[I saw that many book friends wrote about liver flukes. Liver flukes are completely different from schistosomiasis. For details, you can read the previous book for detailed introduction, so I won’t go into details here.] Kawei has indeed not encountered schistosomiasis for a long time and has cirrhosis of the liver. , domestic schistosomiasis.
Moreover, there are endless examination methods in modern times. A liver B-ultrasound alone can make schistosomiasis cirrhosis invisible[1].
Moreover, early bloody stools and anemia will also make clinicians more vigilant. A clear diagnosis can be made by examining feces for eggs and contact history with infected water.
But it may be that the prevention of schistosomiasis in China is too good. Kawei, who has been working in a big city, seems to have forgotten all kinds of schistosomiasis cirrhosis he has encountered, and he is not aware enough of the prevention of this little thing.
Schistosomiasis cirrhosis rarely produces nodules and only produces some fibrous proliferation on the liver capsule, so simple direct viewing is prone to deviations.
Schistosoma is divided into Schistosoma japonicum, Schistosoma mansoni and Schistosoma haematobium. Their life histories are similar [2], but their requirements for the living environment after entering the body are somewhat different.
Most of them gather around the portal vein, adsorb on the blood vessels, continue to suck blood, grow and develop until they grow into adults.
Once the number in the portal system reaches a certain level, obstruction occurs, hence portal hypertension, megasplenism, upper gastrointestinal bleeding, and ascites.
Nowadays, it is meaningless to talk about the history of travel and contact with epidemic water. It is also meaningless to talk about the type of schistosomiasis, whether it is Schistosoma japonicum, Schistosoma mansoni, or Schistosoma haematobium.
Because the black adult worms in the mesenteric blood vessels are enough to explain the problem. At this stage, there is no room for surgical treatment of schistosomiasis cirrhosis. A mere dissection of the porta hepatis can make surgeons miserable.
All Kawi can do now is to try to improve Fernan's upper gastrointestinal bleeding, or at least stop the bleeding.
The operation returned to the previously envisioned giant splenectomy + splenorenal vein shunt. Although it took a long way to go back to the original surgical plan, the clear cause of the disease gave Kawei confidence and he was willing to add something else to the original plan.
But before that, he had to let the audience know about it, and he also needed to make a subjective modification to the medical history of Fernand stated earlier: "The prisoner's body seems to be parasitized by some kind of worm, which can infect the mesentery." You can see them in your veins."
"It looks like a very small nematode." Herman stepped forward and took a closer look and said,
"I remember a German doctor who went to Egypt a few years ago mentioned a nematode that was about the same size as this." Nematodes found in Egypt?
That basically means that Schistosoma haematobium has not escaped. Kawei asked: "Do you know the name of that nematode?"
"It seems to be named after the doctor. It's called Schistosoma." This is a very old name. Because it is too difficult to obtain Western books, it has been active in domestic parasite prevention and control in the 1960s and 1970s. In the manual, its scientific name was slowly changed to Schistosoma until later.
[3] Kawei breathed a sigh of relief. Now that someone has confirmed the bug, it is easier to explain: "The bug is present in his blood vessels and blocks the blood flow, which is why it causes hypersplenism and enlargement. , and also makes the surface of the liver as rough as a layer of linen." The audience, who originally had little interest in surgery, began to narrow their eyes and look at the mesenteric blood vessels in Kawei's hands.
It is such an exciting thing for bugs to burrow into the human body, so they naturally hope to see it clearly. Unfortunately, even if you adjust the telescope to the highest magnification, you can still only see some intestinal segments and mesentery, and there is really nothing you can do about the blood vessels in the mesentery.
"This is the first time I've seen this happen."
"Can an insect do such a thing? It's so weird!"
"Can't see, I can't see at all!!"
"We have to wait until the operation is over to see if we can take two from his hand to watch..." There will be disparagement when there is appreciation, especially when facing Kawei, some people's jealousy and The competitive spirit will go into full gear: "This diagnosis is too hasty, and I have never heard that parasites can enter blood vessels."
"It seemed like a bit of a sensationalist stunt."
"Anyway, the abdomen will be closed immediately after the operation. He doesn't necessarily cut open the blood vessels and take out the worms one by one. Without evidence, there is reason to doubt the authenticity. If everyone imitates what he does, how can surgery develop?" Ka Of course, Wei's operation could not remove the worm. Even if he had a complete set of microsurgery instruments, he would not do it.
Because even if all the bugs visible to the naked eye are subjectively removed, it is still impossible to determine whether there will be bugs remaining elsewhere.
Bugs are like cancer. If you miss one, it won't take long for it to produce thousands of offspring.
To deal with schistosomiasis, you have to use the method of dealing with schistosomiasis, pyridinone. Unfortunately, pyridone is a synthetic drug and certainly did not exist in the 19th century.
In addition to the most basic supportive medical treatment of adrenal gland + pituitary gland extract, Kawei said surgery is a good way to effectively extend the patient's life.
Modern surgery no longer has much interaction with portal hypertension and esophageal and gastric varices. Most of them are left to the endoscopy room for endoscopic hemostasis + sclerotherapy + ligation treatment, or to the interventional room for vascular embolization and devascularization.
Splenectomy is a difficult surgical method for modern medical treatment, and the indications for surgery have basically been eliminated.
Splenorenal venous shunt has gradually withdrawn from the stage of history due to difficulty and complications. But in the 19th century, this set of surgical methods to deal with portal hypertension seemed extremely advanced.
It's so advanced that it feels like you're watching a science fiction movie. At this time, Herman, who knew a little bit about Schistosoma haematobium, reminded Carvey: "I still remember the doctor's description, 'The bladder of a patient with long-term hematuria was filled with gray-white worms.' It’s creepy.” Schistosoma haematobium prefers the bladder after the portal vein matures, and indeed likes to cluster in the bladder.
Mansoni, like Schistosoma japonicum, prefers intestinal blood vessels. But no matter what kind of schistosomiasis it is, its larvae and eggs like to burrow randomly. Now combined with Fernand's bizarre medical history, it is not difficult to see the role of the larvae and eggs in it.
The first thing that appears is bladder stones. Although the incidence of bladder stones is very high without antibacterial measures, there is still a high probability that Fernan's bladder stones were caused by the accumulation of insect eggs.
If you don’t have the habit of breaking and checking, it’s easy to miss this cause. The second is breast hyperplasia.
One thing that has always made Kawei feel strange is the speed of Fernand's breast hyperplasia. In just a few days in the hospital, breast hyperplasia became so obvious. In addition to the role of hormones, insect eggs were also an important reason.
Kawei has experienced the era when schistosomiasis was raging, and has seen cases of eggs, adult worms, and larvae parasitizing the mammary gland ectopically through the medullary veins and intercostal veins.
This external stimulation will cause inflammation in the breast, and then pathological hyperplasia of the breast will occur, and finally even cause breast cancer.
Looking back now, it is a pity that Fernan's bilateral breasts were not carefully dissected and a large number of specimens were pathologically examined.
Finally, there are Gao pills. Fernan's cancer was based on pathological examination, but its cause was unknown.
Just like the breast, repeated stimulation of ectopic parasitism by parasites is a breeding ground for chronic inflammation and is also an important factor in the development of cancer.
On this basis, it was impossible for Kawei to spare any organ in the abdominal cavity. Surgery has also changed from simply treating portal hypertension to treating portal hypertension + investigating multiple intra-abdominal nodules.
The general abdominal cavity exploration has a clear sequence, starting from the liver, passing through the esophageal hiatus into the spleen area, then the stomach, duodenum, bile duct, pancreas, small intestine, appendix and ascending colon, transverse colon and greater omentum, descending colon, The sigmoid colon and rectum, and finally the bladder.
If you are a woman, you also need to check the uterus and appendages.
"Don't rush to give me the scalpel yet, I still have to do a checkup." Kawei refused the knife brought by Damirgaon and put his hands into Fernan's belly.
Because a series of mistakes caused a major reversal in the diagnosis before his eyes, and because there were no examination tools, Kawei became more and more cautious.
At the same time, he also hopes that the three assistants around him will be as cautious as he is now when doing surgery in the future: "The patient has upper gastrointestinal bleeding. Although it now seems to be varicose veins caused by portal hypertension, we still The possibility of rupture and bleeding of peptic ulcer needs to be ruled out." Kawei's hand probed from the pylorus of the stomach along the large and small curvature of the stomach to the cardia. If there is an ulcer causing severe bleeding, he should be able to feel something strange on the surface: "Generally, that At this time, the ulcer will penetrate deep into the muscle layer and even penetrate the entire gastrointestinal wall. At that time, there will be a special feeling of softness with a bit of hardness." After examining the surface of the stomach, his hand entered the lesser omental sac again. The back wall was not taken back until everything was checked out: "Next is the duodenum, ulcers may also occur here..." The half-hour operation started at 1:11 pm and lasted until 1:40 pm. Kavi
"Waste" on the so-called differential diagnosis and abdominal examination. After the investigation of gastroduodenal ulcers, there is also the investigation of egg deposition nodules.
If such a strange nodule is found in the abdominal cavity, considering the impact of the size of the nodule and the degree of inflammation on the organs, you need to choose to ignore palliation or aggressive surgical removal.
Exploration methods for abdominal masses and nodules are more complex than for ulcers. Ulcers are found in the gastrointestinal tract, so exploration can be completed by following the anatomy of the digestive tract.
However, nodules and masses produced by insect egg deposition or ectopic parasitism of insect bodies have no such rules to follow. It is completely a carpet-like search with no clear target.
Excluding the stomach and duodenum that have just been examined, the most troublesome and most likely problem left is the long intestine.
Schistosomiasis lives in the mesenteric blood vessels, and the intestine is the first territory they occupy when they expand outward.
The second is the deep kidney. Whether it is the adrenal gland or the kidney itself, once such nodules appear, there will be no good results.
So after avoiding the unexplorable porta hepatis and the gallbladder, spleen and pancreas that he had just touched, Kawei put all his focus on the lower abdomen.
For the intestines, Kawei tried his best, pinching every section with his hands, and finally found a huge nodule on the left descending colon.
"The position is a bit ambiguous, and the size is quite large." Kawei made a simple measurement with his fingers.
"5*4*1cm, it covers the intestinal wall like a lid. If it weren't for his severe hepatic ascites, it might have been touched during the physical examination." Herman asked: "How to deal with this ?”
"The size is not small, but the degree of invasion is not bad. It protrudes more on the outside and does not cause much damage to the inner part of the intestinal mucosa." Kawei carefully touched the degree of infiltration and explained: "If it continues to increase , or the infiltration is further deepened, which may lead to perforation of the intestinal wall, then surgical resection is necessary. Now we still have major surgery to do, so we should take this matter for a while." Herman nodded and followed the previous instructions After training, he prepared surgical instruments: "Then we will perform splenectomy according to the original plan." Kawei said: "Wait, there is still the last section of the rectum that has not been checked."
"I'm already checking the rectum..." Damirgang, who was standing aside, had continued to explore downwards according to Kavi's method. As he spoke, his fingertips suddenly touched something big.
Damirgang couldn't help but darken his face as he expanded the scope of his exploration: "There's something wrong with his rectum, and there seems to be a bigger nodule around it." [I'm too tired, this chapter and typos will be corrected tomorrow]
