Association of Recanalization of the Left Umbilical Vein With Umbilical Hernia in Patients With Liver Disease
Bibliographic record
Abstract
Transmission of portal hypertension to the umbilical region via a recanalized left umbilical vein may explain the higher prevalence of umbilical hernia than inguinal hernia in men with advanced liver disease. Images from a computed tomography of a 49-year-old man with cirrhosis and hepatocellular carcinoma from hepatitis C virus were reconstructed in 3-dimensional color format. Rupture of the web between the left portal vein and the recanalized left umbilical vein is seen. Penetration of abdominal wall by the varices at the umbilicus is demonstrated. A dilated inferior epigastric vein is seen to drain the varices inferiorly to the right external iliac vein. Umbilical hernia in the general population occurs more frequently in women than men. The difference in prevalence is probably due to pregnancy-related intra-abdominal hypertension and abdominal wall effacement. Umbilical hernia is frequently seen in patients with advanced liver disease. The mechanism is again thought to be high intra-abdominal pressure from ascites and abdominal wall muscle wasting. In men without liver disease inguinal hernia is more common than umbilical hernia, whereas the opposite is true in the presence of liver disease. Abdominal hypertension and muscle wasting promotes both types of hernia. The higher rate of umbilical hernia seen in patients with liver disease may be due to the transmission of portal pressure via the recanalized umbilical vein to the umbilicus.1 This notion is supported by the reduction of umbilical hernia size after portosystemic shunt placement.2 A 49-year-old man with ascites and an umbilical hernia underwent computed tomography of the abdomen during assessment for liver transplantation. He had end-stage liver disease from hepatitis C virus. Blood-test results included the following: albumin, 27 g/L; bilirubin 32 μmol/L; international normalized ratio, 1.6; and platelet count, 79 x 109/L. An alpha fetoprotein level of 49 μg/L and an ultrasound were suspicious for hepatocellular carcinoma. The patient was taking diuretics to control ascites. Computed tomography showed a 2-cm hepatocellular carcinoma in the right lobe of the liver. The umbilical hernia contained large varices that were connected to a dilated tortuous left umbilical vein (Figs. 1, 2 and 3). The varices communicated systemically with the right external iliac vein via the right inferior epigastric vein, which was also dilated. Computed tomography of a patient with end-stage liver disease and hepatocellular carcinoma demonstrating (A) communication between the left umbilical vein and the left portal vein, (B) tortuous path of the dilated left umbilical vein, (C) penetration of the varices through the abdominal wall at the umbilicus, and (D) communication inferiorly to the right external iliac vein via the inferior epigastric vein. Reconstructed 3-dimensional computed tomographic color image of the abdomen (right lateral view) showing varices within an umbilical hernia, communicating superiorly with a tortuous recanalized left umbilical vein and inferiorly with the right inferior epigastric vein. Oblique views of the 3-dimensional color reconstruction showing the communication between the left umbilical vein and the left portal vein. (see the online Supplementary Material at http://www.interscience.wiley.com/jpages/1527-6465/suppmat/) These images demonstrate the ability of chronic portal hypertension to rupture the web between the left portal vein and the obliterated left umbilical vein, resulting in distension and lengthening of the left umbilical vein. Dilated portosystemic connections at the umbilicus become varices. It is reasonable to believe that hypertension in these vessels contribute to weakening of the abdominal wall and herniation at the umbilicus. Ligation of communicating vessels should be considered if varices are encountered during umbilical hernia repair in patients with advanced liver disease. The patient received an orthotopic liver transplantation. A 2-cm hepatocellular cancer in a cirrhotic liver was confirmed by histology. The hernia, which has reduced in size, was repaired 4 months after transplantation. This article contains supplementary material, which may be viewed at the Liver Transplantation website at http://www.interscience.wiley.com/jpages/1527-6465/suppmat/ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".