[The content of this chapter is more about clinical ideas, which is difficult to show with pictures. The degree of hardness exceeds the previous cleft lip and palate, and those who bite hard are all warriors. Personally, I suggest you wait two days for this chapter to be released before you can give it a try. If you can’t finish it, don’t force yourself. 】
In the 19th century, there were no preoperative examination instruments, and everything was just the most basic palpation and auscultation.
Kawei performed palpation on Fernand three times in total. The first time he simply touched the liver to clarify the cause of breast hyperplasia.
He did make some mistakes, and because the liver cirrhosis reached such an extent that there was no need for surgery and no possibility of medical treatment, he did not palpate the spleen, nor measure the ascites according to modern clinical standards.
The first palpation diagnosis was breast hyperplasia caused by simple liver cirrhosis.
In Kawei's view, cirrhosis of the liver had already sentenced Fernand to death, and the subsequent removal of breast hyperplasia was only the product of his strong request.
The second palpation was performed one month after the swelling of the pill appeared.
At that time, Fernan's left gao pill suddenly swelled and swollen with pain. Kawei did a simple abdominal physical examination and diagnosed the gao pill as a possible tumor after confirming liver cirrhosis. The postoperative biopsy pathology confirmed that it was a tumor. At that time, he had a hunch that liver cirrhosis might be caused by the metastasis of cancer.
Although it was only a short month, it was strange to see such a big change in physical signs, but considering the environment at that time, malignant tumors were emerging one after another and developing rapidly, and the progression of the disease was still within the scope of explanation.
In this way, until two days ago, Kawei performed abdominal palpation on Fernand for the third time.
He had a full physical examination systematically this time. The texture of his liver was still cirrhosis, and there was about 700-1000ml of hepatic ascites in his abdominal cavity. At the same time, the spleen is huge, and its lower edge has reached the navel.
In fact, the final diagnosis did not deviate too much. It was still portal hypertension caused by liver cirrhosis, which in turn affected the esophageal and gastric veins, causing varices to rupture. The enlargement of the spleen becomes so huge because of portal hypertension, which leads to blood flow obstruction and subsequent hypercongestion of the spleen. 【1】
In this case, if it were an ordinary patient, Kawei would still not recommend surgery.
Firstly, the risk is too high, and the patient is likely to die on the operating table; secondly, there is no possibility of a radical cure, the effect will not meet expectations, and life expectancy will be affected due to poor physical fitness.
Liver cirrhosis protein loss is severe, immunity will definitely be much worse, and coagulation ability will also be poor. 【2】
An ascites infection alone is already a huge headache, and may even cause intraoperative bleeding, which are major troubles that need to be avoided during surgery. This is one of the reasons why modern surgery requires checking liver and kidney function. Abnormal liver function will greatly increase the risk of surgery. 【3】
Judging from the results, Kawei did not make any mistakes. This is the outcome of liver cirrhosis. When liver transplantation is not possible, non-surgical symptomatic palliative treatment, such as removing liver ascites to reduce abdominal distension, is the best solution.
But in principle, Carvey still made a mistake.
There are many reasons that contribute to this error.
Maybe it was because I was getting used to the dogmatic diagnostic style of the 19th century, maybe because I was overconfident, or maybe because it was too late and I was too tired. In short, if there are any omissions in the examination, you need to reflect on it. Doctors can improve their own skills by constantly learning from such repeated mistakes.
Looking back now, we can see that errors in judgment may have subconsciously influenced Kawei's decision, and eventually became one of the reasons why he suggested surgery.
Before cutting open Fernand's belly, Carvey simply laid out the surgical procedure. The huge spleen is first removed, and then the splenorenal vein shunt is performed. The specific method of shunting depends on the conditions of the abdominal cavity. Finally, the tumor in the liver and the varices in the esophagus and stomach are treated.
Splenectomy and splenorenal venous shunting are necessary, which can greatly delay the progression of gastric varices. 【4】
The latter two are a matter of opinion. Even in modern times, there is a high probability that liver metastases cannot be operated on. For varicose veins, it is often necessary to cut off part of the stomach or directly cut off the diseased esophagus. This involves the problem of thoracotomy, which may not be a good choice now when there is a lack of thoracotomy capability.
In addition, Kawei has other options, but the conditions are so restrictive that it is difficult to use them. 【5】
Fernand's liver function could not tolerate a long operation, and simply removing the spleen had greatly increased the risk of postoperative death. After all, this is surgery, not anatomy, so save what you can. 【6】
But after the abdominal dissection, all the premises established before became weird.
The spleen is indeed big enough, very big, so big that even the first, second and third assistants around him are shocked. Those viewers sitting near the front can also clearly see the spleen occupying one-third of the left abdominal cavity.
Anyone who has a little understanding of the anatomy of the abdominal cavity will be shocked by this giant spleen.
Kawei explained the reason for the huge spleen, and it didn't matter even if most people didn't understand it, or he didn't care at all, because Kawei still had a troubling problem waiting for him.
Cirrhosis of the liver is called cirrhosis because the texture of the liver will become hard, the volume will shrink accordingly, and the surface will be uneven with various nodules of different sizes appearing. Just like a large piece of stinky tofu, the soft and tender parts inside were deep-fried in hot oil for a long time, and finally shriveled into a small piece, making it too hard to eat. 【7】
However, the liver in Kawei's hands is only tough at the edges and a little hard on the surface, but visually it does not have the feeling of ordinary liver cirrhosis.
There are no nodules on its surface, the overall texture is pretty good, and the size should have shrunk but not significantly.
The same disease will have different treatment methods due to different causes. Fernand's abdominal cavity is not what Carvey had previously diagnosed, and the preset surgical plan may not be applicable. Even if it is really applicable, Kawei would not dare to perform surgery rashly out of caution.
It is necessary to make a differential diagnosis to determine the cause.
Does the fact that the liver does not shrink significantly mean that he does not have cirrhosis?
Without cirrhosis, there is a high probability that there will be no portal hypertension, no esophageal and gastric varices, and there is no way to talk about giant spleen...
Kawei stood beside the operating table, his hands still playing with the liver, his head lost in thought. It may be simple portal hypertension, for example, the tumor simply invades the portal venous system and causes portal vein obstruction, resulting in varicose veins, hypersplenism and congestion.
Is the tumor thrombus left in the portal vein system?
But this is only possible with primary liver cancer, and the operation is very troublesome. You need to find the embolized blood vessel and incise and remove the embolus to relieve the problem. For Kawi, who had no means of inspection, the difficulty was too high.
If this was the case, it would be easier. Just cut off the spleen and perform a shunt to close the abdomen, so Kawei still hopes to find out if there are other possibilities.
Another possibility was hilar cholangiocarcinoma, but he quickly dismissed it.
Hilar cholangiocarcinoma will definitely cause biliary obstruction, and jaundice is the first symptom, and the degree will be much more serious than what he is now. The liver parenchyma will shrink, and it will feel similar to this.
Upper gastrointestinal bleeding is uncommon, but it does not mean it is not common. This kind of bleeding is not due to varicose veins caused by portal hypertension, but because cholangiocarcinoma will invade outward into the duodenum. Once the intestinal mucosa is destroyed, gastrointestinal bleeding will occur.
Although Kawei had undergone a physical examination and Fernand had jugular venous distension [8] and there must be a problem with the liver porta, the possibility of gastrointestinal bleeding could not be ruled out.
In fact, even if we ignore this point, there is still another question: where does ascites come from?
Ascites is likely to occur unless intrahepatic metastasis occurs and causes cirrhosis. But if it really reaches this level, Fernan will have become a minion, and even his stool will be white. 【9】
Starting from the huge spleen, plus ascites, portal hypertension, and upper gastrointestinal bleeding, these reminded Kawei of primary myelofibrosis.
But... that's not right either.
Primary myelofibrosis is a blood disease. Because the bone marrow cannot produce blood, the spleen needs to perform the hematopoietic function. The spleen is a blood storage organ. If it is no longer responsible for blood production, it will cause hypersplenism. Therefore, most of the symptoms of this disease are caused by hypersplenism.
If liver cirrhosis is 3+1=4, then myelofibrosis is 2+2=4.
The sources are different, even if other symptoms are similar, the liver lesions are different.
Primary myelofibrosis does not directly damage liver cells, so the liver parenchyma does not collapse and become smaller due to damage, but instead increases secondary to congestion. Sometimes after hypersplenism reaches its extreme limit, the liver will compensate and produce hematopoietic lesions, which are completely different from sclerosis.
Pancreatic cyst?
What’s even more wrong is that pancreatic cysts are just compression and should not cause liver disease. Kawei was worried and turned over the pancreas again. Although the tissue was not separated, the size should be normal from the appearance and there were no cysts.
Three consecutive differential diagnoses were rejected by Kawei. The remaining possible diseases were more focused on internal medicine, and he had none of the possible specific symptoms. This made Kavi begin to doubt the diagnosis of liver cirrhosis. Could it be that Fernand's liver cirrhosis had just begun and was not serious enough to cause varicose veins?
Looking at it this way, could the cause of bleeding be gastric ulcer?
But this still doesn't explain why there is so much ascites.
Kawei once again overturned his assumptions and started from scratch, first selecting the main contradictions in the differential diagnosis. Fernan's liver has shrunk and has no nodules, which shows that cirrhosis exists but is not serious. However, he also has a lot of ascites. It takes these two days to find the correct cause.
There are many points in the differential diagnosis of ascites.
First of all, based on the nature of ascites, it is divided into leakage, exudation and bloody. 【10】
Judging from the characteristics in the bottle, the possibility of the latter two is very low. Of course, protein analysis and occult blood cannot be seen, so it is impossible to make a complete judgment, but the possibility of leakage is very high.
Leaking means that the sieve is leaking, and there is something wrong with the sieve, so it is divided into hepatic origin, gastrointestinal origin, renal origin, cardiogenic origin, portal vein obstruction, and malnutrition.
There is definitely something wrong with malnutrition. How can it be bad if so many people eat it?
Cardiogenic disease requires heart failure and other inflammations, which is also wrong.
Nephrogenic, nephritis? Kidney failure? The urine is regular and clear, at least Kawi can't tell yet.
Gastrointestinal? That's intestinal tuberculosis, intestinal dysplasia, Crohn's disease. Fernand's stools are quite normal, sometimes with blood but more often with black stools after upper gastrointestinal bleeding. And his intestines were right in front of Kawei's eyes, and they didn't look or feel like them.
Finally, it went round and round and returned to the liver. No matter how you look at it, the ascites in this body should be of liver origin. But liver cirrhosis is not serious, so how come there is so much ascites? What is the problem?
In just a minute or two, Kawei eliminated all other possible problems one by one, and now only the liver and its portal system were left.
Bidige
"Originally, I judged it to be liver cancer, but now it seems that the lesions in the liver are not obvious." Kawei repeatedly touched the liver and even tried to explore downward with his fingers. "I couldn't feel the location of the tumor on the surface of the liver, so I wanted to go down." Look around the porta hepatis…”
At this moment, Kawei's hand touched the perihilar tissue. First there is the gallbladder, which has a certain degree of toughness, and then there is the portal liver inside. There should be connective tissue around the liver portal, wrapping a large number of blood vessels, but what Kawei touched was not the common connective tissue.
This touch...
Kawei turned over the liver and exposed the gallbladder underneath. At the same time, he could also see that there were many small blood vessels and lymphatic vessels in the gallbladder triangle that should not be there. This is the collateral circulation produced by the body when the hepatic portal vein is obstructed. Because it looks like a sponge to the touch, it is called portal cavernous degeneration.
When this happens, it means that the liver cells have suffered a lot of necrosis, and cirrhosis is a certainty.
There is no room for liver surgery, and even dissecting the gallbladder triangle is meaningless because there are too many collateral circulations and it is too complicated, and even Kawei cannot be 100% accurate. Once the collateral circulation is injured, poor coagulation function will make bleeding difficult to control.
Questions come one after another, why does liver cirrhosis, which does not appear to be serious, have such severe portal spongiform degeneration?
The changes in the body don't lie. The liver is indeed failing. It is definitely in the decompensated stage of cirrhosis. The spleen enlargement, hemorrhage, and ascites can all be explained. So the contradiction shifts again. Why is such severe liver cirrhosis not obvious?
etc......
Suddenly a strange thought jumped into his mind.
Kawei stopped what he was doing and realized that he seemed to have missed a very important cause of the disease. Although it is almost impossible to see it in China in the 21st century, in the 19th century, it should...
its not right! Europe should not be affected by the disaster. Has he been to Egypt?
Kawi never asked about Fernand's travel history, because from the beginning he determined that Fernand had cirrhosis of the liver caused by alcohol and tumors. Excessive consultations cannot change the fact of liver cirrhosis. Without examination means, it will put Kawei in a never-ending situation.
But there is no point in worrying about this now. What he needs is a diagnosis.
The diagnosis lies in the stool examination, because the bleeding in the upper gastrointestinal tract covers the bloody stool, and there is no chance to do a microscopy now, so we can only look for it from the organs.
"Come and help me dig out the mesentery."
Kawei didn't expect that he would have the opportunity to perform this kind of operation. He quickly put down the liver in his hand and set his target on the lower abdomen: "Take out his intestines and turn out the mesentery. Be gentle. I want to Look at the blood vessels!”
The three assistants had no idea that Kawei had gone through a lot of thinking and investigation during this period, and had long since given up on following Kawei. Even if they didn't understand his purpose, they would obey him unconditionally.
It is indeed difficult to examine the intestines in the lower abdomen through an upper abdominal incision. Fortunately, the distance between the incisions is sufficient and the mesentery and its surrounding vascular plexus can still be well exposed. 【11】
Several people worked together to remove Fernan's intestines from the body, placed them on a clean gauze pad, and then moved the intestines around to expose the internal blood vessels.
Kawei saw what he was looking for at a glance. The last time he saw it was more than 20 years ago. It has been a long time since he said: "It is indeed here."
"What are we looking for?" Damirgan was puzzled.
"Look carefully here." Kawei pointed to the black lines in the mesenteric blood vessels, finally clarifying the cause of Fernand's illness: "These are bugs." [12]
