Bowel crisis could accompany Bolsonaro for a lifetime, doctors say

The probability that President Jair Bolsonaro (PL)’s intestinal obstruction will resolve itself in the next 72 hours with clinical treatment, without the need for surgery, is high, but the risk of the problem recurring may accompany it for the rest of his life, according to digestive tract surgeons heard by leaf.

The obstructions are caused by adhesions (parts of the intestine that stick together) resulting from the history of surgical interventions after the stab wound that Bolsonaro suffered in September 2018, when there was blood and feces spilled on the peritoneum, a layer that lines the abdomen.

For the doctors heard by the report, these crises in general are random and do not depend on the lifestyle, such as eating or practicing physical activities.

But, even without scientific evidence showing a causal link, some situations may be associated with excessive consumption of food and drink, according to surgeon Carlos Sobrado, professor of coloproctology at USP’s Faculty of Medicine.

Sobrado uses the following analogy to explain what is happening to the president’s gut. “It’s like when you’re splashing water in the backyard, the hose bends and water stops,” he compares.

When the intestinal loops bend, it begins to accumulate stool in the intestine and fluid in the stomach, causing abdominal distension and an increased population of bacteria that inhabit the intestine. “The belly is bloated, the cramps are strong, the person is in a lot of pain, wanting to vomit.”

These fluids are the result of swallowed saliva, intestinal mucus, gastric juice, bile, and pancreatic juice. All of this should be being absorbed by the intestine, but because of the blockage, it ends up building up in the stomach — generating up to 2,000 ml of darkened fluid every 24 hours.

Currently, in addition to removing accumulated fluid through a nasogastric tube, Bolsonaro’s therapy consists of oral fasting, hydration solution and replacement of glucose and electrolytes (especially sodium and potassium) and the use of antibiotics to prevent infection. It’s called conservative treatment.

In the next few hours, it is also likely that a catheter will be placed in his neck for parenteral feeding — which will nourish the president with proteins, fat, lipids and others.

According to Diego Adão Fanti Silva, digestive tract surgeon at Unifesp (Federal University of São Paulo), the chances of success for conservative treatment are 80%.

That is, with the removal of liquid from the stomach, abdominal distension tends to decrease and the adhesion that is obstructing the intestinal transit is likely to dissolve on its own.

The fact that Bolsonaro already had the same condition in July of last year does not alter the chances of success of the conservative treatment, says Silva. “It’s like the first event all over again. Each crisis carries within it the chance to [de o tratamento] go right or wrong.”

In the next few hours, there are important signs that should be considered, according to the surgeon. For example, the so-called probe output, that is, the volume of fluid that is leaving the nose probe.

According to Silva, as adhesion begins to loosen, the volume of liquid that comes out of the probe decreases and the color becomes lighter. Another positive sign is when the president begins to eat and drink without vomiting, and finally when to eliminate gas and stool.

If the condition does not improve in two or three days, surgery may be necessary. For Silva, only under these circumstances would intervention be indicated.

“When you operate, the surgery itself causes new bands [aderências], the surgery does not remove this risk. You can also get rid of that grip that’s causing the clog, but when you operate [um intestino como o do presidente], there are several adhesions, not just one.”

The surgeon Carlos Sobrado, from USP, says that when obstructive crises start to repeat themselves, surgery can be a good option.

“When a person has already had three crises, the chance of having new ones is very high, so they need to operate. There is no way. But you have to be an experienced doctor, it’s not surgery for a kid,” he says.

According to Sobrado, these adhesions are, in general, very firm, located in critical regions. “You have to be very patient to displace an intestinal loop stuck in the liver, biliary tree, ureter, iliac vessels, aorta, abdominal vessels.”

According to him, studies that followed patients who had several adhesion crises and that compared medium and long-term outcomes concluded that the operated group had an advantage over the one that received conservative treatment.

“Patients had fewer recurrent attacks than those who were left with medical treatment alone.”

From the surgeon’s point of view, Bolsonaro would be a candidate for surgery. He says medical treatment may provide momentary relief after the bowel loops unfold, but the adhesion that is likely stuck to the abdominal wall will remain there.

“With the surgery, you release all adhesions, put all the organs in the normal position. Can they stick together again? It can, in 10%, 15% of cases”, he says.

For Diego Silva, the risk of new attacks of obstruction will accompany Bolsonaro for the rest of his life, regardless of the treatment he will receive now or the lifestyle he adopts. “It might have it again or it might never have again. It’s totally random.”