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腹膜假性黏液瘤误诊为肝硬化腹水2例

2018-03-11 佚名 临床肝胆病杂志

黏液瘤肝硬化腹水误诊
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患者女性，80岁

病例1

【一般资料】

患者女性，80岁

【主诉】

因“腹胀1个月余”，经门诊以“肝硬化腹水”收住院。

【既往史】

13岁时曾患肺结核，应用链霉素、异烟肼治疗，胸部X线提示病灶已钙化，否认肝病病史。

【体格检查】

皮肤黏膜未见黄染及出血点，无肝掌、蜘蛛痣，心肺未见异常，腹部高度膨隆，肝脾肋下未触及，移动性浊音可疑阳性，双下肢无凹陷性水肿。

【辅助检查】

白细胞计数（WBC）4.22×109/L，中性粒细胞百分比76.9%，红细胞计数（RBC）4.78×109/L，血红蛋白（Hb）110.00g/L，红细胞平均体积（MCV）77.20fl，平均红细胞血红蛋白量（MCH）22.90pg，红细胞平均血红蛋白浓度（MCHC）297．00g/L，血小板计数（PLT）314．00×109/L。肝功能：丙氨酸氨基转移酶（ALT）4.70U/L，天冬氨酸氨基转移酶（AST）12.90U/L，总胆红素（TBil）10.20μmol/L，直接胆红素（DBil）1.60μmol/L，间接胆红素（IBil）8.60μmol/L，血清白蛋白（Alb）39.60g/L，白球比（A/G）1.115，前白蛋白（PA）102．00mg/L。凝血功能：国际标准化比值（INR）1.11，凝血酶原活动度（PTA）85.0%，活化部分凝血活酶时间（APTT）46.3s，纤维蛋白原（Fib）6.86g/L。HBV血清学标志物，铜蓝蛋白，甲状腺功能，甲、戊、丙、丁型肝炎抗体，自身免疫性肝病相关自身抗体检测阴性。肿瘤标志物：糖链抗原（CA）12-540.12U/ml，CA19-9149.52U/ml，CA24-261.45ｋU/L，癌胚抗原（CEA）48.57ng/ml。腹水生化：蛋白定量（TP）25.84g/L。腹水常规：黄色、浑浊、有凝块，蛋白质阳性（﹢），比重1.020，细胞总数7840×106/L，有核细胞数642×106/L，单个核细胞42%，多个核细胞58%，未找到抗酸杆菌。腹部增强CT（图1）提示：肝硬化并大量腹水，腹膜增厚；直肠壁增厚。PET/CT示：（1）回盲部占位，呈边缘代谢性增高，考虑原发性病变，倾向黏液性肿瘤；（2）腹部不均匀增厚，局部形成多发结节，代谢增高，倾向转移。腹水脱落细胞检查：见大量无结构物，成堆及散在间皮细胞，少量中性粒细胞及淋巴细胞，未见恶性细胞。



病例2

【一般资料】

患者女性，62岁

【主诉】

因“反复腹胀、腹痛2个月余”于当地医院诊断为“肝硬化失代偿期”，经利尿、抗感染治疗10ｄ后症状无好转，继而就诊本院，门诊以“肝硬化腹水”收治入院。

【既往史】

否认肝病及结核病史。

【体格检查】

皮肤黏膜未见黄染及出血点，无肝掌、蜘蛛痣，心肺未见异常，腹部膨隆，脐周压痛、反跳痛，肝脾肋下未触及，移动性浊音可疑阳性，双下肢无凹陷性水肿。

【辅助检查】

血常规：WBC4.12×109/L，RBC3.32×109/L，Hb86g/L，红细胞比容（HCT）27.9%，MCH26pg，MCHC311g/L，PLT198×109/L。肝功能：ALT19.98U/L，AST71.83U/L，TBil4.82μmol/L，DBil1.86μmol/L，IBil2.96μmol/L，Alb35.00g/L，A/G1.030，PA128.77ｍg/L。凝血功能：INR0.96，PT107%，Fib480g/L。抗-HBc阳性。铜蓝蛋白，甲状腺功能，甲、戊、丙、丁型肝炎抗体，自身免疫性肝病相关自身抗体检测阴性。腹部CT示：腹盆腔大量积液并肝周、腹膜及盆腔絮状、团状影，疑肿瘤性病变，建议腹水细胞学及生化检查；符合肝硬化失代偿期CT征象，脾脏多发囊状病灶，淋巴瘤待排除（图2）。多肿瘤标志物：CA12-555.75U/ml，CA19-985.84U/ml，CA24-245.98kU/L，CEA112.20ng/ml，铁蛋白377.03ng/ml。腹水生化：氯化物138.33mmol/L，乳酸脱氢酶69.82U/L，淀粉酶17.19U/L，腺苷脱氨酶4.360mmol/L，TP11.83g/L。浆膜腔积液常规＋抗酸染色：蛋白质阳性（﹢），比重1.010，细胞总数2000×106/L，有核细胞70×106/L，单核细胞20%，多个核细胞80%。腹水脱落细胞学：见较多间皮细胞及无结构物，少量中性粒细胞及淋巴细胞，未见恶性细胞。


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    2018-06-30 gdsun

    #黏液瘤#

    0

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    2018-03-13 121832a9m88暂无昵称

    学习了

    0

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    2018-03-13 1249862am72(暂无昵称)

    #肝硬化腹水#

    0

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    2018-03-13 xuyong530

    #腹膜#

    0

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    2018-03-12 秀红

    学习了

    0

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    2018-03-11 cscdliu

    学习了.谢谢

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1933178, encodeId=7fb619331e8d2, content=<a href='/topic/show?id=4c371032459b' target=_blank style='color:#2F92EE;'>#黏液瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103245, encryptionId=4c371032459b, topicName=黏液瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ed25376, createdName=gdsun, createdTime=Sat Jun 30 18:59:00 CST 2018, time=2018-06-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295686, encodeId=f91829568625, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a8f22260741, createdName=121832a9m88暂无昵称, createdTime=Tue Mar 13 05:57:56 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1331263, encodeId=dc8f133126301, content=<a href='/topic/show?id=b0eb81309bf' target=_blank style='color:#2F92EE;'>#肝硬化腹水#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81309, encryptionId=b0eb81309bf, topicName=肝硬化腹水)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c6262500044, createdName=1249862am72(暂无昵称), createdTime=Tue Mar 13 01:59:00 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623793, encodeId=e4c81623e93cd, content=<a href='/topic/show?id=16ba8564526' target=_blank style='color:#2F92EE;'>#腹膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85645, encryptionId=16ba8564526, topicName=腹膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=93e220615097, createdName=xuyong530, createdTime=Tue Mar 13 01:59:00 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295367, encodeId=a62329536ea8, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/01/15/8213228fe923915543544ad3da7e1c64.jpg, createdBy=6bd82014262, createdName=秀红, createdTime=Mon Mar 12 06:10:52 CST 2018, time=2018-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295234, encodeId=32342952341a, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Sun Mar 11 19:47:05 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295194, encodeId=03d62951949a, content=学习了受益匪浅, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicHg2ldsSNmib46PmdzpO7CQEmPjuULp1v45zPWwMYhrnXgvl3OtmUCZSQfgITWn96X9moL94nUGA/0, createdBy=28072041016, createdName=131****1460, createdTime=Sun Mar 11 13:40:09 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295176, encodeId=7a342951e60e, content=学习了.涨知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220115/46bcf39c32de4aa6b45c5f9d66c8ee77/6cb4a20c55bb4b7691122f47747bfca2.jpg, createdBy=9dad1662329, createdName=1ddf0692m34(暂无匿称), createdTime=Sun Mar 11 12:34:58 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295170, encodeId=c6922951e060, content=优质资源.共同学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K0LqDY57Aia0TOQByoJhNt3icm4sfukp500hLH6RHOpFdV01NbECtAV7s0qKpQPibyRukQAwAmqJU3X/0, createdBy=f91f1928792, createdName=九九消寒, createdTime=Sun Mar 11 11:37:33 CST 2018, time=2018-03-11, status=1, ipAttribution=)]
    2018-03-11 131****1460

    学习了受益匪浅

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1933178, encodeId=7fb619331e8d2, content=<a href='/topic/show?id=4c371032459b' target=_blank style='color:#2F92EE;'>#黏液瘤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=103245, encryptionId=4c371032459b, topicName=黏液瘤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ed25376, createdName=gdsun, createdTime=Sat Jun 30 18:59:00 CST 2018, time=2018-06-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295686, encodeId=f91829568625, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a8f22260741, createdName=121832a9m88暂无昵称, createdTime=Tue Mar 13 05:57:56 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1331263, encodeId=dc8f133126301, content=<a href='/topic/show?id=b0eb81309bf' target=_blank style='color:#2F92EE;'>#肝硬化腹水#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81309, encryptionId=b0eb81309bf, topicName=肝硬化腹水)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c6262500044, createdName=1249862am72(暂无昵称), createdTime=Tue Mar 13 01:59:00 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1623793, encodeId=e4c81623e93cd, content=<a href='/topic/show?id=16ba8564526' target=_blank style='color:#2F92EE;'>#腹膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85645, encryptionId=16ba8564526, topicName=腹膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=93e220615097, createdName=xuyong530, createdTime=Tue Mar 13 01:59:00 CST 2018, time=2018-03-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295367, encodeId=a62329536ea8, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/01/15/8213228fe923915543544ad3da7e1c64.jpg, createdBy=6bd82014262, createdName=秀红, createdTime=Mon Mar 12 06:10:52 CST 2018, time=2018-03-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295234, encodeId=32342952341a, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/23/557c1f19aaf5459a8405411e38903c4b.jpg, createdBy=dfc02088287, createdName=cscdliu, createdTime=Sun Mar 11 19:47:05 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295194, encodeId=03d62951949a, content=学习了受益匪浅, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicHg2ldsSNmib46PmdzpO7CQEmPjuULp1v45zPWwMYhrnXgvl3OtmUCZSQfgITWn96X9moL94nUGA/0, createdBy=28072041016, createdName=131****1460, createdTime=Sun Mar 11 13:40:09 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295176, encodeId=7a342951e60e, content=学习了.涨知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220115/46bcf39c32de4aa6b45c5f9d66c8ee77/6cb4a20c55bb4b7691122f47747bfca2.jpg, createdBy=9dad1662329, createdName=1ddf0692m34(暂无匿称), createdTime=Sun Mar 11 12:34:58 CST 2018, time=2018-03-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=295170, encodeId=c6922951e060, content=优质资源.共同学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5K0LqDY57Aia0TOQByoJhNt3icm4sfukp500hLH6RHOpFdV01NbECtAV7s0qKpQPibyRukQAwAmqJU3X/0, createdBy=f91f1928792, createdName=九九消寒, createdTime=Sun Mar 11 11:37:33 CST 2018, time=2018-03-11, status=1, ipAttribution=)]
    2018-03-11 1ddf0692m34(暂无匿称)

    学习了.涨知识

    0

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    2018-03-11 九九消寒

    优质资源.共同学习

    0

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