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Patient Care Vignette

A 70-year-old man, BT, presented to the emergency department with acute onset abdominal pain, vomiting, tachycardia, hypotension, and an increased white blood cell count. Past medical and surgical history were notable for type 1 diabetes mellitus, hypertension, and total knee and hip replacements. His admission weight was 70 kg with a height of 71 inches (BMI 21.5 kg/m2). His weight was stable, and he had a normal appetite until the day prior to admission. Imaging was suggestive of diverticulitis with an uncontained perforation. BT was taken to the operating room for an emergent exploratory laparotomy and underwent a sigmoid colectomy with end colostomy. He was admitted to the ICU due to septic shock, and the need for mechanical ventilation and a continuous vasopressor infusion to maintain an adequate blood pressure. With source control and appropriate antibiotic therapy, BT’s clinical condition rapidly improved.

After having his breathing tube removed, BT was advanced to a diet that included oral nutrition supplements (ONS) appropriate for a patient with diabetes by postoperative day (POD) 2. On POD 4, BT reported poor appetite and was taking less than 25% of his estimated nutritional needs. He related his poor appetite to feeling full earlier than usual (early satiety) and fatigue. To maximize menu options, BT’s diet was liberalized to a regular diet. Alternative ONS were explored, and his family agreed to bring in food from home. By POD 7 his oral intake increased to about 50% of estimated needs from meals and ONS. At this point he had lost ∼3.6 kg (∼5% body weight) since admission. Given his persistent suboptimal intake and weight loss, the patient met criteria for supplemental enteral nutrition (EN). He agreed to nasogastric small-bore feeding tube placement. Nocturnal EN was initiated to provide ∼70% of his estimated caloric needs to supplement his oral nutrition. Despite these maneuvers, BT’s oral intake did not improve. A more durable feeding tube would be of benefit and his surgeon planned on placing a gastrostomy tube (a feeding tube that crosses the abdominal wall to directly enter the stomach).

While awaiting time in the operating room (OR), BT’s wound opened and drained both pus and what seemed to be stool. BT’s wound fell apart due to infection related to a fistula that formed from his colon to the surgical closure. His skin was opened by removing the skin staples and the wound was packed with moistened gauze with plans for regular dressing changes. Relatedly, gastrostomy tube placement was deferred in the setting of acute infection. Since the fistula seemed to be low output, the surgical team pursued nonoperative management of the fistula with continuation of EN and oral diet. Many low-output fistulas will close on their own if their output is low and nutrition is excellent. Unfortunately, the fistula output progressively increased and became a high-output fistula. At that point in time, reoperating would be quite challenging due to adhesions that normally form, ...

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