Detailed Treatment Process
4 min read
Female, 85 years old. Imaging Diagnosis Report Clinical diagnosis: Malignant tumor of the bile duct (probable) Requesting physician: Examination: Upper abdominal CT plain scan + contrast enhancement Imaging findings: The liver is normal in morphology and size, with no widening of the fissures. No abnormal density shadows are seen in the liver parenchyma on plain or contrast-enhanced scans. The portal vein and hepatic veins are clearly visualized. The celiac trunk, hepatic artery, splenic artery, and superior mesenteric artery are clearly displayed. Intrahepatic and extrahepatic bile ducts are dilated, more prominently in the left intrahepatic ducts. A soft-tissue density shadow is suspected in the left intrahepatic duct near the hepatic hilum, showing mild heterogeneous enhancement after contrast administration. The hilar bile duct wall appears slightly thickened with enhancement. The extrahepatic bile duct is mildly dilated, with a maximum width of approximately 1.1 cm. The pancreas is normal in morphology, size, and density. The spleen is normal in morphology, size, and density. Both kidneys are normal in morphology, size, and density. No obvious abnormalities are seen in the bilateral adrenal glands. No obviously enlarged lymph nodes are present in the abdomen. No intraperitoneal fluid collection is seen. Imaging diagnosis: Occupying lesion in the left intrahepatic bile duct near the hepatic hilum, suggestive of possible cholangiocarcinoma with possible invasion of the hilar bile duct; mild dilatation of the extrahepatic bile duct. Examination time: August 26, 15:10:40 Report writing time: August 26, 16:51:02 Report review time: August 27, 12:04:05
Department: Gastroenterology Clinical diagnosis: Chronic liver disease Requesting physician: Assist in diagnosis Examination: Contrast-enhanced MR of the upper abdomen Radiological findings: The liver is normal in morphology and size across all sequences, with no widening of the fissures. A mass-like slightly hyperintense lesion on T2WI-FS with a central even higher signal focus is seen in the left lateral lobe of the liver. The periphery of the lesion shows high signal on DWI, with low signal centrally. The ADC map shows low signal peripherally and high signal centrally. Post-contrast imaging demonstrates peripheral enhancement with centripetal filling. The local liver capsule appears slightly retracted. The gallbladder is not visualized. The left lateral intrahepatic bile duct and common bile duct are markedly dilated; the pancreatic duct is not obviously dilated. The pancreas shows no significant abnormality in morphology or signal, with no obvious abnormal enhancement post-contrast. The spleen is normal in morphology, size, and signal, with no obvious abnormal enhancement post-contrast. Both kidneys are normal in morphology, with multiple punctate high signals on T2WI that show no obvious abnormal enhancement post-contrast. The bilateral adrenal glands are normal in morphology and signal. Lymph nodes around the lesser curvature of the stomach are slightly enlarged. Patchy abnormal signals are seen in the L2 and L4 vertebral bodies, with no high signal on DWI but obvious enhancement post-contrast. MRCP shows no gallbladder, marked dilatation of the left lateral intrahepatic bile duct without definite filling defects, and no obvious narrowing or dilatation of the pancreatic duct. Radiological diagnosis: Possible cholangiocarcinoma in the left lateral intrahepatic bile duct; gallbladder not visualized; marked dilatation of the left lateral intrahepatic bile duct and common bile duct; slightly enlarged lymph nodes around the lesser curvature of the stomach—please correlate with clinical findings and further examinations; multiple small renal cysts; enhancement in L2 and L4 vertebral bodies, possibly hemangiomas—please correlate with clinical findings. Examination time: July 3, 16:01 Report writing time: July 3, 19:16 Report review time: July 5, 12:48
Clinical Pathology Diagnosis Report Specimen submission date: September 8 Department: Hepatobiliary Surgery Specimen type: Left hemi-liver Tumor size: 5 × 3 × 2.2 cm Capsule: Absent Gross type: Periductal infiltrating type Histological type: Cholangiocarcinoma (adenocarcinoma); immunohistochemical testing recommended. Histological grade: Well differentiated Satellite nodules: None Macroscopic vascular tumor thrombus: None Microscopic vascular tumor thrombus: M0 M0: 0; M1: 1–5; M2: ≥6 Bile duct invasion: / Neural invasion: Not definitively identified Invasion of adjacent organs: Difficult to assess pathologically Margin status: Negative Additional margins: / Viral hepatitis: / Lymph node metastasis: Total (0/16) Others or additional: / Report date: September 13
Sample type: Abdominal drainage fluid Gender: Female Receipt date: September 14 Test item: *** Ultra-multiplex PCR targeted sequencing Report date: September 15 Test information *** Ultra-multiplex PCR targeted sequencing uses ultra-multiplex PCR amplification and next-generation sequencing to identify over 280 core pathogenic microorganisms and over 80 resistance genes in samples. It is suitable for all clinical sample types, including whole blood and cerebrospinal fluid. Test results Bacteria including mycobacteria—suspected background microecology Aeromonas hydrophila Resistance genes/virulence genes: Not detected
The patient underwent surgery for cholangiocarcinoma and developed high fever postoperatively. Bacterial culture of the drainage fluid was positive.