Prosst R L, Grobholz R, Kilian A K, Post S
Chirurgische Klinik, Universitätsklinikum Mannheim der Ruprecht-Karls Universität Heidelberg.
Dtsch Med Wochenschr. 2003 Sep 12;128(37):1889-92. doi: 10.1055/s-2003-42156.
We report on a 82 year-old male who presented with chronic pain in the right upper abdomen, nausea and vomitus. An uncomplicated laparoscopic cholecystectomy occurred eight years and a hepatitis 60 years before. Clinical examination showed a normal abdominal status without palpable liver, spleen, enlarged lymph nodes or masses. He had no icteric skin and sclera.
The patient was afebrile without leukocytosis. The tumour markers CEA, CA 19 - 9 and AFP were negative. Ultrasound of the abdomen showed a normal homogeneous echotexture of the liver without signs of cholestasis or cirrhosis. In segment 6 a 3 cm large hypoechoic cystic formation with a central echogenic structure with acoustic shadowing was noted. Magnetic resonance revealed a 2.8 x 3.6 cm large lesion in the dorsal region of segment 6 of the liver, infiltrating the perihepatic fat. Pathologic lymph nodes and metastases were not found.
At laparotomy, the tumour appeared to be malignant with invasion to the perirenal fat. Complete resection with negative margins included segment 6 of the liver and the adjacent fat (the kidney itself was not infiltrated). The cut specimen also showed signs of malignancy with central necrosis. However, histology of the resected specimen revealed a sterile liver abscess without malignancy, but with microscopic foreign bodies. The patient had an uneventful recovery without postoperative complications.
This case report demonstrates the difficulty encountered in the differential diagnosis of inflammatory processes and malignant tumours. Chronic inflammatory changes may mimic solid neoplasms. Despite adequate magnetic resonance imaging and thorough intraoperative examination, the correct diagnosis was finally found by histology. The most likely genesis of the abscess are lost gallstones during cholecystectomy.
我们报告一例82岁男性患者，其表现为右上腹慢性疼痛、恶心和呕吐。8年前曾行无并发症的腹腔镜胆囊切除术，60年前曾患肝炎。临床检查显示腹部情况正常，未触及肝脏、脾脏、肿大淋巴结或肿块。患者无皮肤及巩膜黄染。
患者无发热，白细胞未增多。肿瘤标志物癌胚抗原（CEA）、糖类抗原19 - 9（CA 19 - 9）和甲胎蛋白（AFP）均为阴性。腹部超声显示肝脏回声均匀正常，无胆汁淤积或肝硬化迹象。在肝段6发现一个3厘米大的低回声囊性结构，中央有一强回声结构伴声影。磁共振成像显示肝段6背侧有一个2.8×3.6厘米大的病变，侵犯了肝周脂肪。未发现病理性淋巴结及转移灶。
剖腹手术时，肿瘤看起来为恶性，侵犯了肾周脂肪。切缘阴性的完整切除包括肝段6及相邻脂肪（肾脏本身未受侵犯）。切除标本也显示有恶性征象，伴有中央坏死。然而，切除标本的组织学检查显示为无菌性肝脓肿，无恶性成分，但有显微镜下可见的异物。患者恢复顺利，无术后并发症。
本病例报告显示了在炎症过程与恶性肿瘤鉴别诊断中所遇到的困难。慢性炎症改变可能类似实体肿瘤。尽管有足够的磁共振成像检查及术中仔细检查，最终通过组织学检查才做出正确诊断。脓肿最可能的成因是胆囊切除术中丢失的胆结石。
