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女,49岁。因B超发现胆囊占位病变及脾大入院,3年前患过乙型肝炎。查体:体温、脉搏、血压正常。皮肤、巩膜无黄染。心肺正常。腹软,肝上界正常,肋下未及。脾大,左肋缘下3cm。实验室检查:血红蛋白110g/L,白细胞2.6×10~9/L(2600/mm~3),中性0.55,淋巴0.43,酸性0.02。血小板64×10~9/L,肝功、血糖、二氧化碳结合力以及血清钾、钠、氯及尿素氮正常。食管钡透正常。诊断门静脉高压症,胆囊腺瘤可能性大。
Female, 49 years old. Because of B-found gallbladder lesions and splenomegaly admission, 3 years ago, had hepatitis B. Physical examination: body temperature, pulse, normal blood pressure. Skin, sclera without yellow dye. Cardiopulmonary normal. Abdominal soft, normal upper liver, ribs under the time. Splenomegaly, left margin of the ribs 3cm. Laboratory tests: hemoglobin 110g / L, leukocytes 2.6 × 10 ~ 9 / L (2600 / mm ~ 3), neutral 0.55, lymph 0.43, acid 0.02. Platelets 64 × 10 ~ 9 / L, liver function, blood glucose, carbon dioxide binding and serum potassium, sodium, chlorine and urea nitrogen normal. Esophageal barium through the normal. Diagnosis of portal hypertension, gallbladder adenoma is likely.