2019年 · 第34卷第07期

A 76-year-old male was admitted to the hospital mainly because of "paroxysmal left lower chest pain for 3 days, accompanied by stopping defecation and exhaustion for 1 day". Past history: Radical esophagectomy for esophageal cancer 15 years ago. Physical examination: T 38.5 ℃, symmetrical thorax, about 20 cm old surgical scar in the left lower chest. The left breathing activity was weakened, the percussion was voiced, the speech tremor was enhanced, the auscultation breathing sound was weakened, wet rales were audible, and the intestinal sound was uncertain. Chest CT showed: left thoracic cavity and stomach, a large range of mixed density shadows could be seen in the left thoracic cavity, with unclear boundaries, multiple cystic cavities and gas-liquid levels, and intestinal hernia into the left thoracic cavity, except local intestinal perforation (Figure 1)。 Chest color ultrasound examination showed that there was an anechoic dark area from the 7th intercostal to the 11th intercostal of the left thoracic scapular line, with a depth of 87 mm, multiple septations were seen inside, and luminal echoes were faintly visible at the anterior axillary line of the thoracic cavity, but no peristalsis was seen. Emergency thoracotomy showed a large amount of purulent coating and pale yellow pleural effusion, with a volume of about 800 ml. After aspiration, the adhesions were carefully separated, and no diaphragm rupture and intestinal hernia into the chest cavity were found. A 0.5 cm ×0.5 cm rupture was seen 3 cm below the thoracogastric anastomosis (Figure 2)。 Intermittent full-thickness suture, free intercostal muscle, cut off the anterior end, keep the pedicled blood vessel at the posterior end, cover the muscle flap on the rupture surface, tighten the suture and tie the knot. Rinse repeatedly with a lot of iodophor and saline, and place 2 chest tubes. Postoperative pathology: There were more lymphocytes and plasma cells infiltrated in mucosal tissue, but no cancer cells were found. On the second day after surgery, the anus returned to exhaust and defecate. Re-examination of chest CT: A large range of density shadows can be seen in the left chest cavity, with a few cystic cavities and gas-liquid levels. Lipiodol X-ray showed that the contrast medium descended smoothly, and there was no stenosis, niche shadow or filling defect below the anastomosis.

A 10-year-old female was seen for "painful abdominal wall mass found for 2 days". Two years ago, he had an appendectomy for "gangrene perforation of appendicitis". Ultrasound examination: A 2.8 cm ×1.1 cm ×1.6 cm hypoechoic mass was detected in the fat layer and superficial muscle layer under the scar of the abdominal wall incision. The boundary was unclear, the shape was irregular, the internal echo was uneven, and the consistent very hypoechoic and multiple mass strong echoic calcifications were seen. Color Doppler: Rich colored blood flow was seen around and inside the mass (Figure 1)。 Pulsed Doppler: maximum blood flow velocity 10.4~16.7 cm/s, minimum resistance index 0.97, sometimes diastolic blood flow disappearance, sometimes reverse blood flow. A hypoechoic nodule was detected in the omental layer on the left side of the abdominal wall incision in the abdominal cavity, with a size of about 0.9 cm ×0.7 cm, aspect ratio>1, sharp edge, no envelope, mass-like strong echoic calcification in the center, accompanied by acoustic shadow at the back (Figure 2)。 Color Doppler: rich color blood flow is seen inside and around; Pulsed Doppler: Presents a low-velocity high-resistance blood flow spectrum. Ultrasound revealed: malignant lesion. Tumor resection was performed. During the operation, the abdominal wall tumor was located in the abdominal wall muscle tissue, connected to the upper surgical scar, without obvious boundary, and was tough in texture, with a size of about 5 cm ×4 cm ×2.5 cm and reached the peritoneum. Cut open the peritoneum, and see another tumor behind the anterior peritoneum in the abdominal cavity, with a size of about 1.5 cm ×1.0 cm. It is partially adhered and wrapped with the omentum, and clearly delimited from the intestine and other abdominal organs. Postoperative pathological report: chronic suppurative inflammation with abscess formation, peripheral fibrous tissue proliferation, consistent with the histological changes of Schloffer tumor (Figure 3)。

A 74-year-old female was admitted to the hospital mainly for "intermittent diarrhea for more than 1 year and aggravated for 1 month". Stool routine: WBC (+ +), RBC (-), low serum sodium and potassium. Colonoscopy showed multiple giant polyps of rectum and sigmoid colon, and pathological report: villous tubular adenoma with low-grade intraepithelial neoplasia. After anti-infection and rehydration treatment, the number of diarrhoea still reached more than 10 times/d. After admission, the patient's daily diarrhea volume was 400-1 000 ml, and watery stool. Normal food and intravenous fluid rehydration of 1 000 ml/d, potassium supplementation of 4 g/d, blood potassium was normal. Retest blood routine: WBC 5.92×10⁹/L, HGB 105 g/L. Stool routine: loose stool, WBC 5/HPF, RBC 0/HPF, occult blood (-). The fecal common bacteria smear, common bacteria culture, fungus culture and amoeba culture were all negative. Blood electrolyte : Na 132 mmol/L, K 3.06 mmol/L. Pelvic CT: The local intestinal tube at the junction of rectum and sigmoid colon was thickened, and the tube wall was unevenly thickened. Multiple nodular soft tissue density shadows were seen along the tube wall, and obvious enhancement was seen on enhanced scan. The involvement range of the lesion was about 9 cm, and the local intestinal lumen was eccentric stenosis (Figure 1)。 Colonoscopy: The surface of the intestinal lumen is villous and involved near the circumference at 8~25 cm from the entrance of the scope. More jelly-like matter in the intestinal lumen (Figure 2)。 Pathological report: villous tubular adenoma. Ultrasonic colonoscopy: Proliferative lesions in the intestinal lumen at the junction of rectosigmoid colon, mainly involving mucosa and submucosa, showing uneven and strong echo, the thickest part is 1 cm, the boundary between submucosa and muscle layer is unclear, the structure of serous layer is continuous and complete, and the echo is normal (Figure 3)。 Lower sigmoid colon and upper rectum resection were performed (see specimensFigure 4)。 Pathological report: villous tubular adenoma with low-grade intraepithelial neoplasia. Postoperatively, the patient had normal defecation and normal serum potassium. Follow-up after 2 years showed that the patient had no diarrhea, normal serum potassium and normal colonoscopy.

Example 1Female, 50 years old, was admitted to hospital mainly for "abdominal pain with occasional vomiting for more than 1 year". Pathological examination: (gastric angle bite examination) poorly differentiated adenocarcinoma, some of which were signet ring cell carcinoma. Endoscopic ultrasound showed: ulcer type hypoechoic mass of gastric angle, considered as stage T4 cancer. X-ray angiography of upper gastrointestinal tract showed space-occupying lesions in gastric angle, considering gastric cancer, and compression changes in upper esophagus. Renal ultrasound showed that there was a medium-strong echoreflex area in the upper pole of the left renal cortex, with a clear boundary and a size of 5.8 cm ×6.6 cm ×5.4 cm. Abdominal and pelvic CT showed thickening of the gastric wall in the gastric angle area and adjacent gastric body, which was considered gastric cancer; Left upper pole lesion of kidney (Figure 1)。 Abdominal MRI revealed a mass at the upper pole of the left kidney, with an extent of 6.4 cm ×5.2 cm, which was considered as renal cancer. Case 2, a 71-year-old female, was admitted to the hospital mainly because of "abdominal distension after eating for more than 1 year, aggravated for 2 to 3 months". Endoscopic ultrasonography revealed: (1) multiple hypoechoic masses of muscularis propria in the fundus of the stomach, with sizes of 7 mm ×4 mm and 3 mm ×4 mm, respectively, which were considered as stromal tumors; (2) Hypoechoic mass in the middle and lower part of the stomach body, which is considered as stage T2 cancer. Pathological report: signet ring cell carcinoma (of the stomach body). X-ray of upper gastrointestinal tract showed that the mucosa on the small curved side of gastric antrum was rough and disordered. Abdominal and pelvic ultrasound showed that there was a hypoechoic reflex area in the lower pole of the left kidney, with uneven echoes, 4.4 cm ×3.6 cm in size. CT examination showed: (1) Irregular thickening of the gastric wall near the gastric angle on the small curved side of the gastric body, which was considered as gastric cancer. Local small nodular thickening of the stomach wall at the base of the stomach; (2) Abnormal density tumor shadow was seen at the lower pole of the left kidney, partially convex, with unclear boundary, 4.0 cm ×3.7 cm ×4.6 cm in size. After enhancement scan, it showed obvious uneven enhancement, the surrounding fat layer was turbid, and the gap with the psoas major muscle was unclear, which was considered as renal cancer (Figure 2)。 Abdominal MRI showed a mass at the lower pole of the left kidney, which was considered to be renal cancer.

A 27-year-old male was admitted for "intermittent hematochezia for 3 days and aggravated for 1 h". Physical examination: blood pressure 124/62 mmHg, anemia, lower abdominal tenderness, no rebound pain and muscle tension, no palpable mass, and attenuated intestinal sounds. Blood routine: RBC 3.55×10¹²/L, Hb 109 g/L. Symptomatic supportive treatment was given after admission. Blood routine reexamination 1 h after admission: RBC 2.67×10¹²/L, Hb 82 g/L. Blood transfusion therapy was given. Considering the patient's rapid bleeding and large amount of bleeding, total abdominal enhanced CT examination was performed after active anti-shock: contrast medium could be seen in the terminal ileum entering the cavity of the small intestine, and the bleeding site was considered to be located at the terminal ileum (Figure 1)。 Then, catheterization under DSA was performed in the emergency department, and catheterization was performed through the femoral artery in each branch of the superior mesenteric artery, and local contrast spillage was seen in the branch of the ileocolic artery (Figure 2), excluding bleeding from other parts, placing an indwelling angiography catheter at the bleeding site and fixing the body surface. An exploratory laparotomy was performed, and a small incision of the right lower abdomen through the rectus abdominis muscle was taken, and dark red blood was found in the small intestine about 100 cm from the ileocecal region. During the operation, contrast medium (methylene blue) was injected through DSA catheter. Under direct vision, the contrast medium spilled into the intestinal lumen, and local small intestine and its mesangium were blue stained (Figure 3)。 Partial resection of small intestine and intestinal anastomosis were performed after the hemorrhage site was defined. Examination of the excised specimen showed: small intestinal diverticular hemorrhage (Figure 4)。 The patient recovered well after surgery and was cured and discharged after 1 week.

A 30-year-old male was admitted to the hospital with the main complaint of "sudden hematochezia accompanied by nausea and vomiting for 3 days". The patient experienced nausea and vomiting after eating. The vomit was initially food residue, then about 200 ml of coffee-colored liquid substance, then felt abdominal pain and discomfort, defecated about 300 ml of dark red stools, and gradually appeared pale complexion, cold hands and feet, sweating all over the body and other symptoms. Physical examination: blood pressure: 90/60 mmHg, heart rate: 140 beats/min. Blood routine : Hb75 g/L. Gastroscopy and abdominal ultrasound examination showed no abnormalities. Abdominal plain CT scan: rectal dilatation and pneumatosis. During the symptomatic treatment, a large amount of dark red bloody stool was defecated twice, about 300 ml each time, and was transferred to our hospital after blood transfusion treatment. Physical examination: anemic face, flat abdomen, no gastrointestinal pattern and peristaltic wave, soft abdomen without tenderness, no palpable mass, no muscle tension, rebound pain, intestinal sounds 5~7 times/min, no abnormal intestinal sounds. Routine blood test: RBC 3.01×10¹²/L, Hb: 87 g/L, WBC: 10.51×10⁹/L. After symptomatic and supportive treatment, the patient's blood pressure was maintained at around 95/50 mmHg, and the reexamination Hb was 85 g/L. During the hospitalization, there was still a small amount of blood in the stool intermittently, about 30 ml each time. The patient underwent gastroscopy and fiberoptic colonoscopy immediately after admission, and no abnormalities were found. Capsule endoscopy was performed: a spherical bulge was seen in the proximal segment of the jejunum, about 1.2 cm ×1.2 cm in size, and the surface mucosa was smooth, covering the normal mucosa (Figure 1), no ulceration and bleeding were observed, and multiple submucosal blood vessels were exposed, tortuous, and no obvious dilatation. Diagnosis: Submucosal protuberance of jejunum, gastrointestinal stromal tumor (GIST)? Vascular malformations of the small intestine. After laparoscopic exploration, multiple tumors were seen in the jejunum from 10 cm to 120 cm from the Tritz ligament, with intact capsules and clear boundaries. The largest one was about 2.0 cm in diameter and the smallest one was about 0.3 cm in diameter (Figure 2)。 Eight tumors of different sizes were removed by ultrasonic scalpel and then sutured. Postoperative pathological report: The gray and white matter of the section is slightly tough, mainly spindle cells. Immunohistochemical staining results: CD117 (+) (Figure 3), CD34 (weak +), Ki-67 (3% +), Dog-1 (+), CK (-), Vimentin (+), SMA (-), S-100 (-), β-catenin (-), PHH3 [individual cells (+)], diagnosis: small intestinal stromal tumor (multiple), mitotic<5/50HPF.

A 59-year-old male was admitted to hospital due to upper abdominal discomfort for more than 7 months and intermittent skin sclera yellowing for 3 months. The patient experienced upper abdominal discomfort more than 7 months ago. Gastroscopy: huge submucosal bulge on the large curved side of the stomach body; Abdominal CT: pseudocyst in the omental sac and around the body and tail of the pancreas, considered to be caused by pancreatitis. Endoscopic pancreatic pseudocyst puncture and nasal cyst drainage were performed. The drainage fluid laboratory test showed that amylase was 57 740 U/L, carcinoembryonic antigen was 17.25 ng/ml, and CA19-9 was>1 000 U/ml. The drainage tube was removed after the drainage fluid was significantly reduced. The symptoms recurred 3 months ago, followed by yellowing of the sclera and skin, enhanced CT of the abdomen: cystic lesions around the body and tail of the pancreas, and stenosis of the end of the common bile duct (Figure 1)； Endoscopic retrograde cholangiopancreatography showed that the pancreatic cyst communicated with the main pancreatic duct, the pancreatic head was edema, and the end of the common bile duct was compressed and narrowed. The common bile duct and pancreatic duct stents were placed. Bilirubin and blood and urine amylase gradually decreased to normal after operation, and skin and sclera yellowing appeared again 2 days ago. MRI + MRCP: abnormal signal of pancreatic uncinate process, pancreatic cancer may (Figure 2)。 The patient had severe symptoms of obstructive jaundice, and nasobiliary drainage was performed on the second day after admission. Considering that the patient's pancreatic head occupied space, the possibility of malignancy was high. After the patient's general condition improved, exploratory laparotomy was performed. During the operation, the tumor was mainly located in the pancreatic head, with a diameter of about 2 cm and a hard texture. The body and tail of the pancreas were tough, with obvious edema around them, and the resorption of pancreatic pseudocyst disappeared. A puncture biopsy of pancreatic mass was performed. Intraoperative frozen pathology showed highly suspicious cancer, but preoperative imaging data did not suggest tumor metastasis. Radical pancreatic head and duodenectomy was performed. A gray-white mass with a diameter of about 2 cm was visible on the head of the pancreas, which was hard in texture, unclear in boundary and without envelope. Postoperative pathology: moderately to poorly differentiated adenocarcinoma of the pancreas (Figure 3), about 1.8 cm in diameter, invaded the lower end of the common bile duct and duodenum, and cancer metastasis was seen in the surrounding lymph nodes (1/9). The patient was discharged successfully after surgery.

aggressive fibromatosis (AF), also known as hard fibroma or desmoid fibroma, is a rare tumor of mesenchymal origin with an incidence of 5 to 6 parts per million^[1]。 AF is benign in pathological features, and the tumor does not metastasize distantly, but presents local invasive growth. AF can occur in myofascial tissues of the whole body. AF can be divided into abdominal wall type, intraabdominal cavity type and extraabdominal type according to the different growth positions, among which abdominal wall type is the most common^[2]。 Because the location of AF growth is related to its biological behavior, it affects the choice of treatment and prognosis. Of all AFs, the abdominal wall AF had the best prognosis, followed by intra-abdominal AF, while the extraabdominal AF had the worst prognosis^[3]。 The treatment status of abdominal wall AF is reviewed below.