Chapter 196 193. Reflection Differential Diagnosis Intra-abdominal Exploration

[The content of this chapter is more about clinical ideas, and it is difficult to show it with pictures. The hard core is greater than the previous cleft lip and palate. Those who are hard-hitting are all warriors. I personally recommend that you try to release this chapter in two days. If

If you can't eat it, you don't have to force yourself.]

There were no preoperative examination instruments in the 19th century, and everything was just the most basic palpation and auscultation.

Kavey had palpated Fernan three times in total. The first time he simply touched the liver to clarify the cause of breast hyperplasia.

He did make some mistakes, because he had reached this level of cirrhosis without surgery and the possibility of internal medicine treatment, so he did not palpate the spleen and did not measure ascites according to modern clinical standards.

The first palpation was determined by breast hyperplasia caused by cirrhosis.

In Carvey's view, cirrhosis has been sentenced to death by Fernan, and the subsequent mast hyperplasia is just a product under his strong request.

The second palpation came one month after the gao pills showed swelling.

At that time, the Gao Pill on the left side of Fernan suddenly swelled and swelled and painful. Kawei had a simple abdominal examination and gave the possible diagnosis of gao Pill cancer when the cirrhosis was confirmed. The pathology of the postoperative section was also confirmed to be a tumor.

He had a premonition that cirrhosis may be caused by metastasis of gao pill cancer.

Although it was only one month and it was strange that such signs changed, considering the environment at that time, malignant tumors emerged one after another and developed rapidly, and the progress of the disease course was still within an explanation.

That's it, until two days ago, Kavey gave Fernan a third palpation of the abdomen.

He had a systematic physical examination this time. The texture of the liver was still cirrhosis, and there was about 700-1000ml of liver ascites in the abdominal cavity. At the same time, the spleen was huge and the lower edge had reached the navel.

In fact, the final diagnosis did not deviate too much. It was still caused by cirrhosis, which affected the esophageal gastric vein and showed varicose rupture. The spleen enlargement was also caused by portal vein hypertension, which led to blood flow obstruction, and then spleen congestion and hypercongestion

It will become so huge. [1]

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

Firstly, the risk is too high, and the patient is likely to die on the operating table; secondly, the operation is not cured. Not only does the effect not meet expectations, but lifespan will also be affected by poor physical fitness.

The loss of cirrhosis protein is severe, and the immunity is definitely much worse, and the coagulation ability is also poor. [2]

Ascites infection alone is already a headache, and may cause continuous bleeding during surgery, which is a big trouble that needs to be avoided during surgery. This is also one of the reasons why modern surgery requires checking liver and kidney function, which is abnormal

The 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 cirrhosis. In the absence of liver transplantation, non-surgical symptomatic palliative treatment, such as extraction of liver ascites to relieve abdominal distension, is the best way to deal with it.

But in principle, Kawei made a mistake.

There are many reasons for this error.

Maybe I am gradually getting used to the arbitrary diagnostic style of the 19th century, maybe I am overwhelmed by my self-confidence, or maybe I was too late at the beginning. In short, if there are omissions in the examination, I need to reflect on it. Doctors are constantly absorbing it through this kind of repeated mistakes.

Only by teaching a lesson can one improve one's own level.

Looking back on the way, judgment errors may have subconsciously influenced Kawei's decision, and finally became one of the reasons why he proposed surgery.

Before cutting Fernan's belly, Kawei briefly formulated the surgical procedure. First, cut off the huge spleen, then do spleen and renal vein shunt. The specific diversion depends on the abdominal conditions, and finally treat the tumors in the liver and the esophageal and gastric fundus.

Varieties vein.

Removal of spleen and spleen renal vein shunt is a must, which can greatly delay the degree of varicose veins in the stomach. [4]

The latter two are different. Even in modern times, liver metastasis tumors are likely to not be operated. For vascular varicose, part of the stomach or the lesions of the lesions are often required to be cut off. This involves the problem of chest opening, and lack of opening

The breast ability is not necessarily a good choice now.

In addition, Kawei has other options, but the conditions are subject to limitations and it is really difficult to implement. [5]

Fernan's liver function cannot tolerate long-term surgery. Just cutting off the spleen has greatly increased the risk of postoperative death. After all, this is surgery, not anatomy, so you can save it. [6]

But after opening the abdomen, all the prerequisites established before became strange.

The spleen is indeed big enough, very big, so big that it shocks the Ai Ye San Sukki. Those who sit in front can also clearly see this spleen that occupies 1/3 of the abdominal cavity on the left.

As long as you understand a little bit of the abdominal anatomy, you will be frightened by this giant spleen.

Kawei explained the reason for the huge spleen. It didn't matter even if most people couldn't understand it, or he didn't care at all, because there was a troublesome problem waiting for him in front of Kawei.

The reason why cirrhosis is called cirrhosis is that the liver will become harder and its volume will shrink accordingly. The surface is uneven and the surface has nodules of different sizes. Just like a large piece of stinky tofu, the soft and tender part inside is heated for a long time.

Fried thoroughly, and finally wrinkled into a small piece, making it hard to get out of the mouth. [7]

However, the liver in Kawei's hand now only has a tough feeling on the edge and a little hard on the surface, but it does not visually feel like ordinary cirrhosis.

It has no nodules on the surface, the overall texture is pretty good, and the volume should be reduced but not significantly reduced.

The same disease will have completely different treatment methods due to different causes. Fernan's abdominal cavity was not as diagnosed by Kavey before, and the preset surgical plan becomes unfavorable. Even if it is really applicable, the surgery is based on the

With a cautious attitude, Kawei dared not take the knife rashly.

Differential diagnosis must be made to clarify the cause.

Doesn’t the liver shrinkage show that he does not have cirrhosis?

Without cirrhosis, there is a high probability that there will be no portal hypertension, and there will be no esophageal and gastric varicocele, so there is no way to start with the giant spleen.

Kawei stood by the operating table, his hands were still tinkering with his liver, and his head fell into deep thought. Perhaps it was simply portal hypertension, such as a tumor simply invading the portal vein system, causing portal vein obstruction, which caused varicose veins, hypersplenary spleen and congestion.

Is the tumor's cancer thrombus left in the portal vein system?

But this is a situation that only primary liver cancer can occur, and the operation is very troublesome. It requires finding the embolized blood vessels and incision and removal of the embol to relieve it. For Kawei, who has no examination methods, it is too difficult.

If this is true, it will be simple. You can cut off the spleen directly and perform diversion to close the abdomen. So Kawei still hopes to find out if there are other possibilities.

Another possibility is hilar cholangiocarcinoma, but he soon denied it again.

Hierarchical cholangiocarcinoma will definitely have bile duct obstruction. Jaundice is the first symptom, and the degree is much more serious than it is now. The liver parenchyma will shrink, but it will feel similar to this one.

Although upper gastrointestinal bleeding is not common, it does not mean that there is no. This type of bleeding is not a varicose vein caused by portal hypertension, but because cholangiocarcinoma will invade the duodenum outside. Once the intestinal mucosa is damaged, digestion will occur.

Canal bleeding.

Although Kavey had a physical examination and Fernan had jugular vein ventricular anger [8] and there must be problems with the liver duct, the possibility of gastrointestinal bleeding cannot be ruled out.

In fact, even if you ignore this, there is another question: how does ascites come from?

Ascites may occur unless intrahepatic metastasis occurs and cirrhosis occurs. But to reach this level, Fernan has long become a minor, and even his stool is white. [9]

If we start from the huge spleen, including ascites, portal hypertension, and upper gastrointestinal bleeding, these remind us of primary myelofibrosis.

But, not right.

Primary myelofibrosis is a blood disease. Because the bone marrow cannot produce hematopoiesis, the spleen needs to be used as a guest in the hematopoietic function. The spleen is a blood-storing organ. If it is responsible for hematopoiesis, it will cause the spleen to become hypertrophy. Therefore, the symptoms of this disease are mostly caused by hypersplenia.

cause.

If cirrhosis is 3+1=4, then myelofibrosis is 2+2=4.

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

Primary myelofibrosis will not directly damage liver cells, so the liver parenchyma will not collapse and become smaller due to damage. Instead, it will increase secondaryly due to congestion. Sometimes, after the spleen reaches its limit, the liver will also

Compensational production of hematopoietic foci, and sclerosis are completely different feelings.

Pancreatic cyst?

Even more wrong, pancreatic cysts are just simple compression and should not have liver lesions. Kawei was worried and turned the pancreas again. Although there was no tissue separation, the volume should be normal from the appearance and there were no cysts.

Kawei rejected three differential diagnoses in a row, and the remaining possible diseases were more inclined to internal medicine. He had no specific symptoms that might appear. This made Kawei begin to doubt the judgment of cirrhosis. Could it be that Feier

Nan's cirrhosis has just begun and is not as serious as varicose veins?

If you look at it this way, is the cause of bleeding gastric ulcer?

But this still cannot explain why so many ascites appear.

Kawei once again overturned his idea, started again, and first selected the main contradiction in the differential diagnosis. Fernan's liver shrinks and has no nodules, which shows that cirrhosis exists but is not serious, but at the same time, he has

There are many ascites, and only by starting from these two points can we find the correct cause.

There are many differential diagnosis points for ascites.

First, starting from the nature of ascites, it is divided into leaky, exudative, and bloody. [10]

Judging from the characteristics in the bottle, the possibility of the latter two is very low. Of course, it is impossible to see protein analysis and occult blood. There is no way 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 hepatogenic, gastrointestinal, nephrogenic, cardiogenic, portal vein obstruction, and malnutrition.

It is definitely wrong to have malnutrition. How can people get bad after eating so many people?

Cardiac-derived heart failure and other inflammations are not correct.

Nephritis? Renal failure? Regular urination and clear urine. At least Kawei can't see it yet.

Gastrointestinal tract? That is intestinal tuberculosis, intestinal dysplasia, Crohn's disease. Fernan's stool is normal, sometimes with blood, but more often it is black stool after bleeding from the upper gastrointestinal tract. And his intestines are swaying

In front of Kavi, it doesn't look like it.

Finally, after going around, I returned to the liver. No matter how I look at it, the ascites in this body should be liver-derived. But cirrhosis is not serious, so how can there be so many ascites? What is the problem?

In just one or two minutes, Kawei eliminated other problems that might arise one by one, and now only the liver and its portal system remain.

"I used to judge that it was liver cancer, but now it seems that the liver disease is not obvious." Kawei repeatedly touched the liver, his fingers even tried to explore it down, "I can't touch the tumor on the surface of the liver, so I hope to go down

Look around the liver duct.”

At this moment, Kawei's hand touched the tissue around the liver duct. First, there was a gallbladder with a certain degree of toughness, and then the liver duct inside. The liver duct should be surrounded by connective tissue, wrapping a large number of blood vessels in it, but Kawei touched
To be continued...