2021年 · 第36卷第03期

A 55-year-old female was seen for "sudden severe abdominal pain for 1 d". Physical examination: heart rate 109 beats/min, blood pressure 110/75 mmHg (1 mmHg =0.133 kPa), total abdominal tenderness with rebound pain and muscle tension, especially on the left side of the abdomen, and the lower edge of the spleen was located in the three horizontal fingers under the costs. Past history: Pancreaticoduodenectomy due to duodenal neuroendocrine carcinoma 2 and a half years ago, and primary biliary cirrhosis was diagnosed 1 year ago. History of trauma denied. Blood routine: white blood cells 18×10⁹/L, hemoglobin 99 g/L; Liver function: AST 149 U/L, ALT 87 U/L, total bilirubin 39.4 μ mol/L, direct bilirubin 25.4 μ mol/L. Whole abdominal enhanced CT: the spleen volume increased significantly; Postoperative changes of pancreaticoduodenum, tortuous increased vascular shadows were seen around the small intestine adjacent to the gastrointestinal anastomosis (Figure 1), a vascular shadow can be seen locally continuing to the left abdominal wall (Figure 2)。 Diagnostic abdominal puncture extracted dark red non-coagulating blood, so he was admitted to the undergraduate intensive care unit with "abdominal hemorrhage and diffuse peritonitis". Half an hour after hospitalization, the patient's blood pressure dropped and his heart rate accelerated. Active bleeding was considered. A large number of dark red blood clots and bloody effusion were found in the abdominal cavity during emergency surgery, with a volume of about 2,000 ml. The spleen was obviously enlarged and congested, the spleen envelope was intact, and the gastrointestinal anastomosis veins were obviously varicose and adhered to the left abdominal wall, showing obvious active bleeding. After separating the adhesion, the abdominal wall and the ruptured veins of the gastrointestinal anastomosis were sutured, and the veins with obvious varices after gastrointestinal anastomosis were sutured one by one. Postoperative diagnosis: bleeding from ruptured varices of gastrointestinal anastomosis. The patient was transferred to intensive care, the tracheal intubation was withdrawn on the 2nd postoperative day and discharged on the 8th postoperative day.

A 47-year-old male was admitted to hospital for one month due to repeated low back pain and had a history of hepatitis B for more than 20 years. CT examination in the local hospital found that the liver occupied space and the left waist occupied space. The left lumbar mass was treated by microwave ablation in a local hospital. Pathology: (left lumbar mass) malignant tumor, immunohistochemical Hepatocyte (+ + +), CK (+ + +), EMA (-), CD99 (scattered +), CD34 (vascular +), CD31 (vascular +), AFP (-), Ki67 (+ +, 20%), P53 (+), suggesting metastatic hepatocellular carcinoma. Admission examination: HBsAg (+), HBeAb (+), HBcAb (+); AFP: 45.14 ng/ml. Abdominal MRI: space-occupying lesions in the right liver, with a high possibility of hepatocellular carcinoma, enlarged lymph nodes in the hilar region, and metastases in the left psoas major and erector spinal muscles. Lumbar MRI: Mass in left psoas major and erector spinal muscle considered metastatic tumor (Figure 1)。 Lumbar color ultrasound contrast enhancement: After ablation of hypoechoic mass in the left psoas major muscle, enhancement was seen at the medial local margin. The patient underwent cholecystectomy and hepatectomy under general anesthesia. Postoperative pathology: nodular-beam-cord hepatocellular carcinoma grade III.

A 48-year-old male was admitted with a complaint of "palpation of a huge mass in the right lower abdomen with abdominal cramps". Previous history of right-sided cryptorchidism. Physical examination: The abdomen is soft, and a huge mass about 18 cm in size can be palpable in the lower abdomen. The surface is not smooth, fixed, hard in texture, the boundary is not clear, and there is no tenderness. The testis in the right scrotum was absent, the testis in the right inguinal area was not found, and the left testis was not abnormal. Enhanced CT examination of the whole abdomen showed that large soft tissue shadows in the middle and lower abdominal cavities were about 20.0 cm ×19.5 cm ×12.7 cm in size, which were lobulated, with clear boundaries and uneven internal density. Patchy lower density necrotic shadows and scattered nodular and cord-like calcification shadows were visible. The bottom of the lesion seemed to be unclear from the bladder wall, and the traction of the bladder wall changed. The lesions of enhanced scan showed mild to moderate heterogeneous continuous enhancement, and the adjacent organs were compressed and pushed to change. There were multiple slightly larger lymph nodes at the root of the mesangium and retroperitoneum, and patchy encapsulated low-density effusion shadows were seen around it (Figure 1)。 Serum tumor markers: alpha-fetoprotein and HCG were normal. Exploratory laparotomy was performed. During the operation, the tumor was found to be located behind the peritoneum, with huge volume and irregular shape, closely related to the right spermatic cord, infiltrating and compressing the sigmoid colon and the right abdominal wall, and tumor nodules were seen in the sigmoid mesocolon. Abdominal mass resection + appendectomy + partial sigmoidectomy were performed. The postoperative pathological examination results showed irregular tissue, size 18 cm ×19 cm ×7 cm, multi-nodular lobulated section, external capsule, gray-white matter section, necrosis in some areas, adhesion of appendix to mass, unclear boundary, sigmoid colon serosa, one nodule in gray-white matter section. Under light microscope, the tumor cells were divided into nests of different sizes by fibrous tissue. The tumor cytoplasm was abundant, the nucleoli were clear, and a few lymphocytes infiltrated in the fibrous tissue (Figure 2)。 Immunohistochemistry showed: CK (−), EMA (−), Vim (−), CD30 (−), HCG (−), LCA (−), D2-40 (2+), PLAP (focal +), CD117 (2+), Ki-67 (10% +). Pathological examination showed that retroperitoneal seminoma, appendix from submucosa to serosa layer can be seen cancer involvement, sigmoid colon can be seen lesion involvement outside serosa. The patient was given chemotherapy after operation, and the follow-up has been 10 months so far, and no local recurrence and metastasis were seen.

The patient was a 64-year-old female. The main cause was "intermittent dull pain in the upper abdomen for 1 month, accompanied by melena for half a month". Physical examination: anemia appearance. The abdomen was flat and soft, with tenderness in the right upper abdomen, no rebound pain, and no palpable mass. Laboratory test: Hemoglobin 90 g/L. Abdominal CT examination revealed: duodenal intussusception (Figure 1)。 Gastrointestinal barium meal angiography showed that the esophagus was normal. The stomach was hooked and no abnormalities were found. Multiple round or elliptical filling defects were seen in the bulb, descending part and part of the jejunum of the duodenum, with different sizes and chronic distribution, irregular edges of the lesions, and acupuncture-like niche shadows were seen, the intestinal mucosa was disordered and reticulated, the intestinal lumen was dilated, the "C"-shaped curvature of the duodenum disappeared, and there was a central barium column in the inner layer of the insertion part (Figure 2)。 Gastroscopy showed adenomatous lesions in the duodenum, the size of the lesion was approximately 2 cm ×3 cm ×2 cm. Surgical exploration showed that the duodenum and part of the jejunum were dilated, and there was a spherical mass in the upper lateral segment of the descending duodenum, which was tough in texture and had acceptable mobility. The lateral peritoneum was opened on the lateral side of the duodenum, and the intestinal lumen was filled with polypoid protrusions, and the surface was lobulated (Figure 3)。 Polyp + duodenal mucosal resection was performed. Pathological examination showed that the tumor was arranged in a tubular structure, the glandular epithelium was stratified, the nucleus was large, the cytoplasm was basophilic, and there were atypical proliferative cells. Pathological diagnosis: tubular adenoma of the duodenum.

A 75-year-old male was seen for "pain and weakness in both lower limbs for 9 h". The patient experienced pain and weakness in the right lower limb during sleep, and then the symptoms progressively aggravated with pain, numbness and weakness in the left lower limb. Physical examination: the muscle tone of the limbs was normal, the muscle strength and sensation of both upper limbs were not obviously abnormal, the sensation below the umbilical plane was reduced, the sensation below the pubic symphysis plane was lost, the muscle strength of both lower limbs was grade 0, the skin temperature of both lower limbs was low, the pulsation of bilateral dorsal pedis arteries disappeared, and the defecation was disordered. After asking about the medical history, in the past year, pain and numbness in both lower limbs appeared after walking, which could be relieved after rest, but the symptoms progressively aggravated. The patient had a history of "hypertension and atrial fibrillation" in the past, but did not undergo systematic diagnosis and treatment. He had a history of smoking for 50 years and found that blood lipids had increased for more than 3 years. Improve aortic CTA after patient visit (Figure 1) showed that multiple calcified plaques were seen in the walls of the aortic arch, thoracic and abdominal aortas, superior mesenteric artery and renal artery initiation, bilateral common iliac artery and bilateral internal iliac artery, and the lumen was narrowed to varying degrees. Filling defects were seen in the lumen of the aorta and branches at all levels below the opening level of the bilateral renal arteries, and no exact contrast medium images were seen in the distal vessels. Ultrasound of lower extremities showed: arteriosclerosis of both lower extremities with plaque formation, no blood flow signals in the left and right common iliac arteries and external iliac arteries, and no spinal cord compression and signal changes in thoracolumbar MRI. Based on the medical history, the initial diagnosis was Leriche syndrome, and the patient was recommended to undergo aortoiliac artery artificial vascular bypass. After consultation, the patient's family members refused the operation and signed off from the hospital. After telephone follow-up, the patient died on the third day after the onset of disease.