2021年 · 第59卷第03期

The patient, a 57-year-old female, was admitted to our hospital on December 6, 2019 due to "physical examination found that the liver occupied 4 d". The patient underwent abdominal CT examination in our hospital 4 days ago, and the results showed "cholangiocarcinoma of the caudal lobe of the liver, involving the hilar blood vessels and bile ducts, with intrahepatic bile duct dilation". For further treatment, the outpatient clinic was admitted to the hospital with "liver space-occupying lesions". The patient has clear spirit, good appetite, average sleep, no special defecation, no obvious weight loss, no fever, chills, abdominal pain and distension and other discomfort. Has a history of chronic hepatitis B and has not been treated with medication. Admission physical examination: respiratory rate 18 times/min; Body temperature 36.6 °C; Pulse 84 beats/min; Blood pressure 108/63 mmHg (1 mmHg =0.133 kPa); The mind was clear, the lips were not cyanotic, the superficial lymph nodes of the whole body were not swollen, and the skin and sclera were not yellowed. Cardiopulmonary physical examination is not special. The abdomen was flat and soft, with no tenderness in the whole abdomen, no rebound pain, and no mass. The liver and spleen were not reached under the costs, the gallbladder was not palpable, the Murphy sign was negative, the intestinal sound was 3~5 times/min, and the mobile voiced sound was negative. There was no edema in both lower limbs. There was no obvious tenderness in the bilateral ureteral running area. The pathological signs were negative. Main laboratory findings after admission: white blood cell count 5.4×10⁹/L, hemoglobin 118 g/L, platelet count 201×10⁹/L, percentage of neutrophils 65.3%, absolute number of neutrophils 3.56×10⁹/L; Potassium ion 4.12 mmol/L, AST (rate method) 366 U/L, ALT 255 U/L, alkaline phosphatase 449 U/L, glutamyl transpeptidase 1 336 U/L, albumin 39.6 g/L, total bilirubin 29.3 μ mol/L, direct bilirubin 9.3 μ mol/L, hypersensitive C-reactive protein 5.1 mg/L; CA125 49.30 U/ml, CA153 2.40 U/ml, CA19-9 480.01 U/ml, alpha-fetoprotein 4.93 μ g/L, carcinoembryonic antigen 1.48 μ g/L; HBV-DNA 2.20×10³U/ml. Enhanced abdominal CT examination: cholangiocarcinoma of the caudal lobe of the liver, involving hilar vessels and bile ducts, with intrahepatic bile duct dilatation (Figure 1）。 Enhanced MRI of the liver: cholangiocarcinoma of the caudal lobe of the liver, involving hilar blood vessels and bile ducts, with intrahepatic bile duct dilation; Small peritoneal metastases outside the inferior pole of the right liver; Pelvic malignancies are extensively implanted, with bilateral adnexes, lower uterine segment and cervical involvement (Figure 2）。 Admission diagnosis: Liver space-occupying lesion: liver cancer (stage IV)? Chronic hepatitis B.

The patient, a 49-year-old male, was admitted to the basic surgery department of our hospital on November 18, 2019 because "physical examination found that the duodenum occupied space for more than 2 months". The patient underwent gastroscopy in an external hospital 2 months ago and found multiple duodenal lesions, the largest of which was located on the anal side of the descending large nipple, which was a near-circumferential bulging lesion with uneven surface. Biopsy pathological examination showed chronic mucosal inflammation, papillary hyperplasia with low-grade dysplasia in part of the epithelium, and focal high-grade dysplasia. Tumor markers (-). Enhanced CT scan of the abdomen + three-dimensional reconstruction showed that the intestinal wall at the junction of the descending-horizontal segment of the duodenum was thickened, showing multiple nodules convex into the cavity, considering multiple adenomas, with a maximum diameter of about 4.5 cm (Figure 1）。 PET-CT showed that the metabolism of the descending duodenum was increased, and it was considered that it was malignant. During the course of the disease, fever, abdominal pain, abdominal distension, nausea and vomiting, melena, etc. were denied, and the spirit and stomach appetite were acceptable, and the weight did not change significantly. 19 years ago, total colectomy + partial small intestine resection + ileostomy was performed in an external hospital due to familial adenomatous polyposis, and the pathological results were unknown; Smoked 30 cigarettes/d for 30 years; Drink beer 1 000 ml/d for 20 years. The father, younger brother and son all found multiple colon polyps, among which the father suffered from rectal cancer and the younger brother saw multiple polyps in the duodenum. Physical examination at admission: an old surgical scar about 12 cm long was seen in the lower abdomen, and an ileostomy was seen in the right lower abdomen. The intestine was rosy, the defecation was unobstructed, and there were no positive signs in the rest. Laboratory tests: blood routine, coagulation, liver and kidney function were normal. Peripheral blood lymphocyte subsets: absolute number of lymphocytes 1 694/μ L (reference range: 1 752~2 708/μ L), absolute number of natural killer cells 115/μ L (reference range: 175~567/μ L), natural killer cell ratio 6.8% (reference range: 9.5% ~23.5%), absolute number of T lymphocytes 1 405/μ L (reference range: 1 185~1 901/μ L), T lymphocyte ratio 82.9% (62.6% ~76.8%), absolute number of CD4+ lymphocytes 1 005/μ L (reference range: 561~1 137/μ L), absolute number of CD8+ lymphocytes 342/μ L (reference range: 404~754/μ L), CD4/CD8 2.94 (reference range: 0.95~2.13). Admission diagnosis: multiple mass occupation in descending duodenum; Multiple adenomas; Focal high-grade intraepithelial neoplasia; Chronic atrophic gastritis with low-grade dysplasia; Familial adenomatous polyposis; After total colorectal resection; ileostomy; Left upper lobe nodule; Thyroid nodules.