2021年 · 第59卷第10期

Male, 71 years old, was admitted to our hospital on September 3, 2020 due to "skin sclera yellowing for half a month". The patient underwent orthotopic classical liver transplantation in our hospital in 2002 due to hepatocellular carcinoma. After operation, he took tacrolimus (1 mg, once/d), and the plasma concentration was maintained at about 1 μ g/L. The liver function was good, and there was no obvious rejection reaction. Previous history of diabetes for 18 years, injection of insulin therapy, glycemic control can. At the beginning of April 2020, the patient came to our hospital due to sudden right upper abdominal pain, jaundice and fever. The bilirubin and inflammatory indicators were significantly increased. The MRI results of the liver showed stones in the lower common bile duct and dilated intrahepatic and extrahepatic bile ducts. He was admitted to the hospital with acute obstructive suppurative cholangitis, and the stones were removed by endoscopic retrograde colangiopancreatography (ERCP). At the same time, the blood routine and liver function returned to normal after anti-inflammatory, liver protection and symptomatic treatment, and he was discharged. In August 2020, the patient developed sclera and skin yellowing with progressive exacerbation, without abdominal pain and fever. CT examination of the upper abdomen was performed in this visit. The results showed that the intrahepatic and extrahepatic bile ducts were dilated, the end of the common bile duct was not clear, and the high-density shadow in the common bile duct disappeared. Liver function tests: total bilirubin 237.09 μ mol/L, direct bilirubin 206.93 μ mol/L, AST 43.7 U/L, ALT 34.5 U/L, glutamyl transpeptidase 338 U/L, alkaline phosphatase 451 U/L. Tumor markers: CA19-9>1 000 μ g/L, carcinoembryonic antigen 17.9 μ g/L. ERCP results showed that the common bile duct was dilated without significant filling defects (Figure 1）； Tumor cells were seen on bile duct smear. Preoperative diagnosis: (1) Malignant tumor of lower common bile duct? (2) Ampullary cancer? (3) Malignant tumor of duodenal papilla? (4) After liver transplantation; (5) Diabetes.

Male, 53 years old, was admitted to the hospital on April 18, 2020 due to "abdominal distension 8 d". The patient denied a history of schistosomiasis. Physical examination: the spleen is accessible under the costs, flat around the umbilicus, hard in texture; Abdominal distension is mainly on the left side. Laboratory results: Mild anemia (hemoglobin 104 g/L), platelet count, coagulation function, complete set of bacteria, viruses, fungi, parasites, autoimmune-related antibodies, HIV etiology test, gastroscopy no obvious abnormalities. The results of abdominal CT examination showed that the spleen was significantly enlarged, the spleen density was unevenly reduced, multiple irregular lower density areas were seen inside, and nodular vascular-like enhancement was seen in the arterial phase after enhancement (Figure 1）。 Bone marrow puncture and biopsy showed no obvious abnormalities. Ultrasound findings showed multiple hypoechoic nodules in bilateral neck, axilla, groin and left clavicle, which were considered as lymph nodes. The results of right inguinal lymph node biopsy showed that the sectional lymph node structure remained, and it was considered that there was lymph node reactive hyperplasia. The results of PET-CT examination showed that the spleen was significantly enlarged, and there was no obvious shadow of abnormal increased glucose metabolism and abnormal density space-occupying shadow. The shadow of lymph nodes with increased glucose metabolism in nodular focuses could be seen in both hilars, considering the possibility of lymph node reactive hyperplasia, and no shadow of abnormal increased glucose metabolism was seen in other areas.