Detailed Treatment Process
Female, 62 years old Laboratory report Application time: 2022-12-06 17:17 Collection time: 2022-12-07 05:54 Preliminary diagnosis: Obstructive jaundice Serial No.\Item Name\Abbreviation\Result\Unit (Reference Range) 1CA_125CA_12540.80 (0-22U/ml) 2CA_199CA_199>12000.00 (0-43U/ml) 3Carcinoembryonic AntigenCEACEA648.24 (0-5ng/ml) 4Alpha-fetoproteinAFPAFP3.36 (0-7ng/ml) Receiving time: 2022-12-07 08:06 Report time: 2022-12-07 10:04
Discharge record Admission time: 2022-12-06 Discharge time: 2022-12-19 15:54 Admission diagnosis: Obstructive jaundice; Hypertension Discharge diagnosis: Cholangiocarcinoma occupying lesion; Obstructive jaundice; Liver dysfunction; Hypertension Admission status: The patient was admitted due to “poor appetite and fatigue for more than 20 days accompanied by progressive worsening of skin jaundice.” Twenty days prior, without obvious inducement, the patient developed poor appetite and fatigue, accompanied by skin jaundice, without abdominal pain, back radiation, nausea, vomiting, chills, or fever. There was slight abdominal distension, no belching or acid reflux, no palpitations or chest tightness, no shortness of breath, and no obvious cough or expectoration. Local hospital provided symptomatic treatment (details unknown). There was no obvious improvement, and the skin jaundice progressively worsened. For further treatment, an MRI at an external hospital suggested: pancreatic head occupying lesion, retroperitoneal lymph node metastasis. For further treatment, the patient visited our hospital outpatient clinic and was admitted to our department under the impression of “pancreatic occupying lesion.” Since onset, the patient had been conscious, with average appetite and spirit, average sleep, and normal urination and defecation. PE: Skin and sclera jaundiced, abdomen flat and soft, no intestinal type or peristaltic waves seen, liver and spleen not palpable below costal margin, Murphy’s sign negative, slight tenderness in mid-upper abdomen, rebound tenderness negative, shifting dullness negative, bowel sounds 3-4 times/min. Hospitalization course: After admission, relevant examinations were completed. On 2022-12-07, magnetic resonance cholangiopancreatography MRCP1.5T showed cholangiocarcinoma with high biliary obstruction, suspected invasion of pancreatic head; viscous bile; intrahepatic cystic lesions; multiple enlarged retroperitoneal lymph nodes. On 2022-12-08, upper abdominal CT plain scan + enhanced scan showed intrahepatic bile duct dilation, common hepatic duct and common bile duct stenosis, considered cholangiocarcinoma; enlarged retroperitoneal lymph nodes with local fusion, rough edges of common hepatic artery and pancreatic head, considered invaded; concentrated bile in gallbladder; liver cyst; tracheal diverticulum, anterior mediastinal soft tissue nodule, recommend follow-up. Anti-infection, liver protection, and fluid support symptomatic treatment were given. On 2022-12-08, ultrasound-guided percutaneous transhepatic cholangial drainage catheter placement was performed. Postoperatively, drainage was smooth and bilirubin decreased. On 2022-12-12, ERCP was performed with biopsy. Postoperatively, acid suppression, enzyme suppression, anti-inflammatory, and liver protection symptomatic treatment were given. The patient had intermittent abdominal pain postoperatively. Re-examination showed elevated white blood cells and bilirubin levels. Antibiotics were changed for symptomatic treatment. The patient’s general condition is now acceptable. The family requested transfer to a higher-level hospital for further treatment, so discharge was arranged. Pathology suggested: “Ampulla” biopsy: mucosal tissue, acute and chronic inflammatory cell infiltration in the lamina propria, with a small amount of fragmented intestinal mucosal glandular tissue. Discharge status: The patient had no obvious discomfort complaints. PE: Conscious, fair spirit, no obvious abnormalities on heart and lung auscultation, abdomen flat and soft, liver and spleen not palpable below costal margin, no obvious tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Low-salt, low-fat diet, increase nutrition. 2. Further treatment at a higher-level hospital. 3. Follow-up in our department.
MR diagnostic report Registration time: 2022-12-07 7:42:19 Report time: 2022-12-07 10:15:42 Clinical diagnosis: Examination item: Magnetic resonance cholangiopancreatography MRCP1.5T Imaging findings: Liver size and morphology normal, intrahepatic signal uniform. Limited soft tissue mass shadow at hepatic hilum bile duct - lower common bile duct, showing iso-T1 and slightly long T2 signal. Surrounding and lower common hepatic duct show “rat tail” sudden interruption. Intrahepatic bile ducts, left and right hepatic ducts, and common hepatic duct dilated. Intrahepatic bile duct branches show soft vine-like changes. Enhanced scan shows irregular thickening of bile duct wall with obvious enhancement, unclear boundary with pancreatic head. Multiple enlarged retroperitoneal lymph node shadows seen, with enhancement on enhanced scan. Cystic long T1 and long T2 signals in upper segment of right posterior lobe and lateral segment of left lobe of liver, clear borders, no enhancement on enhanced scan, larger one with long diameter about 21mm. Intrahepatic vessels normal. No dilation of intra- and extrahepatic bile ducts. Gallbladder not enlarged, intracystic filling with short T1 and slightly short T2 signal. Spleen not enlarged. No obvious fluid in abdominal cavity. MRCP shows “rat tail” interruption of lower common hepatic duct, dilation of intrahepatic bile ducts, left and right hepatic ducts, and common hepatic duct. Intrahepatic bile duct branches show soft vine-like changes. Gallbladder not enlarged, smooth wall, reduced intracystic signal. Pancreatic duct not dilated. No fluid in abdominal cavity. Diagnostic opinion: In summary, cholangiocarcinoma with high biliary system obstruction, suspected invasion of pancreatic head; Viscous bile; Intrahepatic cystic lesions; Multiple enlarged retroperitoneal lymph nodes.
CT diagnostic report Requesting department: General Surgery Hepatobiliary and Pancreatic Ward Registration time: 2022-12-08 7:43:23 Report time: 2022-12-08 10:49:51 Clinical diagnosis: Examination item: Upper abdominal CT plain scan + enhanced scan Imaging findings: Bilateral thoracic cages symmetric, bilateral lung markings slightly increased, no obvious abnormal density in bilateral lung parenchyma. Tracheal diverticulum, bilateral main bronchi patent. Mediastinal window shows mediastinum centered, anterior mediastinum with nodular soft tissue density shadow, clear border, diameter about 17mm. No obvious free fluid in bilateral pleural cavities. Liver size and morphology normal, intrahepatic bile ducts dilated, common hepatic duct and upper common bile duct stenosed. After enhancement, nodular and ring-like wall obvious continuous enhancement. Lower common bile duct shows ring-like enhancement. Intrahepatic oval low-density non-enhancing lesions seen, larger one in right lobe of liver, size about 16*20mm. Gallbladder enlarged, intracystic bile density increased. Pancreas slightly atrophied, main pancreatic duct slightly dilated. Spleen not enlarged, no abnormal enhancement. Multiple enlarged retroperitoneal lymph nodes seen, local density uneven, appearing fused, unclear boundary with common hepatic artery and pancreatic head. No obvious free fluid in abdominal cavity. Diagnostic opinion: Intrahepatic bile duct dilation, common hepatic duct and common bile duct stenosis, considered cholangiocarcinoma; Enlarged retroperitoneal lymph nodes with local fusion, rough edges of common hepatic artery and pancreatic head, considered invaded; Concentrated bile in gallbladder; Liver cyst; Tracheal diverticulum, anterior mediastinal soft tissue nodule, recommend follow-up.
Discharge record Admission time: 2022-12-20 Discharge time: 2023-01-09 09:36 Admission diagnosis: Obstructive jaundice; Malignant cholangiocarcinoma Discharge diagnosis: Malignant cholangiocarcinoma; Obstructive jaundice; Liver dysfunction; Hypertension Admission status: The patient was admitted due to “progressive worsening of skin and sclera jaundice for 1 month.” One month prior, without obvious inducement, skin and sclera jaundice appeared and progressively worsened, with poor appetite and fatigue, without abdominal pain, back radiation, nausea, vomiting, chills, or fever. Slight abdominal distension, no belching or acid reflux, no palpitations or chest tightness, no shortness of breath, no obvious cough or expectoration. MRI at a civilian hospital suggested: pancreatic head occupying lesion, retroperitoneal lymph node metastasis. After anti-infection symptomatic treatment in our hospital, for further treatment the patient again visited our outpatient clinic and was admitted to our department under the impression of “obstructive jaundice.” PE: Severe jaundice of skin and sclera, scattered scratch marks on skin, abdomen flat and soft, no intestinal type or peristaltic waves seen, liver and spleen not palpable below costal margin, Murphy’s sign negative, no tenderness in whole abdomen, rebound tenderness negative, shifting dullness negative, bowel sounds 3-4 times/min. Hospitalization course: After admission, relevant examinations were completed. On 2022-12-20 liver and kidney function: total bilirubin 162.5μmol/L, direct bilirubin 133.7μmol/L, indirect bilirubin 28.8μmol/L, ALT 70.0U/L, AST 56.4U/L, total protein 62.4g/L, albumin 29.4g/L. Liver protection, jaundice reduction, anti-inflammatory, fluid, and nutritional support treatment were given. Gemcitabine + cisplatin chemotherapy was administered. On 2023-01-03 percutaneous transhepatic cholangial drainage catheter placement was performed. The patient recovered well, liver function improved, and jaundice decreased. The patient and family requested discharge, which was arranged. Discharge status: The patient had no obvious discomfort complaints. PE: Conscious, fair spirit, mild jaundice of skin and sclera, no obvious abnormalities on heart and lung auscultation, abdomen flat and soft, liver and spleen not palpable below costal margin, no obvious tenderness or rebound tenderness, normal bowel sounds. PTCD tube fixed well, bile drainage smooth. Discharge orders: 1. Low-salt, low-fat diet, increase nutrition. 2. Regular re-examination of liver and gallbladder ultrasound, return for chemotherapy again in 3 weeks. 4. Follow-up in our department. Physician signature: Record time: 2023-01-09
Discharge record Admission time: 2023-02-12 Discharge time: 2023-02-22 09:52 Admission diagnosis: Malignant cholangiocarcinoma; Cholangiocarcinoma occupying lesion Discharge diagnosis: Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Admission status: The patient was admitted due to “skin and sclera jaundice for more than 2 months.” More than two months prior, the patient was admitted due to skin and sclera jaundice. In our hospital, malignant cholangiocarcinoma was considered. After active treatment, liver function improved, jaundice decreased, and chemotherapy was given (gemcitabine + cisplatin regimen). No nausea or vomiting, no chills or fever, no abdominal distension, accompanied by skin yellowing, eye yellowing, and urine yellowing. No belching or acid reflux, no palpitations or chest tightness, no shortness of breath, no obvious cough or expectoration. Now admitted for another cycle of chemotherapy. Outpatient impression “malignant cholangiocarcinoma” led to admission to our department. Since onset, conscious, appetite and spirit poor, sleep average, no urinary frequency, urgency or pain, normal urine volume, normal stool. PE: Abdomen slightly distended, no intestinal type or peristaltic waves seen, liver and spleen not palpable below costal margin, Murphy’s sign negative, no upper abdominal tenderness, rebound tenderness negative, shifting dullness negative, bowel sounds 3-4 times/min. Hospitalization course: After admission, routine pre-chemotherapy examinations were performed. After confirming no obvious chemotherapy contraindications, gemcitabine + cisplatin chemotherapy combined with camrelizumab immunotherapy was given. No significant adverse reactions during chemotherapy. Now spirit and diet normal, discharged today. Discharge status: Patient’s temperature normal, spirit, diet, and urination/defecation normal, no special discomfort. PE: Conscious, fair spirit, no obvious abnormalities on heart and lung auscultation, abdomen flat and soft, liver and spleen not palpable below costal margin, no obvious tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Regular return for re-examination (liver and gallbladder, chest CT, blood count, tumor markers); 2. Rest, strengthen nutrition, manage chemotherapy side effects; 3. Follow-up in our department. Record time: 2023-02-22
Discharge record Admission time: 2023-03-12 Discharge time: 3-24 13:00 Admission diagnosis: Fever; Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Discharge diagnosis: Maintenance chemotherapy for malignant tumor; Malignant cholangiocarcinoma Admission status: The patient was admitted due to “fever for 3 days.” Three days prior, without obvious inducement, fever occurred, maximum 37.9℃, accompanied by chills, general fatigue, cough (mainly dry cough), no rash, abdominal pain, diarrhea, headache, palpitations, or vomiting. Home antipyretic treatment failed to control temperature. Visited our hospital. On 3-10 blood routine (emergency, Yuejiah u branch): white blood cells 2.34 * 10⁹ /L, neutrophil ratio 13.2%, lymphocyte ratio 59.3%, monocyte ratio 25.4%, red blood cells 2.25 * 10¹² /L, hemoglobin 68g/L. Chest CT plain scan: nodules in upper lobes of both lungs; interstitial changes under pleura in right lower lobe; anterior mediastinal nodule. Outpatient gave active anti-infection and white blood cell elevation treatment. Temperature improved. For further diagnosis and treatment, admitted under impression “fever.” Since onset, conscious, spirit poor, poor diet, urination and defecation basically normal, weight no obvious change. PE: Conscious, spirit poor, chronic disease face, no jaundice of skin and sclera, superficial lymph nodes not enlarged, bilateral lung breath sounds clear, no dry or wet rales, abdomen soft, no tenderness or rebound tenderness, lower limbs not swollen, pathological signs negative. Hospitalization course: After admission, routine pre-chemotherapy examinations were performed. After confirming no obvious chemotherapy contraindications, gemcitabine + cisplatin chemotherapy combined with camrelizumab immunotherapy was given. No significant adverse reactions during chemotherapy. Now spirit and diet normal, discharged today. Discharge status: Patient’s temperature normal, spirit, diet, and urination/defecation normal, no special discomfort. PE: Conscious, fair spirit, no obvious abnormalities on heart and lung auscultation, abdomen flat and soft, liver and spleen not palpable below costal margin, no obvious tenderness or rebound tenderness, normal bowel sounds. Discharge orders: 1. Regular return for re-examination (liver and gallbladder, chest CT, blood count, tumor markers); 2. Rest, strengthen nutrition, manage chemotherapy side effects; 3. Follow-up in our department. Record time: 2023-03-24
CT diagnostic report Registration time: 2023-04-01 8:55:22 Report time: 2023-04-01 10:04:54 Clinical diagnosis: Examination item: Upper abdominal CT plain scan + enhanced scan Imaging findings: Patient post comprehensive treatment for malignant cholangiocarcinoma for re-examination: Liver size and morphology normal. Intrahepatic round-like low-density shadows seen, larger one in right lobe of liver, size about 16mm*20mm, no obvious enhancement on enhanced scan. Gallbladder enlarged, density increased. Intrahepatic bile ducts and left and right hepatic ducts slightly dilated. Local common bile duct stenosis, wall appeared thickened, surrounding fat space blurred, hepatic artery invaded. Fat space around pancreatic head blurred. Spleen morphology normal, no abnormal density shadows. Enlarged retroperitoneal lymph node shadows. Multiple patchy low-density shadows under abdominal wall, borders relatively clear, enhanced scan shows cyst wall enhancement, intracystic low-density shadows no obvious enhancement. Diagnostic opinion: Post comprehensive treatment re-examination for malignant cholangiocarcinoma; Increased gallbladder density; Multiple cystic lesions under abdominal wall; Enlarged retroperitoneal lymph nodes; Liver cyst.
Outpatient record (scan, cannot ensure 100% match with original) 2023-04-04 Discovered cholangiocarcinoma occupying lesion nearly 4 months Female patient, 62Y. In 2022-11, poor appetite and fatigue with skin jaundice appeared. On 2022-12-05 external hospital CT showed occupying lesion. On 2022-12-08 PTCD performed at external hospital, jaundice improved. On 2022-12-12 ERCP with biopsy: no cancer found, only mucosal tissue with chronic inflammatory cell infiltration in lamina propria. From 2022-12 to 2023-03-24 completed 5 cycles of gemcitabine + cisplatin chemotherapy and 2 times camrelizumab immunotherapy. On 3-10 external hospital blood routine: WBC: 2.24 * 10⁹ /L↓ Hb: 68g/L↓ After blood transfusion and white blood cell elevation symptomatic treatment, on 3-16 re-examination blood routine: WBC: 4.72 * 10⁹ /L Hb: 86g/L↓ Patient now has good spirit and diet, no obvious discomfort. Enhanced CT (2022-12-08 external hospital): intrahepatic bile duct dilation, common hepatic duct and common bile duct stenosis, considered cholangiocarcinoma. (2023-04-01 external hospital) local common bile duct stenosis, wall appeared thickened, increased gallbladder density.
Discharge record Admission time: 2023-06-26 Discharge time: 2023-07-11 Admission diagnosis: 1. Cholangiocarcinoma; 2. Bone marrow suppression after chemotherapy; 3. Hypertension. Discharge diagnosis: 1. Malignant cholangiocarcinoma; 2. Bone marrow suppression after chemotherapy; 3. Hypertension. Admission status: The patient was admitted for “cholangiocarcinoma chemotherapy for 6 months, for surgical treatment.” Six months prior, admitted due to skin and sclera jaundice. In our hospital, malignant cholangiocarcinoma was considered. After active treatment, liver function improved, jaundice decreased, and chemotherapy was given (gemcitabine + cisplatin regimen). No nausea or vomiting, no chills or fever, no abdominal distension, accompanied by skin yellowing, eye yellowing, and urine yellowing. No belching or acid reflux, no palpitations or chest tightness, no shortness of breath, no obvious cough or expectoration. Now admitted for surgical treatment. Outpatient impression “malignant cholangiocarcinoma” led to admission to our department. Since onset, conscious, appetite and spirit poor, sleep average, urination and defecation normal. PE: Abdomen slightly distended, no intestinal type or peristaltic waves seen, liver not palpable below costal margin, spleen not palpable below costal margin, Murphy’s sign negative, no upper abdominal tenderness, rebound tenderness negative, bowel sounds 3-4 times/min. Hospitalization course: After admission, relevant examinations completed. On 2023-06-28 upper abdominal CT plain scan + enhanced scan: bronchial infection in both lungs; anterior mediastinal cystic lesion; tracheal diverticulum; intrahepatic cystic lesion; increased gallbladder bile; left retroperitoneal infectious lesion, please correlate with clinical. After evaluation, no obvious surgical contraindications. On 2023-07-01 under general anesthesia, “radical pancreaticoduodenectomy + abdominal drainage” was performed. Postoperatively, acid suppression, enzyme suppression, anti-inflammatory, fluid, and nutritional support given. Patient recovered well and was discharged. Postoperative pathology not yet reported. Discharge status: Patient’s general condition acceptable. Physical examination: Alert, fair spirit, abdomen slightly distended, no intestinal type or peristaltic waves, liver and spleen not palpable below costal margin, Murphy’s sign negative, no abdominal tenderness or rebound tenderness, wound healed well, bowel sounds 3-4 times/min. Discharge orders: 1. Rest, increase nutrition. 2. 3-5 days after discharge, remove sutures depending on wound healing. 3. Outpatient review in 1 month after discharge. 4. Outpatient follow-up in our department. Record time: 2023-07-11
Laboratory report Application time: 2023-06-27 16:59 Collection time: 2023-06-28 07:16 Preliminary diagnosis: Cholangiocarcinoma Serial No.\Item Name\Abbreviation\Result\Unit (Reference Range) 1CA_125CA_12514.70 (0-22U/ml) 2CA_199CA_19933.41 (0-43U/ml) 3Carcinoembryonic AntigenCEACEA3.15 (0-5ng/ml) 4Alpha-fetoproteinAFPAFP2.78 (0-7ng/ml) Receiving time: 2023-06-28 08:09 Report time: 2023-06-28 10:10
CT diagnostic report Registration time: 2023-06-27 17:08:37 Report time: 2023-06-28 14:58:23 Clinical diagnosis: 1: Cholangiocarcinoma Examination item: Upper abdominal CT plain scan + enhanced scan, chest CT plain scan Imaging findings: Bilateral thoracic cages symmetric. Bilateral bronchial vascular bundles increased, scattered patchy density increases in both lungs, unclear borders. Patchy density increase in right lower lobe, unclear border. Trachea and bronchi patent, no obvious stenosis or obstruction. Anterior mediastinum with cystic low-density shadow, clear border, size about 11mm*14mm. No enlarged lymph nodes in mediastinum or bilateral hila. No obvious fluid in bilateral pleural cavities. Cystic gas density shadow behind right trachea. Liver size and morphology normal, parenchymal density slightly uneven, with round-like low-density lesions, clear borders, larger one about 15mm*23mm, no enhancement in all enhanced phases. Intrahepatic duct system not dilated. Gallbladder not enlarged, intracystic bile increased. Pancreas and spleen morphology normal, no abnormal density shadows, no abnormal enhancement. Left retroperitoneum with patchy slightly high-density shadow, unclear border with psoas major, ring-like enhancement after enhancement, significantly smaller compared with previous film (March 19), no obvious free fluid in abdominal cavity. Diagnostic opinion: Bronchial infection in both lungs; Anterior mediastinal cystic lesion; tracheal diverticulum; Intrahepatic cystic lesion; Increased gallbladder bile; Left retroperitoneal infectious lesion Please correlate with clinical.
Pathology report Delivery date: 2023-07-01 Clinical diagnosis: 1. Cholangiocarcinoma; 2. Bone marrow suppression after chemotherapy; 3. Cholangiocarcinoma specimen information: Pancreaticoduodenal specimen, abdominal lymph nodes Gross examination: Partial gastrectomy and duodenectomy specimen, stomach size 7*5*2.8cm, duodenum length 21cm, pancreatic head size 5.5*3.5*2.8cm, common bile duct length 5.5cm, circumference 2cm. Gastric and intestinal mucosa smooth, no masses or ulcers. Distance from duodenal margin 11.5cm. Duodenal mucosal surface with a polypoid protrusion, diameter 1cm. Common bile duct no obvious rough areas or masses. Pancreas multiple sections no masses. One gallbladder, size 9*3.5*2.5cm, containing dark green bile, no stones, mucosa rough, wall thickness 0.2cm. 5 lymph nodes detected beside gastric tissue, diameter 0.1-0.2cm. 1 lymph node around pancreas, diameter 0.2cm. No lymph nodes detected beside duodenum. Note: Removed gross specimen, opened common bile duct, no obvious lesion area seen grossly. Telephone notification to clinical doctor to come to our department to jointly identify the lesion and take samples together. Pathological diagnosis: Post-chemotherapy pancreaticoduodenal specimen: No definite tumor tissue in common bile duct and duodenal papilla. Common bile duct and duodenal wall with vascular congestion and chronic inflammatory cell infiltration. No tumor tissue in surrounding pancreatic tissue. Chronic inflammatory cell infiltration around pancreatic ducts. Focal low-grade intraepithelial neoplasia of interlobular duct epithelium. Local fibrous tissue hyperplasia around pancreas, cholesterol crystal clefts, lymphocyte and foam cell infiltration. Gastric margin, duodenal margin, pancreatic margin, common bile duct margin, gallbladder neck margin all no definite cancer tissue. Gastric lymph nodes (-) (0/5), pancreatic lymph nodes (-) (0/1); Duodenal submucosal lipoma; Gallbladder mucosal tissue chronic inflammation with mucosal epithelial necrosis. Note: 1. Please refer to preoperative relevant examination results. 2. Sampling jointly participated by pathology and clinical doctors to identify lesion status. Diagnosis date: 2023-07-08
Outpatient record (scan, cannot ensure 100% match with original) Tumor markers (external hospital)\CA199\CEA 2022-12-06 >12000U/mL↑ 648.24ng/mL↑ 2023-02-02 >1000U/mL↑ 314ng/mL↑ 2023-02-12 4240.07U/mL 18.55ng/mL 2023-03-12 1182.11U/mL↑ Not tested 2023-04-07 554.72U/mL 5.54ng/mL
Outpatient record (scan, cannot ensure 100% match with original) 2023-05-01 Patient has completed 5 cycles of gemcitabine + cisplatin chemotherapy and 4 times camrelizumab treatment. Post-chemotherapy CA199 (2023-06-28) decreased to normal 33.4U/mL. 6-28 assessment CT showed: no dilation of intrahepatic bile ducts. Suggests disappearance of mass shadow (lower common bile duct). Thus on 2023-07-01 PD surgery performed. Pathology: No definite tumor tissue in common bile duct and duodenal papilla. Common bile duct and duodenal wall with vascular congestion and chronic inflammatory cell infiltration. Chronic inflammatory cell infiltration around pancreatic ducts. Focal low-grade intraepithelial neoplasia of interlobular duct epithelium. Local fibrous tissue hyperplasia around pancreas. Cholesterol crystal clefts (IV C0/7). Duodenal submucosal lipoma. CT (2023-07-06): Post PD, liver cyst, retroperitoneal exudative lesion and multiple enlarged lymph nodes considered.
CT diagnostic report Registration time: 2023-08-17 10:50:29 Report time: 2023-08-17 15:36:16 Clinical diagnosis: 1: Postoperative malignant tumor chemotherapy; 2: Ampullary tumor Examination item: Upper abdominal CT plain scan + enhanced scan, chest CT plain scan Imaging findings: Liver parenchymal density uniform, with several round-like low-density lesions, clear borders, larger one about 16mm*22mm, no obvious enhancement in all enhanced phases. Intrahepatic duct system not dilated, gas in left lobe bile duct. Gallbladder and pancreatic head not displayed. Residual pancreas no obvious abnormal enhancing shadows. Spleen morphology normal, no abnormal density shadows, no abnormal enhancement. Multiple nodular slightly high-density shadows in retroperitoneum, mild enhancement after enhancement. Bilateral thoracic cages symmetric. Bilateral bronchial vascular bundles increased, normal course. Small patchy density increases in both lungs, borders unclear. Trachea and bronchi patent, no obvious stenosis or obstruction. Anterior mediastinum with nodular soft tissue density shadow, maximum diameter about 8mm. No obvious fluid in bilateral pleural cavities. Diagnostic opinion: Post cholangiocarcinoma occupying lesion surgery changes; Multiple liver cysts considered; Gas in left lobe bile duct; Multiple enlarged retroperitoneal lymph nodes; Slight interstitial changes in both lower lungs considered; Anterior mediastinal enlarged lymph nodes considered; Correlate with history and compare with previous films.