Nineteenth Century Medical Guide

Chapter 196 193. Reflective Differential Diagnosis Intra-abdominal Exploration
[The content of this chapter is more about clinical thinking, which is difficult to show with pictures. The degree of hard core exceeds that of the previous cleft lip and palate, and those who gnaw hard are all warriors.Personally, I suggest that you wait for two days before this chapter is released and you can try it out. If you can’t read it, don’t force yourself. 】

In the 19th century, there were no preoperative examination instruments, and everything only had the most basic palpation and auscultation.

Carvey palpated Fernan three times in total, the first time he simply touched the liver, in order to clarify the cause of the hyperplasia of mammary glands.

He did make some mistakes, and it was also because the liver cirrhosis reached such a degree that there was no need for surgery, and there was no possibility of medical treatment, so he did not palpate the spleen, nor did he measure the ascites according to modern clinical standards.

The judgment of the first palpation was mammary gland hyperplasia caused by simple liver cirrhosis.

In Carvey's view, liver cirrhosis has already sentenced Fernand to death, and the mammary gland hyperplasia removal afterward was only the product of his strong request.

The second palpation was one month after the gao pill appeared swollen.

At that time, Fernan's left gao pill was suddenly swollen and painful. Carvey did a simple abdominal physical examination. He gave a possible diagnosis of gao pill cancer when liver cirrhosis was confirmed.At that time, he had a premonition that liver cirrhosis might be caused by the metastasis of gao pill cancer.

Although it was only a short period of one month, it was strange to have such a large change in physical signs, but considering the environment at that time, malignant tumors emerged in endlessly and developed rapidly, and the progress of the disease was still within the scope of explanation.

In this way, until two days ago, Carvey gave Fernan the third abdominal palpation.

He did a complete set of physical examination systematically this time, the texture of the liver is still cirrhosis, and there is about 700-1000ml of liver ascites in the abdominal cavity.At the same time, the spleen is huge, and the lower edge has reached the position of the navel.

In fact, the final diagnosis did not deviate too much. It was still liver cirrhosis leading to portal hypertension, which in turn affected the esophageal and gastric fundus veins and ruptured varices.The splenomegaly is also due to portal hypertension, which leads to blood flow obstruction, and then hyperemia of the spleen becomes so huge. 【1】

In this case, if it is an ordinary patient, Carvey will still not recommend surgery.

One is that the risk is too high, and the patient is likely to die on the operating table; the other is that there is no possibility of a radical cure, not to mention that the effect cannot meet expectations, and the life expectancy will be affected by poor physical fitness.

The loss of liver cirrhosis protein is serious, the immunity must be much worse, and the blood clotting ability is also poor. 【2】

An ascites infection alone is already a very headache, and it may cause bleeding during the operation, which is a big trouble that needs to be avoided in surgery.This is one of the reasons why modern surgery needs to check the liver and kidney function. Abnormal liver function will greatly increase the risk of surgery. 【3】

From the results, it can be seen that Carvey did not make a mistake. This is the outcome of liver cirrhosis. In the absence of liver transplantation, non-surgical symptomatic palliative treatment such as extracting liver ascites to reduce abdominal distension is the best way to deal with it.

But in principle, Carvey was wrong.

There are many reasons for this error.

It may be that I gradually got used to the dogmatic diagnosis style of the 19th century, it may be that my self-confidence is bursting, or it may be that it was too late and I was too tired.In short, if there are omissions in the examination, you need to reflect on it. Doctors have to learn from these repeated mistakes in order to improve their own level.

Now looking back at this journey, the misjudgment may have influenced Carvey's decision subconsciously, and finally became one of the reasons why he suggested surgery.

Before cutting Fernan's stomach, Carvey simply formulated the operation procedure.The huge spleen is removed first, and then the spleen-renal vein shunt is performed. How to do the shunt depends on the condition of the abdominal cavity. Finally, the tumor in the liver and the varicose veins in the esophagus and gastric fundus are dealt with.

Spleen cutting and splenorenal vein shunt must be done, which can greatly delay the degree of gastric varicose veins. 【4】

Different people have different opinions on the latter two. Even in modern times, there is a high probability that liver metastases will not be operated on. For varicose blood vessels, it is often necessary to cut off part of the stomach or directly cut off the diseased esophagus.This involves the problem of opening the chest, which may not be a good choice now that the ability to open the chest is lacking.

In addition, Kavey has other options, but the constraints are really difficult to display. 【5】

Fernand's liver function could not tolerate long-term surgery, and the removal of his spleen alone had greatly increased the risk of postoperative death.After all, this is surgery, not dissection, so save as much as you can. 【6】

But after the laparotomy, all the premise established before became weird.

The spleen was indeed big enough, very big, so big that it shocked the first, second and third assistants around him.Those sitting in front of the audience can also clearly see the spleen occupying the left 1/3 of the abdominal cavity.

Anyone who knows a little bit about the anatomy of the abdominal cavity will be shocked by this giant spleen.

Carvey explained the reason for the huge spleen, even if most people can't understand it, or he doesn't care at all, because Carvey still has a disturbing problem waiting for him.

Cirrhosis of the liver is called cirrhosis because the texture of the liver will harden, the volume will shrink accordingly, and various nodules of different sizes will appear on the uneven surface.Just like a big piece of stinky tofu, the soft and tender part inside has been fried in hot oil for a long time, and finally shrunk into a small piece, which is too hard to eat. 【7】

However, the liver in Carvey's hands now only has toughness on the edges, and the surface is a bit hard, but visually it does not reach the feeling of ordinary liver cirrhosis.

It has no nodules on the surface, and the overall texture is not bad. The volume should have shrunk but the shrinkage is not obvious.

The same disease will have completely different treatment methods due to different causes. Fernan's abdominal cavity is not what Kavey had previously diagnosed, and the preset surgical plan may not be applicable.Even if it is really applicable, in line with the cautious attitude of surgery, Carvey would not dare to take the knife rashly.

It is necessary to make a differential diagnosis to clarify the cause.

Does the lack of significant liver shrinkage mean that he does not have liver cirrhosis?
Without cirrhosis, there is a high probability that there will be no portal hypertension, and there will be no esophageal and gastric varices, and there is no way to talk about a giant spleen.
Carvey stood by the operating table, his hands were still fiddling with the liver, his head lost in thought.It may be pure portal hypertension, such as tumors simply invading the portal venous system leading to portal vein obstruction, resulting in varicose veins and hypersplenism and congestion.

Is the tumor thrombus left in the portal vein system?

However, this is only possible with primary liver cancer, and the operation is very troublesome. It is necessary to find the embolized blood vessel, incise and remove the embolus to relieve it.For Kawi, who doesn't have any means of inspection, the difficulty is too high.

If this is the case, it would be simpler, cut off the spleen directly, and the abdomen can be closed after the shunt is done, so Kavey still hopes to find out if there are other possibilities.

Another possibility was hilar cholangiocarcinoma, but he quickly rejected it.

Hepatic hilar cholangiocarcinoma will definitely cause biliary obstruction, and jaundice is the first symptom, which is much more serious than what he is now.The liver parenchyma will shrink, but it feels similar to this.

Although upper gastrointestinal bleeding is uncommon, it does not mean that it does not exist.This kind of bleeding is not caused by varicose veins caused by portal hypertension, but because cholangiocarcinoma will invade outwards into the duodenum. Once the intestinal mucosa is damaged, gastrointestinal bleeding will occur.

Although Carvey had a physical examination and Fernan had distended jugular veins [8], there must be a problem with the hilum of the liver, but the possibility of gastrointestinal bleeding still cannot be ruled out.

In fact, even if you ignore this point, there is still a problem, how did the ascites come from?

Ascites may not occur unless intrahepatic metastases occur and cause cirrhosis.But if he really wanted to reach this level, Fernan would have become a minion long ago, and even his stool would be white. 【9】

Starting from the huge spleen, including ascites, portal hypertension, and upper gastrointestinal bleeding, these made Carvey think of primary myelofibrosis.

But it's not right either.

Primary myelofibrosis is a blood disease. Because the bone marrow cannot make blood, it is necessary for the spleen to play the role of hematopoietic function.The spleen is a blood storage organ. If it is responsible for blood production, it will cause hypersplenism, so the symptoms of this disease are mostly caused by hypersplenism.

如果肝硬化是3+1=4，那骨髓纤维化就是2+2=4。

The source is different, even if the other symptoms are similar, but the liver lesions are different.

Primary myelofibrosis does not directly damage liver cells, so the liver parenchyma will not shrink and become smaller due to damage, but will increase secondaryly due to congestion.Sometimes after the hypersplenism reaches the limit, the liver will also produce hematopoietic foci compensatoryly, which is completely different from cirrhosis.

Pancreatic cyst?

What's more wrong, pancreatic cysts are simply oppressive, and liver lesions should not occur.Carvey was worried, and turned over the pancreas again. Although no tissue separation was done, the volume should be normal from the appearance, without cysts.

A series of three differential diagnoses were rejected by Kawei, and the remaining possible diseases were more inclined to internal medicine, and he did not have any specific symptoms that might appear.This can't help but make Carvey start to doubt the judgment of liver cirrhosis. Could it be that Fernan's liver cirrhosis has just begun, and it is not serious enough to have varicose veins?
If you look at it this way, is the cause of the bleeding a gastric ulcer?

But this still doesn't explain why there is so much ascites.

Carvey once again overturned his own assumptions and started from the beginning, first selecting the main contradiction in the differential diagnosis.Fernand's liver shrank without nodules, which indicated that cirrhosis of the liver existed but was not serious, but at the same time he had a lot of ascites, and the correct cause could only be found from these two points.

Ascites has many points for differential diagnosis.

First of all, starting from the nature of ascites, it can be divided into exudative, exudative and bloody. 【10】

Judging from the properties 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.

Leakage means that the sieve is leaking, and there is a problem with the sieve, so it is divided into hepatic, gastrointestinal, renal, cardiac, portal vein obstruction, and malnutrition.

Malnutrition is definitely not right, how can so many people be malnourished after eating it.

Cardiogenic requires heart failure and other inflammation, which is not right.

Nephrogenic, nephritis?Kidney failure?The urination is regular and the urine is clear, at least Kavi can't tell yet.

Gastrointestinal?That is intestinal tuberculosis, intestinal dysplasia, Crohn's disease.Fernan's stools are fairly normal, sometimes with blood but more often black stools after upper gastrointestinal bleeding.And his intestines are right in front of Carvey's eyes, and it doesn't look like it.

In the end, it went around and went back to the liver. No matter how you look at it, the ascites in this body should be of liver origin.But cirrhosis of the liver is not serious. How could there be so much ascites? What is the problem?
In just one or two minutes, Carvey ruled out other possible problems one by one, and now only the liver and its portal system are left.

"I originally judged it to be liver cancer, but now it seems that the liver lesions are not obvious." Carvey touched the liver repeatedly, and even tried to probe down with his fingers. Look around the hepatic portal"

At this moment, Carvey's hand touched the tissue around the porta hepatis.First there is the gallbladder with a certain degree of toughness, and then there is the liver door inside.There should be connective tissue around the hilum of the liver, wrapping a large number of blood vessels in it, but what Kavey touches is not the usual connective tissue
This touch.
Carvey turned the liver over, exposing the gallbladder underneath, and at the same time, he could see many small blood vessels and lymphatic vessels that should not exist in the gallbladder triangle.This is the collateral circulation produced by the body in the case of hepatic portal vein obstruction. Because it looks like a sponge to the touch, it is called hepatic portal spongy degeneration.

Encountering this situation, it means that a large number of liver cells have been necrotic, and liver cirrhosis is a certainty.

There is no room for liver surgery, and even the dissection of the gallbladder triangle is meaningless, because there are too many collateral circulations and complicated, even Carvey can't be 100% accurate.Once the collateral circulation is injured, poor coagulation can make the bleeding difficult to stop.

One question after another, why does the seemingly innocuous liver cirrhosis have such severe spongy degeneration of the hepatic porta?
The changes in the body will not lie. The liver is indeed failing. It is definitely the decompensated period of liver cirrhosis. Megaspleen, hemorrhage, and ascites all make sense.So the point of contradiction has shifted again, why is such severe liver cirrhosis not obvious?

and many more
Suddenly a strange idea jumped into his mind.

Carvey stopped what he was doing, realizing that he seemed to have missed a very important cause.Although it is hardly seen in China in the 21st century, in the 19th century, it should be.
its not right!Europe should not have been affected by the disaster. Could it be that he has been to Egypt?

Carvey never asked about Fernan's travel history, because from the very beginning he believed that Fernan had liver cirrhosis caused by alcohol and tumors.Excessive interrogation cannot change the fact of liver cirrhosis, but it will make Kavey fall into an endless crisis without means of examination.

But it's pointless to worry about these things now, what he needs is a diagnosis.

The diagnosis lies in the stool examination, because the bleeding in the upper gastrointestinal tract covers up the bloody stool, and now there is no chance to do a microscopic examination, so we can only look for it from the viscera.

"Come help me dig out the mesentery together."

Kavi didn't expect that he would still have the opportunity to perform this kind of operation, so he quickly put down the liver in his hand, and set his target on the lower abdomen instead: "Fill out his intestines, turn out the mesentery, and move gently, I want to Look at the veins!"

The three assistants had no idea that Kavey had gone through a lot of thinking and investigation during this period, and had given up on keeping up with Kavey long ago. Even if they didn't understand his purpose of doing so, they would obey him unconditionally.

It is indeed difficult to inspect the intestinal tract in the lower abdomen through the upper abdominal incision. Fortunately, the incision distance is sufficient, and the mesentery and its surrounding vascular plexus can be well exposed. 【11】

Several people worked together to pull Fernan's intestines out of the body, placed them on a clean gauze pad, and then moved the intestines to the surroundings to expose the internal blood vessels.

Carvey saw what he was looking for at a glance. The last time he saw it was more than 20 years ago. It was a long time ago: "It really is here."

"What are we looking for?" Damirgang was puzzled.

"Look here carefully." Carvey pointed to the black lines in the mesenteric blood vessels, and finally clarified the cause of Fernan's all along: "These are bugs."【12】

(End of this chapter)