The liver function of patients with suspected liver disease is poor, as demonstrated by the patient’s jaundice—an inability to conjugate bilirubin. Importantly, because some liver products are blood-clotting factors involved in the clotting cascade, the blood-clotting ability of patients with severe liver disease is significantly impaired. These patients therefore have a high risk of bleeding.
Another issue is the presence of ascites.
Normally the liver rests against the lateral and anterior abdominal walls. This direct contact can be useful for care after a liver biopsy has been obtained. After the procedure, the patient lies over the region where the biopsy has been obtained and the weight of the liver stems any localized bleeding. When patients have significant ascites, the liver cannot be compressed against the walls of the abdomen and blood may pour freely into the ascitic fluid.
The patient has ascites, so another approach for a liver biopsy must be considered.
The patient was referred to the radiology department for a transjugular liver biopsy.
The skin around the jugular vein in the neck was anesthetized. Access was obtained through insertion of a needle and a guidewire. The guidewire was advanced through the right internal jugular vein and into the right brachiocephalic vein. It entered the superior vena cava, was passed along the posterior wall of the atrium, and entered the superior aspect of the inferior vena cava. A catheter was inserted over the wire and directed into the right hepatic vein. Using a series of dilators, the hole was enlarged and a biopsy needle was placed over the wire and into the right hepatic vein. The liver was biopsied through the right hepatic vein and the biopsy sample was removed. A simple suture was used to close the internal jugular vein in the neck, and minor compression stemmed any blood flow.
Assuming that the biopsy needle does not penetrate the liver capsule, it is not important how much the patient bleeds from the liver, because this bleeding will enter the hepatic vein and is immediately returned to the circulation.
A 30-year-old man had a diffuse and poorly defined epigastric mass. Further examination revealed asymmetrical scrotal enlargement.
As part of her differential diagnosis, the resident considered the possibility that the man had testicular cancer with regional abdominal para-aortic nodal involvement (the lateral aortic, or lumbar, nodes).
A primary testicular neoplasm is the most common tumor in men between the ages of 25 and 34 and accounts for between 1% and 2% of all malignancies in men. A family history of testicular cancer and maldescent of the testis are strong predisposing factors.
Spread of the tumor is typically to the lymph node chains that drain the testes.
The testes develop from structures adjacent to the renal vessels in the upper abdomen, between the transversalis fascia and the peritoneum. They normally migrate through the inguinal canals into the scrotum just before birth. The testes take with them their arterial supply, their venous drainage, their nerve supply, and their lymphatics.
A computed tomography scan revealed a para-aortic lymph node mass in the upper abdomen and enlarged lymph nodes throughout the internal and common iliac lymph node chains.
Assuming the scrotal mass was a carcinoma of the testes, which would normally drain into the lateral aortic (lumbar) nodes in the upper abdomen, it would be very unusual for iliac lymphadenopathy to be present.
Further examination of the scrotal mass was required.
A transillumination test of the scrotum on the affected side was positive. An ultrasound scan revealed normal right and left testes and a large fluid collection around the right testis. A diagnosis of a right-sided hydrocele was made.