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患者女,44岁,工人。因上腹部疼痛伴畏寒发热半月,于1992年5月12日以胆囊炎、胆囊结石入院。2年前曾有类似腹痛史。体检:T37.5℃,P86次/min,R22次/min,BPl5.3/10.2kPa。略消瘦,皮肤巩膜黄染。心肺无异常发现,腹部可触及肿大的胆囊,有触痛,无肌卫。实验室检查:血Hbll2g/L,WBC 5.8×10~9/L,N0.78,L 0.22,PL 101×10~9/L;肝功能:黄胆指数42U,总胆红素239.4μmol/L,直接胆红素111μmol/L,碱性磷酸酶800IU/L总蛋白54g/L白蛋白40g/L,球蛋白14g/L BUN 2.9mmol/L,Cr 155μmol/L。B超示胆囊明显增大,壁粗糙增厚,囊内有小光点;胆总管直径2.4cm,内见双线条光带及强光点,部分光点有活动;肝内胆管明显扩张迂曲;肝左叶胆管内能探及1.2cm回声增强光团,并伴少许声影,肝大,肝区回声不均匀;胰腺无殊。B超诊断为慢性胆囊炎。
Patient female, 44 years old, worker. Due to epigastric pain with chills and fever for half a month, she was hospitalized with cholecystitis and gallstones on May 12, 1992. There was a history of similar abdominal pain 2 years ago. Physical examination: T37.5°C, P86 beats/min, R22 beats/min, BPl5.3/10.2kPa. Slightly thin, yellow skin and sclera. There was no abnormality in the heart and lungs. The abdomen could touch the enlarged gallbladder with tenderness and no muscle protection. Laboratory tests: blood Hbll2g/L, WBC 5.8×10~9/L, N0.78, L 0.22, PL 101×10~9/L; liver function: yellow gallbladder index 42U, total bilirubin 239.4μmol/L Direct bilirubin 111μmol/L, alkaline phosphatase 800IU/L total protein 54g/L albumin 40g/L, globulin 14g/L BUN 2.9mmol/L, Cr 155μmol/L. B-ultrasound shows that the gallbladder is obviously enlarged, the wall roughness is thickened, and there is a small spot in the capsule; the diameter of the common bile duct is 2.4cm, the double-line light band and strong light spot are seen, and some spots have activity; the intrahepatic bile duct is obviously dilated and bent. The left hepatic bile duct can be probed with 1.2cm echo-enhanced light masses, with a little sound shadow, large liver, and uneven echo in the liver; the pancreas is not special. B-diagnosis is chronic cholecystitis.