should go to surgery and who shouldn't? 

Well, I've learned that our bodies work like this. 

Think of how many times you've heard someone say that they're grandparents, or loved one was doing so well, and a time came where something tipped them over the point of being able to return to normal health. Stick with me here. No more equations, I promise.  

The blue line. Look at the left side of the blue line and imagine (extrapolate) that and you can see that it very, very gradually moves towards the black horizontal line. 

Now, let us say that the blue line measures a person's life and their overall health. A larger number is bad and getting to ten means death. 

Things are great and only slowly get bad. But, after that slow worsening, as noted by the blue line curving upwards, it gets bad real fast. 

It doesn't take long for the blue line to go from a generally horizontal vector to a vertical one. 

This can be extended to individual disease processes as well. 

Let's look at a bacteremia type of situation. Bacteremia means that there is a bacterial infection of the blood. Not good. Bacteria replicate. This curve on the left looks familiar, yes? 

I think this is fairly obvious, thinking about how growth curves would work. Less obvious is disease processes that cause real physical deficits that our body adapts to compensate. 

The simplest one that comes to mind is congestive heart failure (CHF). There are multiple kinds of heart failure but for our purposes here we only need to think of it as our pump is not pumping well. Less pumping per heart beat, right? 

Well, if your pump ain't pumping too good, what would you do? 

Agreed. Pump faster! We can make up for power with speed! I mean, duh, F=m/a, afterall. 

Maybe we could make the arteries squeeze down so they're smaller, because if we make the space for the blood smaller, the pressure will go up, right? 

Yes. That is true. All of it is true and super common. 

I actually give patients with CHF who show up in the hospital the diagnosis of decompensated systolic congestive heart failure, or whatever. 

Our bodies are quite adept at compensating. Over time, whatever we're compensating for (looking at you with the lifted pick-up truck who drives on the interstate to work) will force the mechanism of compensation to be its own unique problem. 

I think we as humans see our reality through a lens that lends itself to defaulting in ones worldview to one of linear progression. It is easy to understand a one-to-one relationship, basically. It is more difficult to imagine a progression with such a great rate of change. Not a perfect connection, but this is similar to how compounding interest is not intuitive and therefore is employed to take advantage of those who are ignorant in the ways of usury. 

Even when we experience this kind of progression, we struggle to understand it. 

The patient coming in with severe septic shock due to bacteremia can become gravely ill, very fast. Remember that curve of the bacteria growth? That curve can describe the proliferation of the bacteria in the patient's blood, more or less. 

Toxins secreted by the bacteria in conjunction with another process which follows this kind of curve -- the inflammatory response cascade serve as some of the reasons that severe septic shock is the number one cause of mortality in the ICU setting. 

The first time you see a person deteriorate in this fashion, it leaves an impression. 

Thankfully my grandmother is recuperating and doing well. She's beat the odds not only this past week but also has in the long run as she's been suffering from Parkinson's Disease for over twenty years. 

It is a testament to her strength that her rate of change has been shallower than not.  

Despite theorizing that most of us fail to see a logarithmic progression, I do believe that many patients feel this, and instinctively know that it is their time, when that time comes. 

It is the families and loved ones who often cannot reconcile the emotions involved and acceptance of the universal truth -- nobody gets out of this life alive.

I will always search for ways to reach people and help guide them through their own death or the passing of a loved one. It is often a thankless position to be in -- and truly, the only thanks I seek is that of the patient, whether it be in this world or the next.