Objective:Laparoscopic/robotic radical resection and super minimally invasive surgery(SMIS)are currently the main surgical methods for the treatment of gastric cancer.However, there are the following issues in clinical decision-making before and after surgery: (1)There is still a lack of effective means for accurately determining the scope of lymph node dissection in laparoscopic/robotic radical resection surgery; (2)There are still difficulties in accurately determining the presence of lymph node metastasis around the stomach after non-curative resection of super minimally invasive surgery.Currently, the use of the antigen-specific imaging agent 68Ga-NC-BCH in combination with positron emission tomography-computed tomography (PET/CT) has shown promising results in guiding Chimeric Antigen Receptor T-Cell Immunotherapy (CART) treatment for gastric cancer patients. However, there is no relevant research on whether it can be combined with lymph node immune tracing to guide preoperative and postoperative clinical decisions for gastric cancer patients.Therefore, this study aims to explore the impact of 68Ga-NC-BCH combined with PET-CT lymph node immune tracing on preoperative and postoperative clinical decisions for gastric cancer patients.Methods:From April to September 2023, five cases of advanced gastric cancer patients who received treatment at the First Medical Center of PLA General Hospital were selected. Prior to surgery, abdominal CT scans and 68Ga-NC-BCH combined PET-CT lymph node immune tracing were performed, followed by laparoscopic/robotic gastric cancer resection and extended lymph node dissection.Result:Among the 5 cases, preoperative CT scans indicated enlarged gastric lymph nodes in 3 cases (60%). However, lymph node immunostaining using 68Ga-NC-BCH combined with PET-CT did not reveal any abnormalities. Postoperative pathological examination of the enlarged lymph nodes confirmed the absence of cancer tissue in all 3 cases.The results of preoperative lymph node immunostaining using 68Ga-NC-BCH combined with PET-CT were consistent with postoperative pathological examination results in all 5 cases (100%). These preliminary findings suggest that compared to CT, lymph node immunostaining using 68Ga-NC-BCH combined with PET-CT has higher accuracy in determining gastric lymph node metastasis in patients with gastric cancer.Conclusion:This study preliminarily confirmed the feasibility and safety of using 68Ga-NC-BCH combined with PET-CT lymph node immune tracing to guide preoperative and postoperative clinical decisions for gastric cancer patients. However, further prospective studies with larger sample sizes are needed to confirm the above conclusion.
In recent years, with the continuous advancement of endoscopic technology, from endoscopic retrograde cholangiopancreatography (ERCP) to peroral cholangioscopy, the concept of "super minimally invasive surgery" (SMIS) has made the endoscopic treatment of biliary and pancreatic diseases a reality, which can achieve the purpose of "curing diseases" on the basis of preserving organ and functional integrity, which is an important goal of future medical development.
Objective:Objective To develop expert consensus on the environment and layout of digestive endoscopy center.The overall layout, area partition and the configuration of medical equipment, protective equipment and fire facilities were designed according to the principle of "definite function, matched quantity, safe specification, reasonable layout". To avoid the risk of infection control and improve operation safety and patient satisfaction.Method:A compilation team was established to conduct article search on several databases such as China National Knowledge Infrastructure (CNKI) according to relevant domestic and foreign guidelines and consensus to screen and grade evidence.The preliminary draft of the consensus was completed, and was discussed through two rounds of expert demonstration meetings to carry out adjustment and modification before the consensus was developed.Result:The consensus suggest the digestive endoscopy center consist six functional area: appointment waiting area, diagnosis and treatment area, cleaning and disinfection area, resuscitation area, office and public living area and medical auxiliary area. The contents cover the layout and environmental requirements and standards of the relevant functional areas of the digestive endoscopy center, as well as how to do a good job in the relevant medical care of the digestive endoscopy center.Conclusion:The consensus item is simple, clear and easy to implement. The new content can complement and improve the existing norms and standards to a certain extent. It can provide reference standards for new, rebuilt and expanded endoscopic diagnosis and treatment centers and guide clinical practice.
The development of peroral biliary-pancreaticoscopy made it possible to treat biliary-pancreatic duct diseases using super minimally invasive techniques under direct vision. These techniques benefit those patients with indeterminate biliary-pancreatic duct stricture, difficult biliary-pancreatic duct stones, Mirizzi syndrome, gestational common bile duct stones, biliary stricture after liver transplantation, biliary malignant lesions, biliary hemobilia, foreign bodies in biliary-pancreatic duct, intraductal papillary mucinous neoplasm and so on. In view of the great progress of Chinese endoscopists in the field of peroral biliary-pancreaticoscopy super minimally invasive techniques, Chinese society of digestive endoscopy (CSDE) published this consensus, in order to standardize the related operations.
临床资料：患者男，40岁，因"发现食管下端占位性病变2月余"于2022年06月09日收入西安交通大学第二附属医院消化内科。患者自诉：2月前因胸闷气短于外院就诊，查冠脉CTA提示：左前降支近端阶段性轻度狭窄，胸部食管下段软组织密度影，考虑占位性病变。外院胃镜检查示食管隆起性病变(性质结合病理)，病理活检诊断报告：(食管)病变组织被覆鳞状上皮，上皮增生，其下间质可见炎性细胞浸润。建议行超声胃镜检查。近期患者自觉反酸烧心，无吞咽障碍，无其他不适症状来我院就诊。入院后实验室检查血尿粪常规、凝血功能、肝肾功、电解质、男性肿瘤标志物全套无明显异常。2022年6月14日本院内镜检查提示：食管下段距门齿35 cm可见一大小约2.5 cm × 1.5 cm不规则隆起性病灶，表面光滑，局部发红，稍凹陷，向腔内生长(图1)。超声内镜(endoscopic ultrasonography，EUS)检查示：食管病变处扫描见黏膜深层及黏膜下层不均匀偏低回声占位，内部未见血流，局部与黏膜层粘连，黏膜下层未中断，固有肌层未见异常占位，壁外、纵隔内未见肿大淋巴结；病变最大截面大小约29.7 mm×12.9 mm。诊断：食管隆起性病变考虑黏膜深层及黏膜下层偏低回声占位(图2)。胸部增强CT示：食管下段管壁增厚并结节状凸向腔内，管腔呈偏心性狭窄，增强后管壁呈渐进性强化；诊断：食管下段肿瘤性病变待排(图3)。上腹部平扫及增强CT未见明显异常。无明显手术禁忌，2022年6月15日在气管插管全麻下行内镜下黏膜剥离术(endoscopic submucosal dissection，ESD)，完整切除病灶(图4)。
Objective:To study the clinical characteristics of children swallowing magnetic digestive tract foreign bodies by mistake and analyze the risk factors, so as to seek effective preventive measures and optimize the treatment plan.Methods:Retrospective analysis was performed on the case data of children hospitalized for swallowing magnetic foreign bodies by mistake in Xi 'an Children's Hospital from January 2015 to December 2021.Results:Among the 153 cases of children who mistakenly swallowed magnetic foreign bodies, most of them were male (68.6%), mostly in early childhood and early school age, and the age fluctuated from 6 months to 14 years old.The number of hospitalizations and the number of surgical operations showed an increasing trend year by year.The number of mistakenly swallowed magnetic foreign bodies varied (1-60), and the types of foreign bodies were different. 85% of patients mistakenly swallowed multiple magnetic foreign bodies or magnetic foreign bodies combined with metal foreign bodies.Eighty-five patients(55.6%) underwent surgical intervention, and the main clinical symptoms were abdominal pain, among which 81 patients had digestive tract fistula, and entero-enteric fistula was the most common (50.6%). compared with the low age group, the OR value of complications in the high age group was 2.280 (95%CI: 1.155-4.501); Compared with other types of foreign bodies, the OR of buckball complications caused by swallowing magnetic beads by mistake was 30.816(95%CI: 7.291-130.254). The presence of clinical symptoms and the time of treatment >1 day significantly increased the risk of complications (P<0.05).Conclusion:Swallowing magnetic foreign bodies can easily cause serious complications such as digestive tract perforation, thus early detection, diagnosis and treatment are particularly important. Emergency gastroscopy within 24 hours after misingestion is the preferred treatment. If the location of magnetic foreign bodies on X-ray is not moved after multiple dynamic monitoring for more than 24 hours, surgery should be performed in time if there are clinical symptoms.In addition, comprehensive preventive measures should also be taken by age group and multiple parties to reduce the incidence.
Objective:To study the in vitro killing of Helicobacter pylori by a novel Nisin mixture and type A Nisin and to evaluate the bactericidal efficacy of the novel Nisin mixture.Methods:(1)Three strains of Hp standard strain NCTC 11637, clinical strain C27 and clinical strain C28 were selected in the experiment.The same concentration of type A Nisin, new Nisin mixture and blank control group were applied to H. pylori for two hours, and the growth of bacteria in each experimental group and blank control group was recorded after four days of incubation; (2)The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of the new nisin mixture against Hp standard strain NCTC 11637 and clinical strains were detected by critical dilution method, and the antibacterial diameter of the new nisin mixture was determined by disk diffusion method; (3)To investigate the effect of hydrochloric acid acidification on the novel Nisin mixture; (4)Antibiotic drug sensitivity testing was carried out by the E-test method.Results:(1)At the same concentration, the novel Nisin mixture group had a bactericidal effect compared with the type A Nisin group; (2)The MIC of novel Nisin mixture varied in different H. pylori strains, with values between 16 IU/ml to 32 IU/ml, and the MBC was the same at 32 IU/ml.the inhibitory diameters of novel Nisin mixture against Hp standard strain NCTC 11637, clinical strain C27 and clinical strain C28 ranged from 3.3 cm to 3.8 cm; (3)Hydrochloric acid acidification did not affect the bactericidal effect of novel Nisin mixture; (4)novel Nisin mixture has synergistic effect with tetracycline to kill HP, but the synergistic effect with metronidazole is not obvious.Conclusion:The novel Nisin mixture has good killing effect on H. pylori under the present experimental conditions and good acid resistance, and it has synergistic effect with tetracycline to kill Hp, which is expected to provide a new way for antibiotic synergistic therapy to eradicate H. pylori infection.
Mesenteric panniculitis is a chronic non-specific inflammatory disease involving mesenteric adipose tissue. The etiology of the disease is still unclear and is relatively rare in clinical practice. The paper provides a systematic review of its etiology and pathogenesis, clinical manifestations, auxiliary examinations, diagnosis and differential diagnosis, treatment and prognosis, with the aim of providing a more powerful reference for the clinical treatment of the disease.
Objective:To explore the operation cooperation and skills of simultaneous placement of biliary bimetallic stent anddifferent placement methods under endoscopic for malignant stricture ofhilar bile duct.Methods:The clinical data of 79 patients with malignant stricture of hilar bile duct who were planned to undergo simultaneous endoscopic biliary stent implantation were collected from January 2021 to December 2021 in the Endoscopic Department of the Third Affiliated Hospital of Naval Medical University (Shanghai Eastern Hepatobiliary Surgery Hospital). To summarize and analyze the operation cooperation skills before, during and after the simultaneous placement of biliary bimetallic stent via endoscope.Results:After preoperative evaluation, 77 patients were planned to undergo endoscopic placement of bilateral biliary metallic stent.Five of the 77 patients had complications after successful placement of bilateral metallic stent in the biliary tract, including 3 cases of cholangitis, 1 case of pancreatitis, and 1 case of bleeding at the cutting edge of duodenal papilla, with a complication rate of 6.49%.Conclusion:Standardized operation and skilled operation cooperation skills play an important role in the success of endoscopic simultaneous placement of biliary bimetallic stent. The cooperator has rich operation experience, solid theoretical knowledge and familiar with the doctor′s operation intention, which can not only shorten the operation time, improve the operation success rate, but also reduce the probability of postoperative complications.
Objective:To explore the early application and nursing methods of nasal jejunal nutrition tube in acute severe pancreatitis, and evaluate its nursing effect.Methods:82 patients with acute severe pancreatitis admitted to the Department of Gastroenterology at the First Medical Centre of the Chinese PLA General Hospital from June 2020 to October 2022 were selected as the research subjects.They were divided into an observation group (comprehensive nursing intervention) and a control group (routine nursing), with 41 patients in each group. The nursing effects of the two groups were compared.Results:The serum albumin (ALB) levels of the observation group patients after nursing were (36.14 ± 4.67) g/L > (31.48 ± 5.09) g/L, t=4.320, and the prealbumin (PA) levels were (221.89 ± 11.08) mg/L > (192.07 ± 13.57) mg/L, t=10.889, which were higher than those of the control group (P<0.05). The acute physiology and chronic health score (APACHE-Ⅱ) of the observation group patients after nursing was (13.37±2.95) points less than (16.12±3.43) points, t=4.607, lower than that of the control group (P<0.05). The observation group patients′ health survey summary (SF-36) score after nursing was (68.43±5.10) points > (59.05 ±5.49) points, t=8.015, which was higher than that of the control group (P<0.05). The disappearance time of abdominal pain symptoms in the observation group was (3.04±0.86) d 78.05%, χ2=5.145, higher than the control group (P<0.05). The incidence of complications in the observation group was 4.88% <19.51%, χ2=4.554, lower than the control group (P<0.05).Conclusion:In the rehabilitation process of patients with acute severe pancreatitis, early application of nasal jejunal nutrition tubes, implementation of enteral nutrition support interventions, and comprehensive nursing interventions can better improve the patient's nutritional status, improve their quality of life, and obtain good prognosis.
As an important part of the hospital information construction, the self-service reservation system plays an important role in improving the quality of outpatient service and improving the patient experience. G. I. endoscopic Center in department of Gastroenterology, First Medical Center of PLA General Hospital designed and developed a self-service reservation system according to own conditions, The waiting time of reservation was significantly reduced, the occurrence of adverse events was reduced, and the patient satisfaction was high. This paper focused on the design, implementation and optimization of the self-service reservation system.
The number of patients with intestinal diseases is increasing year by year. With the continuous replacement of image enhanced endoscopy (IEE) technology, the brightness and quality of images have been significantly improved. By optimizing visualization methods, the detection rate of intestinal diseases is expected to increase. In 2012, Fuji Corporation of Japan officially launched the Blue Laser Endoscopy System LASEREO.Fuji Corporation′s innovative multi LED light source integration technology can achieve four different observation modes: white light imaging (WLI), blue laser imaging (BLI), bright blue imaging (BLI-bright), and linked color imaging (LCI). LCI mode can reconfigure colors by adding a red accent signal. By expanding the color near the "redness" of the mucosa, signal processing increases color contrast, making it a special light staining technique.Numerous studies have shown that LCI can significantly improve the detection rate of redness and discoloration lesions.The effectiveness of LCI has been unanimously recognized by endoscopic physicians both domestically and internationally.Based on the current literature reports on the role of LCI in intestinal diseases, the following summary is made on the research progress of LCI in this field.
Gastroesophageal flap valve is closely related to gastroesophageal reflux disease. The Hill classification is a standard based on the different forms of gastroesophageal flap valve. This study aims to summarize the relevant literature of Hill classification, and evaluate the application value of it from the clinical characteristics, related diseases, objective examination and treatment methods of patients.
Objective:Obesity has become a serious global health concern. A number of studies suggest that chronic diarrhea is frequent in obese people. We performed a systematic review and meta-analysis to assess the prevalence of chronic diarrhea in obese adults.Methods:We systematically searched PubMed, Embase, and Web of Science for studies from inception through October 15, 2022.We included population-based or obese patient-based studies that could calculate the prevalence of diarrhea. Two researchers independently determined study eligibility, extracted data, and assessed quality.Data were pooled using a random effects model.Results:Overall, 8 studies with 19, 701 respondents were assessed, including 11, 820 overweight and obese individuals.The pooled chronic diarrhea rate was 23.02% (95%CI: 17.47%, 28.57%) in people with a BMI≥ 25 kg/m2.The prevalence of diarrhea in the obese group (23.79%, 95%CI: 16.29%, 31.29%) was higher than that in the overweight group (18.82%, 95%CI: 13.02%, 24.62%), but it was not statistically significant (P=0.30).Conclusions:Chronic diarrhea is quite common in obese populations.With the increasing number of obese people, and the coexistence of obesity and chronic diarrhea deserves extra attention.
Objective:To investigate the clinical significance of esophageal mean nocturnal baseline impedance (MNBI) in patients with extra-esophageal symptoms of gastroesophageal reflux disease (GERD).Methods:We performed a retrospective study of 210 patients with heartburn, reflux, cough, and hoarseness as their main symptoms who underwent 24-hour multichannel intraluminal impedance and pH monitoring in Beijing ChaoYang hospital from January 2018 to December 2019.According to diagnostic criteria and their main clinical manifestations, patients were divided into four groups, the extra-esophageal symptoms group, the typical symptoms group, the mixed symptom group with both typical and extra-esophageal symptoms, and the control group.We analyzed and compared distal and proximal esophageal MNBI value and other reflux parameters among the four groups.Results:The proximal esophageal MNBI value and mean pH at distal esophagus in GERD extra-esophageal symptoms group were lower than those in the typical symptom group (P<0.05). Correlation analysis showed that the proximal and distal esophageal MNBI value were negatively correlated with DeMeester score, acid exposure time and acid reflux times (P<0.05). According to ROC analysis, for GERD patients with extra-esophageal symptoms, area under curve of the proximal esophagus MNBI value was significantly higher than the area under curve of the distal esophageal MNBI value (P<0.05), the cut-off value for diagnosis was 2484.38 ohms. The sensitivity and accuracy of the proximal esophageal MNBI value in diagnosis GERD patients with extra-esophageal symptoms reached 92.3% and 84%, which were higher than those of the distal esophageal MNBI value.Conclusions:Both the proximal and distal esophagus MNBI values negatively correlate with acid exposure. Proximal esophagus MNBI value can improve the detection rate of multi-channel pH-impedance monitoring for patients with extra-esophageal symptoms of GERD, which has important clinical diagnostic value.
Objective:Currently, endoscopic retrograde cholangiopancreatography(ERCP)is the main modality for the removal of common bile duct stones.During ERCP procedures, radiation damage to the patient from a single procedure, as well as cumulative radiation damage to the operator from multiple procedures, is a problem that can′t be ignored. The advent of cholangioscopy has allowed indirect images during the procedure to become direct images, which can substantially reduce the need for intraoperative fluoroscopy.In this study, we explored the feasibility and safety of extraction for small-caliber and sediment-like common bile duct stones under cholangioscopy.Methods:Eight patients diagnosed with CBDSs (stones≤1 cm in diameter, or sediment-like stones) without previous ERCP at PLA General Hospital First Medical Center, from July 2022 to September 2022, were included. The clinical characteristics and treatment outcomes of the 8 patients were prospectively collected and analyzed.Results:The extraction of CBDSs by basket catheter under cholangioscopy was achieved in four cases, and the remaining four cases received aspiration extraction. Technical success was achieved in all 8 cases in a single procedure and one patient developed postoperative pancreatitis.Conclusion:This study initially demonstrated the feasibility and safety of extraction for small-caliber and sediment-like common bile duct stones under direct view of the choledochoscope.
Objective:To study clinical application value of Vonoprazan combined with amoxicillin for 7 day regimen of Helicobacter pylori eradication.Methods:The clinical data of 100 cases of Hp infection admitted to the Gastroenterology Department of the Fifth Affiliated (Zhuhai) Hospital of Zunyi Medical University were divided into study group (Vonoprazan+ amoxicillin) and control group (Standard quadruple therapy). There were 50 patients in each group. Statistical analysis of Helicobacter pylori eradication, remission of clinical symptoms, occurrence of adverse reactions and cost-effectiveness of the two groups.Results:The radical cure rate was 94% in the study group and 88% in the control group, the difference was not statistically significant (P>0.05); The remission rate of clinical symptoms in the study group was 84%, Significantly higher than the 62% of the control group, The difference was statistically significant (P<0.05); The incidence of adverse reactions in the observation group was 12%, Significantly lower than the 54% of the control, The difference was statistically significant (P<0.05); The total cost of the study group was 143.02 yuan, and the total cost of the control group was 384.41 yuan, The cost of the study group was significantly lower than that of the control group.Conclusion:The 7-day regimen containing Vonoprazan and amoxicillin can achieve the eradication rate of standard quadruple, the high remission rate of clinical symptoms, low adverse reactions, low cost, which is more worthy of promotion.
Objective:To evaluate the efficacy and safety of endoscopic treatment for patients with anastomotic varices(AV)and explore the optimal treatment.Methods:Eight patients with AV were enrolled. These patients were diagnosed by endoscopy from 2006 to 2020 in our center. Clinical features, endoscopic findings, treatment methods, adverse events and follow-up data were analyzed retrospectively.Results:Of the 8 patients, 4 had cavernous transformation in portal vein, and 1with liver cirrhosis. Hematemesis and melena were the most common initial symptom. During endoscopic examination, active bleeding in 2 cases and positive red color signs in other 3 cases were found. Five patients received endoscopic treatment. Three cases were treated with endoscopic cyanoacrolate injection (ECI), one with endoscopic injection sclerotherapy (EIS), and one with endoscopic variceal ligation(EVL). Immediate hemostasis rate was 100% post-endoscopic treatment for anastomotic variceal bleeding . Five-day treatment failure ratio was 20% . Six-week mortality after endoscopic treatment for anastomotic variceal bleeding was 0. The only adverse event was fever in one patient. During the follow-up period, one rebleeding case died of failure of conservative treatment for rebleeding.Conclusions:AV bleeding is rare and has the characteristics of difficult diagnosis, large volume of bleeding, difficult hemostasis, and poor prognosis. Endoscopic treatment of AV bleeding is feasible, safe, and effective. The recurrent bleeding rate of this disease is not satisfied, endoscope follow-up should be emphasized. If rebleeding occurring, endoscopic treatment or interventional treatment should still be used.
患者男，71岁。主因"右上腹痛伴黄疸1月"于2022年3月11日收入保定市第一中心医院消化内三科。患者1月前无明显诱因出现右上腹部疼痛，呈持续性钝痛，并向肩背部放射，伴发热，体温维持在37.8℃左右，以午后为重，伴寒战、皮肤及小便发黄、偶有恶心、无呕吐、体重下降约2.5 kg。既往19年前因"胆管结石"行"胆总管切开取石及胆道镜下肝内胆管取石术"；1年前又因"胆囊结石"行"胆囊切除术"。入院查体：T 37.6℃、P 70次/分、R 17次/分、BP 120/80 mmHg，神志清楚、精神差、结膜无苍白、巩膜黄染、周身浅表淋巴结未触及肿大、心肺查体无异常、腹平软、上腹部可见手术疤痕，有压痛、无反跳痛及肌紧张、肝脾肋下未触及、肝区叩击痛阳性、移动性浊音阴性、肠鸣音正常。入院后辅助检查：血常规：白细胞7.70×109/L、血红蛋白117.00 g/L、血小板226.00×109/L、中性粒细胞比率72.20%；肝功：丙氨酸氨基转移酶46.60 U/L、天门冬氨酸氨基转移酶41.10 U/L、白蛋白36.90 g/L、总胆红素52.60 μmol /L、直接胆红素36.00 μmol/L、间接胆红素16.60 μmol/L、γ-谷氨酰转肽酶620.00 U/L、碱性磷酸酶337.20 U/L；肿瘤标记物：AFP 2.02 ng/ml、CEA 1.62 ng/ml、CA-19927.26 IU/ml；门诊上腹部CT提示：肝左叶体积小；胆总管下段高密度影，结石？考虑低位胆道梗阻。初步诊断：胆总管结石伴化脓性胆管炎。给予抗感染、保肝、抑酸、补液等支持治疗。于2022年3月14日经内镜中心行经内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography，ERCP)取石，术中泛影葡胺造影可见胆总管扩张1.2 cm，下端约见1.0 cm充盈缺损影，胆总管上段不规则充盈缺损影，肝内胆管未见异常，弓形电刀沿乳头11点方向切开约0.3 cm，1.2 cm扩张球囊扩张乳头，取石网篮取出黄褐色结石及黄白色脓性分泌物(图1)，术后置入鼻胆引流管，胆汁引流通畅。术后给予暂禁食水、抑酸、补液等综合治疗。患者仍感腹痛，体温最高达38℃，术后第3天复查腹部CT示：ERCP术后改变，肝内胆管扩张；肝顶稍低密度。当时考虑患者腹痛为鼻胆管刺激所致，遂予拔除。复查血常规及肝功能较术前无明显变化，C反应蛋白：37.30 mg/L、血淀粉酶及脂肪酶正常，考虑胆管内感染脓液引流不畅，于3月21日再次行ERCP术：术中胆管造影仍提示胆总管内不规则充盈缺损影，用取石球囊取出大量黄白色脓性分泌物(图2)，术毕置入8.5Fr-8 cm塑料胆管支架(图3)。术后患者腹痛仍不能缓解，并出现持续高热，体温最高达38.9℃，抗生素升级为比阿培南0.3 g，12 h 1次静脉点滴。同时口服熊去氧胆酸胶囊250 mg,每日3次，监测肝功能及炎症指标。3月24日行上腹增强CT示：肝顶多发异常强化，考虑肝脓肿可能(图6)。因治疗效果不佳，请感染性疾病科会诊后仍建议继续抗感染治疗，监测炎症指标及脓肿影像学变化，尽可能穿刺引流以缩短病程，并留取血培养以明确致病菌。遂调整比阿培南0.3 g，8 h 1次、加用莫西沙星0.4 g，每日1次联合抗感染，同时加用人血白蛋白支持对症治疗。患者腹痛及发热症状仍无明显缓解，3月31日进行上腹MRI平扫+增强检查提示为肝内多发异常信号，肝内外胆管及胆总管扩张，肝门区胆管截断，肝门区淋巴结肿大(图7)。复查腹部彩超提示肝脓肿，液化不明显，不易穿刺。于2022年4月6日加用去甲万古霉素抗感染治疗，患者治疗效果欠佳。再次请普外科会诊，仔细阅片考虑肝门区胆管截断，肝内多发不均低密度，不除外恶性肿瘤可能，建议穿刺活检。超声造影提示肝内不均质回声，倾向炎性病变，因周边血管丰富穿刺出血风险高，不宜进行穿刺活检。此时患者内科保守治疗效果不佳，恶性肿瘤不能除外，经与患者及家属反复沟通，建议手术治疗，于4月4日转入普外科并行手术探查，术中发现肝左叶萎缩、质硬，多发肿物突出肝表面，右肝未见明显肿物，腹腔广泛粘连，肝门部多发肿大淋巴结，术后病理证实为左半肝低分化胆管细胞癌(图8)。患者术后腹痛好转，体温恢复正常，家属拒绝进一步治疗，自动出院，离院后1个月病逝。
