2019年 · 第34卷第08期

Case 1: A 24-year-old male was admitted with intermittent right upper abdominal pain for 5 d as the main complaint. Complaint: Skin sclera yellowing was discovered since childhood. Physical examination: skin sclera yellow stain, no liver palm, spider nevus, right upper abdominal tenderness positive. Laboratory Tests: Liver Function: AST: 26.5 U/L, ALT: 70.4 U/L, TP: 73.2 g/L, ALB: 45.5 g/L, TBiL: 103.0 μ mol/L, ALP: 91.0 U/L, DBiL: 87.5 μ mol/L, IBiL: 15.5 μ mol/L. No abnormalities were found in the comprehensive surgery, and no abnormalities were found in the examination of autoimmune liver disease antibody. Abdominal ultrasound showed that high-density shadows were seen at the bottom of the gallbladder, moving with body position. Diagnosis: gallstones with cholecystitis. Abdominal CT showed that there was no dilatation of intrahepatic bile duct, no dilatation of common bile duct, enlarged gallbladder, thick wall, and high density shadow in gallbladder cavity. Consideration: gallbladder stones with cholecystitis, no abnormalities on biliary MRI, laparoscopic cholecystectomy and liver biopsy. The liver tissue was black, uniform in texture and normal in size during the operation (Figure 1), liver tissue biopsy was taken, and postoperative pathology showed that the structure of liver acin was basically normal, liver cells were watery degenerated, and pigment particles (brown to black) were seen in liver cells (Figure 2)。 Hepatocyte steatosis, no punctate necrosis, Kupffer cell proliferation in hepatic sinus, no dilatation and fibrosis in portal area, no cholangitis, and a small amount of lymphocyte infiltration scattered in interstitium. Consistent with bilirubin metabolism abnormalities, consider Dubin-Johnson.

A 79-year-old male patient experienced upper abdominal pain and discomfort without obvious trigger 1 d ago, accompanied by nausea and vomiting, and the vomit was stomach content. He was given anti-inflammatory treatment, and the effect was average. Physical examination and laboratory examination showed no obvious abnormalities.

A 45-year-old male was first admitted to hospital in November 2014 due to "discovery of liver occupation"; Admission liver function grade A; HBSAg (+), hepatitis B DNA quantification negative, AFP 84.85 μ g/L; MRI: Left lobe occupation of liver (2.7 cm ×2.0 cm), cirrhosis (Figure 1), and there were no abnormalities in the other inspections. Excluding surgical contraindications, liver tumor resection was performed on November 25, 2014. The postoperative pathology was hepatocellular carcinoma. AFP was 9.3 μ g/L after operation, and CT showed the changes after hepatocellular carcinoma resection (Figure 2)。 After that, abdominal MRI and blood AFP were reviewed every six months.

The patient was a 61-year-old female. The patient was seen in Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology on August 23, 2018 due to distension and pain in the right upper abdomen. Abdominal CT showed that the gallbladder was slightly enlarged, nodular high-density shadows were seen in the gallbladder, and the gallbladder wall was slightly thickened. Diagnostic opinion: gallstones and cholecystitis. The patient refused surgery, and the symptoms were relieved after conservative treatment. Half a month later, he appeared again with distension and pain in the right upper abdomen and was admitted to our hospital. Physical examination: No yellowing staining of the skin and sclera, flat and soft abdomen, tenderness in the right upper abdomen, no rebound pain, and negative Murphy sign. There were no obvious abnormalities in blood routine, liver and kidney function and chest radiographs. Abdominal color Doppler ultrasound showed that the size of the gallbladder section was normal, the wall was not smooth, and strong echoic light clusters could be seen in the gallbladder cavity, followed by acoustic shadows. In order to further determine whether there are stones in the intrahepatic and extrahepatic bile ducts, MRCP examination was performed. MRCP showed that there was no stenosis, obstruction and dilation in the intrahepatic and extrahepatic bile ducts. See double gallbladder (Figure 1，Figure 2), the wall is thick, and stones can be seen in the cavity of both gallbladders. To improve the perioperative preparation, the patient underwent laparoscopic cholecystectomy (LC) on September 18, 2018. Intraoperative exploration showed that the cystic duct opened in the right wall of the common bile duct, and the cystic duct and gallbladder artery were separated and clipped and severed. When the ampulla of the gallbladder was continued to be separated to the hilar, a cystic deformity was seen. Combined with the preoperative MRCP results, it was considered as a mutant "small gallbladder" (Figure 3，Figure 4), it was confirmed that there were double gallbladders during the operation, and the two gallbladders had their own cystic ducts communicating with the common bile duct respectively. The two gallbladders were densely connected and wrapped by connective tissue. Postoperatively, the "large gallbladder" was about 8 cm ×2 cm in size, containing yellow-brown bile, and a brown stone with a diameter of about 2 cm ×1 cm was found in the cavity. The "small gallbladder" was about 2 cm ×1 cm in size, without obvious bile, and the cavity was a filled white small stone with a diameter of about 0.2 cm (Figure 5，Figure 6)。 He was discharged 8 days after surgery. Pathology: Under light microscope, inflammatory cell infiltration was seen in the wall of the larger gallbladder and the smaller gallbladder, and stones were seen in the cystic cavity (Figure 7，Figure 8), diagnosis: (1) cholecystolithiasis; (2) Chronic cholecystitis.

The patient was a 50-year-old male. He was admitted to the hospital on February 9, 2018 due to sigmoid colon cancer 3 years after surgery, and the examination found that the liver occupied half a month.

The patient was a 45-year-old female. Admitted to hospital because "physical examination found multiple spleen occupying space". Two-dimensional + contrast-enhanced ultrasound examination: Several hypoechoes were seen in the spleen, and the internal echoes were uniform. The larger one was about 3.0 cm ×2.1 cm in diameter, and the boundary was clear. Contrast-enhanced ultrasound showed that the hypoechoes in the spleen increased rapidly and unevenly from the periphery to the center, and gradually withdrew and increased continuously after 22 s. Imaging examination: CT plain scan showed that the spleen was slightly swollen locally, and multiple round shadows with slightly lower density were seen inside, with unclear boundaries. The boundaries of the lesions in the arterial phase after enhancement were clear, showing slow, uniform and mild continuous enhancement. MRI plain scan and enhancement showed that the mass showed a slightly high signal in T1-weighted imaging, and the signal of T1 lipid pressure sequence did not change significantly (FIG. 1A), the T2 lipid pressure sequence mass showed slightly low signal, and there was no obvious high signal change in the diffusion weighted imaging (DWI) lesion; The pattern of lesion enhancement after enhancement was basically similar to that of CT (FIG. 1B)。 Primary lymphoma of the spleen was diagnosed.