A review of the patient’s old notes revealed that at the time of the injury the spleen was removed surgically, but it was not appreciated that there was a small rupture of the dome of the left hemidiaphragm. The patient gradually developed a hernia through which bowel could enter, producing the “hump” on the diaphragm seen on the chest radiograph.
Because this injury occurred many years ago and the patient has been asymptomatic, it is unlikely that the patient will come to any harm and was discharged.
A medical student was asked to inspect the abdomen of two patients. On the first patient he noted irregular veins radiating from the umbilicus. On the second patient he noted irregular veins, coursing in a caudal to cranial direction, over the anterior abdominal wall from the groin to the chest. He was asked to explain his findings and determine the significance of these features.
In the first patient the veins were draining radially away from the periumbilical region. In normal individuals, enlarged veins do not radiate from the umbilicus. In patients with portal hypertension the portal venous pressure is increased as a result of hepatic disease. Small collateral veins develop at and around the obliterated umbilical vein. These veins pass through the umbilicus and drain onto the anterior abdominal wall, forming a portosystemic anastomosis. The eventual diagnosis for this patient was cirrhosis of the liver.
The finding of veins draining in a caudocranial direction on the anterior abdominal wall in the second patient is not typical for veins on the anterior abdominal wall. When veins are so prominent, it usually implies that there is an obstruction to the normal route of venous drainage and an alternative route has been taken. Typically, blood from the lower limbs and the retroperitoneal organs drains into the inferior vena cava and from here to the right atrium of the heart. This patient had a chronic thrombosis of the inferior vena cava, preventing blood from returning to the heart by the “usual” route.
Blood from the lower limbs and the pelvis may drain via a series of collateral vessels, some of which include the superficial inferior epigastric veins, which run in the superficial fascia. These anastomose with the superior, superficial, and deep epigastric venous systems to drain into the internal thoracic veins, which in turn drain into the brachiocephalic veins and the superior vena cava.
After the initial inferior vena cava thrombosis, the veins of the anterior abdominal wall and other collateral pathways hypertrophy to accommodate the increase in blood flow.
A 52-year-old woman visited her family physician with complaints of increasing lethargy and vomiting. The physician examined her and noted that compared to previous visits she had lost significant weight. She was also jaundiced, and on examination of the abdomen a well-defined 10-cm rounded mass was palpable below the liver edge in the right upper quadrant (Fig. 4.185).
The clinical diagnosis was carcinoma of the head of the pancreas.
It is difficult to appreciate how such a precise diagnosis can be made clinically when only three clinical signs have been described.
The patient’s obstruction was in the distal bile duct.
When a patient has jaundice, the causes are excessive breakdown of red blood cells (prehepatic), hepatic failure (hepatic jaundice), and posthepatic causes, which include obstruction along the length of the biliary tree.
The patient had a mass in her right upper quadrant that was palpable below the liver; this was the gallbladder.
In healthy individuals, the gallbladder is not palpable. An expanded gallbladder indicates obstruction either within the cystic duct or below the level of the cystic duct insertion (i.e., the bile duct).
The patient’s vomiting was related to the position of the tumor.