Clinical case of surgical treatment patient with multiple metal foreign bodies of gastrointestinal tract suffering from schizophrenia

Abstract

Relevance: acute surgical diseases manifest with increasing intra-abdominal pressure (IAP). Persistent intra-abdominal hypertension (IAH) cause development of severe local and systemic dysfunctions including abdominal compartment syndrome which has mortality rate 60%-90%. According to this points, the process of monitoring IAP is significant measure to clarify pathological changes in abdominal cavity and adapt therapy to this changes [1]. Clinical case: 12.11.2020 in 9.37 a.m. Patient Sh., 29 years old, was admitted to 1 surgery department of City Clinical Hospital №4 with diagnosis “Multiple foreign bodies of gastrointestinal tract. Acute bowel obstruction”. The patient complained about abdominal pain without well-defined localization, nausea, vomiting with masses of brown color, multiple liquid and nonformed chair. Anamnesly, 08.11.2020 he swallowed “nearby 40 pieces” metal bodies whereafter the above listed symptoms manifested. From 9.11.2020 to 11.11.2020 due to severe state of patient his mother few time call for an ambulance but the hospitalization was categorically declined by him. Suffering from schizophrenia from 2011 year. Pulls 100 per min, blood pressure 90/50 mm Hg. The tongue is dry, covered with whitish scurf, the stomach is bloated, tense till palpation, painful in all divisions. The symptoms of Sklyarov and Shchotkin-Blumberg are positive. During the per rectum examination, a metal bolt (8x0.5 cm) was evacuated. In the X-ray and sonographic examination the evidence of acute bowel obstruction were found. We perform catheterization of the urinary bladder by double balloon three-luminal catheter Foley for longtime measurement of IAP intravesicaly. For interpretation we use modified in our clinic Burch classification (1996). Initial IAP was 26 mm Hg. The conservative treatment had been started to prepare patient for intervention: nasogastric decompression, intravenous therapy, after which operation was performed. Intraoperatively we found diffused fecal peritonitis, hydropic bloated small intestine with multiple bedsores (venous stasis) in large and small intestine (foreign bodies were palpable). In terminal part of ileum perforation (2 cm) was discovered from which the conglomerate of metallic foreign bodies with a metallic luster was protruded. In the center of this conglomerate is a magnet. Elimination of foreign bodies, right hemicolectomy with ileo-transverse anastomosis, intubation of small intestine and lavage and drainage of the abdominal cavity ware performed. Postoperative period in intensive care unit. The patient was extubated. Consciousness was clear, critically referred to happened. Control measurement of IAP during first day 13,5+0,2 mm Hg, second day 10,7+0, mm Hg. During this days the peristaltic and self-depended defecation acts appeared. But in 3 day (15.11.20) there was increasing of IAP to 17,6 mm Hg, later from drainage in subhepatic space intestinal content came out. During the relaparotomy the perforation in 1,25 m distal from duodenojejunal flexure was found. The perforation closure was performed. The intestinal edema and paresis were absent, the pulsation of mesenteric vessels was satisfactory, parts of the wall with bedsores have restored their trophic and color, part of the bedsores with visible changes were peritonized. The wound is stitched on the turnstiles for future scheduled relaparotomy, peritoneal dialysis hsd been started. Planned relaparotomy for sanation 17.11, 19.11, 21.11 - the state of the abdominal cavity was satisfactory. The IAP was 8,2+0,4; 6,5+0,3; 5,4+0,2, in accordance. 21.11.20 the abdominal cavity was peritonized and wound was sutured. 26.11.20 the patient was transferred to a psycho-neurological health center. Conclusions: 1. Using of long-term monitoring of IAP is important not only for the choosing and correction of the treatment scheme, but also for the in-time detection of intra-abdominal complications that require urgent surgical intervention. 2. Вownward factors of the disease are: 1) late hospitalization in the stage of septic shock and multiple organ failure due to the uncritical attitude patient with schizophrenia to himself; 2) the effect of the magnetic field on the mucous lining, which led to dysfunction in microcirculation of the lamina propria [2] and through induction microcurrents in the metal bodies which cause microburns of the gastrointestinal mucosa with subsequent perforation of the small intestine. References 1. Bezrodnyi B.G., Teplyi V.V., Kolosovych A.I. 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