2019年 · 第34卷第05期

The child was a 6-year-old girl. He was admitted to the hospital with the main complaint of "pus and blood stools for half a month, abdominal pain and fever for 1 week". One week ago, the child started abdominal pain, which was paroxysmal, accompanied by fever, and the maximum body temperature was 40 ℃. Physical examination: mental poor, thin, dehydrated appearance. The abdomen is slightly swollen, full of tenderness and muscle tension, no mass is touched, and the bowel sounds disappear. A small amount of white mucus is discharged from the digital anus. Routine blood test: WBC 25×10⁹/L, N 0.86. Color ultrasound examination: uneven fluid echo in intestinal space. Abdominal X-ray plain film: No free gas under the diaphragm was seen, and the abdominal fat line was unclear. Operation: A large amount of white mucous fluid in the abdominal cavity, multiple ulcers and perforations in the terminal ileum, ascending colon, transverse colon and descending colon, and the remaining part of the colon was pale and thin. The diseased intestine was removed, the abdominal cavity was cleaned, the rectum was preserved about 13 cm, and ileostomy was performed. Meropenem and metronidazole were used for anti-infection, anti-shock and symptomatic treatment after operation. He was cured and discharged 14 days after operation, and the intestinal fistula was closed six months after operation. Pathological report: Extensive semi-liquefaction necrosis of mucosal layer and submucosal layer of intestinal wall tissue, and more amoeba trophozoites can be seen in necrotic tissue (Figure 1，Figure 2)。

The patient, a 58-year-old male, went to a local hospital in September 2017 mainly because of "abdominal distension and loss of appetite after eating for more than 2 months". Gastroscopy showed chronic atrophic gastritis. Abdominal CT examination showed: small curved side tumor shadow, considering gastric stromal tumor. Multiple enlarged lymph nodes in the hilar. In October 2017, he visited the gastric oncology department of Tianjin Cancer Hospital. The patient denied a history of tuberculosis. Epidemiological examination showed: anti-Mycobacterium tuberculosis antibody negative, HIV negative. Enhanced CT showed: left lung apical cord, no tumor and tuberculosis shadow; Irregular thickening of cardia and adjacent small curves of stomach body; Multiple abnormally enhanced lymph nodes in the abdominal cavity, retroperitoneum, and mediastinum (Figure 1)。 Endoscopic ultrasonography showed that a bulging lesion was seen on the small curved side of the upper part of the stomach body. The five-layer ultrasound structure of the stomach wall at the lesion disappeared and thickened, and the lesion broke through the stomach wall and convexed to the abdominal cavity. Pathological examination of gastric wall tissue under endoscopic ultrasound showed chronic mucosal inflammation, local necrosis and exudation; The gastric mucosal tissue showed chronic inflammation. Clinical diagnosis of gastric cancer (cT4aN3M0). Exploratory laparotomy was performed. During the operation, it was found that the tumor was located next to the stomach wall on the small curvature of the stomach body, with serous infiltration, and the lymph nodes around the small curvature of the stomach were obviously enlarged. No lymph nodes were enlarged in the great curvature of the stomach, retroperitoneum and hepatic hilum, and no tumors and peritoneal dissemination in other abdominal and pelvic organs were observed. The tumor and surrounding lymph nodes were excised from the small curvature of the stomach body for 4 times for intraoperative frozen pathological examination. At the same time, a small amount of cheese-like substance exudated from the tumor was found (Figure 2), no tumor cells were found, suggesting granulomatous inflammation with large caseous necrosis, which was considered tuberculosis. Postoperative pathological examination showed granulomatous lesions (omentum and small curvature of stomach), considering the possibility of tuberculosis (Figure 3)。

The patient was a 62-year-old female. The patient was admitted to the hospital with "repeated abdominal pain for 1 month and aggravated for 2 days". The patient's abdominal pain was paroxysmal and tolerable, more than nighttime attacks, without radiant pain, independent of body position and eating, and the duration varied. There was no yellowing of skin and eye whites, no nausea and vomiting, and there were no abnormal signs. Hepatitis B (-), LDH ↑, tumor markers, blood, biochemical routine were all negative. Physical examination: buckling pain in the liver area (+), tenderness under the xiphoid process (+), no swelling of the lymph nodes in the whole body, and no obvious abnormalities were found. Imaging examination: CT plain scan showed low-density foci in the medial segment of the left lobe of the liver with poor boundary (FIG. 1A), the CT value was about 40 HU, the local liver contour was slightly swollen, and the enhancement degree in the arterial phase was similar to that in the normal liver parenchyma after enhancement, while the enhancement degree in the portal vein phase and the equilibrium phase was significantly lower than that in the liver parenchyma. The CT values in the three phases were about 63, 85, and 81 HU, respectively. At the same time, the lesions were clear and showed multiple nodular changes (FIG. 1B，Figure 1C，Figure 1D), the diameter of the larger nodule was about 18 mm, and there was no obvious sign of envelope. In the arterial phase, the arterial vessels of the left lobe of the liver could be seen passing through the lesion, and there was no obvious abnormal change in the morphology of the vessels. There was no obvious enlarged lymph node shadow in the retroperitoneum, and the adjacent left inner lobe hepatic parenchymal artery stage showed flaky mild enhancement. In addition, a hemangioma was seen in the caudate lobe of the liver. MRI plain scan and enhancement showed that the lesions showed low signal in T1WI, slightly high signal in T2WI, and obviously high signal in DWI. The enhancement and enhancement mode was basically similar to that of CT, and the slight enhancement of the lesions and the adjacent left inner lobe parenchyma of the liver was more clearly displayed in the arterial phase (Figure 2)。 Two-dimensional + contrast-enhanced ultrasound showed hypoechoic left inner lobe of the liver, with unclear size and boundary, and normal intrahepatic blood flow distribution. The caudate lobe of the liver is hyperechoic, with nodular enhancement from outside to inside (Figure 3)。 After completing the relevant preoperative examinations, peritoneal exploration and open liver tumor resection were performed on August 15, 2017. During the operation, the left lobe of the liver was large, and the S4 segment of the liver could reach a mass, indicating tumor resection. Postoperative pathology: (Left liver mass) diffuse large B-cell lymphoma with three gray-red nodules with a maximum diameter of 0.5~1.6 cm. Immunohistochemistry: CD20 (+ + +), Ki-67 (+) 90%, Bcl-2 (+ + +), c-myc (weak +), MUM-1 (+ +), CD21 (weak +), PAX-5 (+ + +).