The Third People's Hospital of Taiyuan

CT Examination Report

Name: XXXX                            Gender: Female                Age: 66y                                                 Image No.: XXXX

Dept.: Group 1 of Infection and immune liver diseases      Examination No.: XXXX                  Inpatient No.: XXXX

Report time: 2023-10-26 at 09: 58: 01                                     Scan Method: Helical CT plain scan+Contrast scan+3D reconstruction

Examination site: Upper abdomen+Lower abdomen

Examination findings:

Abdominal CT scan and 3D reconstruction showed:

There was liver deformation, with small volume of the left lobe, the proportion of each lobes were dysregulated; The fissure of liver was not widened, intrahepatic vascular space was not widened, the hepatic edge was not smooth, the density of liver parenchyma was uneven with uneven enhancement. Multiple nodular and slightly lower density were found in the liver, with unclear boundaries, the enhancement was not obvious in each phase of contrast scan, but was evident in the venous phase. The intra-and extrahepatic portal veins showed good, the diameter of the main portal vein at the hepatic hilum was about 1.1cm, and the esophageal and gastric fundus and gastric left veins were tortuous and dilated, the paraumbilical vein was open, and the spleen and renal veins were shunt. The local bile ducts inside and outside the liver were slightly dilated, with local gas accumulation. The gallbladder was absent. There was no obvious abnormality in pancreas size, shape and density, with uniform enhancement. The spleen was enlarged with uniform parenchymal density, and punctate calcification was found in the spleen.There were no significant abnormalities in the bilateral adrenal glands, with uniform enhancement. A circular low density shadow was found in bilateral kidney parenchyma, about 1.1cm*1.0cm in size, no enhancement was found after contrast scan. Multiple lymph nodes were visible in the cardio-diaphragmatic angle area, peritoneal cavity and retroperitoneal area. Small intra-abdominal effusion was found. The gastric filling was well, without localized thickening of the gastric wall. No dilated effusion was found in the intestine. The cystic pouch shadow was found in the descending segment of the duodenum, gas and liquid level were found in it.

Diagnostic opinion:

1.       Cirrhosis, splenomegaly, a small amount of ascites, and opened collateral circulation.

2.       The left lobe of the liver was small, please combined with clinical practice.

3.       Multiple low-density images in the liver, please combine with other imaging examinations and clinical studies, and perform further MRI if necessary.

4.       Changes after cholecystectomy. Mild dilated and gas accumulation in local bile duct inside and outside the liver.

5.       Calcium in the spleen.

6.       Bilateral renal cysts.

7.       Multiple lymph nodes were visible in the cardio-diaphragmatic angle area, peritoneal cavity and retroperitoneal area.

8.       Diverticulum in the descending segment of the duodenum.

Report physician:                                                          Review (Consultation) physician:

Kindly reminder: This report is for clinical reference only, please bring the original film for comparison after review! Thank you for your cooperation!

The Third People's Hospital of Taiyuan

Ultrasound examination reportName: XXXX                                       Gender: Female                                              Age: 66y

Examination No.: XXXXX                       Inpatient No.: XXXX                                     Ultrasound No.: XXXX

Application Dept.: Group 1 of Infection and immune liver diseases                                  Examination equipment: PHILIPS EPIQ5        Examination site: Liver, gallbladder, pancreas, spleen, kidney, portal vein, ascites positioning, pleural fluid positioning

Examination parameters:

Left lobe thickness of liver                  2.5cm                      Left lobe length of liver           3.3cm                  Maximum slope of the right lobe                                          13.2cm       Long diameter of spleen               13.9cm

Intercostal thick diameter of the spleen                             5.8cm             Subcostal diameter                       3.5cm                      Pancreatic head                                          1.1cm         Body                        0.8cm

Tail                                     1.1cm         Left kidney               8.9*4.4cm      Right kidney      9.8*3.2cm           Main portal vein width       0.8cm

Blood flow velocity of the main portal vein                        129cm/s        Common bile duct width               0.4cm

Examination findings:

A massive intestinal tympanites reflex was found in the abdominal cavity.

The left lobe of the liver was small, the capsule of the right lobe of the liver was undulating, rough echo and uneven distribution within the liver parenchymal were found, multiple small hypoechoic reflected areas were found in the liver parenchyma with unclear boundaries and without blood flow signal; The right lobe of the liver could found a small strong echo, with acoustic shadow, the size was 0.5cm, there was no expansion of the tube around it; A heterogeneous echo region was visible in the right lobe of the liver, with unclear borders and the range was about 3.1*2.2cm, with obvious abnormal blood flow signal; Portal vein, splenic vein, and superior mesenteric vein all blood flow to the liver. In the left branch sac of the portal vein, a pipe structure extended to the liver surface, the inner diameter was 0.6cm, within which the venous spectrum from the liver could be found, Vmax: 17.2cm/s.

After cholecystectomy, there was no expansion of the interhepatic and extrahepatic bile ducts.

There was no abnormal echo of pancreas size and shape, and no dilatation of the main pancreatic duct.

A cystic dark region was visible in the middle pole of the left kidney with a smooth wall, and an enhancement effect in the posterior wall was ? cm, there was no abnormality in the remaining structures. The right kidney was normal in size and showed no structural abnormalities.

The long diameter of spleen: 13.9cm.

The liquid dark zone 0.9cm in size was visible above the bladder.

There was no free liquid dark zone in the bilateral thorax.

Examination suggestions:

1. Cirrhosis, it might be multiple small nodules in the liver; Calcification lesions in the right lobe of the liver; Heterogenous echo of the right lobe of the liver, and its nature? The paralignal vein was opened.

2. Splenomegaly

3. Left renal cyst

4. No abnormalities were observed in pancreas and right kidney

5. Ascites; No pleural effusion was found.

Regular review is recommended

Examination time: 2023-10-21                                                              Examined physician: XXXX

Inputted by: XXXX

Ultrasound examination is affected by many factors in the patient himself . (obesity, gas disturbance, poor coordination, special lesion location, different stages of the disease, etc.) This report is for clinical reference only and is valid for this examination only.

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