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患者女,72岁。上腹部疼痛、食欲不振3天入院。体格检查:腹部平坦,腹肌软,剑突下及右上腹压痛,无反跳痛,Murphy征(-)。右上腹触及肿大胆囊,约6 cm×6 cm大小,质硬,压痛明显,肝脾肋下未触及,肝区无叩痛。超声检查:胆囊体积增大,壁厚0.5 cm,内见一大小约6.4 cm×4.9 cm包块。超声诊断:胆囊占位性病变。CT检查:胆囊体积明显增大,壁增厚,胆囊腔内见略高密度软组织肿块,大小约5.1 cm×5.6 cm,平扫CT值46 HU
Female patient, 72 years old. Upper abdominal pain, loss of appetite 3 days admitted. Physical examination: flat abdomen, abdominal muscle soft, under the xiphoid and right upper quadrant tenderness, no rebound tenderness, Murphy sign (-). Right upper quadrant palpable enlargement of the gallbladder, about 6 cm × 6 cm size, hard, tenderness significantly, liver and spleen ribs were not touched, no percussion pain in the liver area. Ultrasonography: gallbladder volume increases, the wall thickness of 0.5 cm, see a size of about 6.4 cm × 4.9 cm mass. Ultrasound diagnosis: gallbladder mass lesions. CT examination: the volume of gallbladder increased significantly, thickening of the wall, see slightly high density soft tissue mass in the gallbladder cavity, the size of about 5.1 cm × 5.6 cm, CT scan 46 HU