Mr. Li Zhenguo, 72 years old, was born in Zhangjiakou, Hebei Province. He developed upper abdominal discomfort, weight loss, fatigue and poor appetite in November 2010. His symptoms worsened in January 2011 and his urine turned yellow. He then went to the hospital for treatment. Ultrasound and CT scans revealed pancreatic mass, CA199 (tumor marker)>3000, and abdominal CT scans showed: plain scan showed dilatation of the intrahepatic bile duct, no obvious dilatation of the common bile duct, abnormal anatomical structure of the liver hilar region, soft tissue density shadows of about 4.5cm*4.2cm in size, CT values of 38-64HU (units), unclear boundaries, uneven density, invasion of the edge of the pancreatic head, full pancreas, significantly enlarged volume, pancreatic duct dilatation, spleen enlargement, occupying 7 rib units. After contrast agent treatment, the inferior vena cava was significantly dilated, both kidneys were evenly enhanced, no obvious abnormal density shadows were found, lymphadenopathy was seen in the liver hilar region, and no fluid was found in the abdominal cavity. Because the patient had undergone gallbladder cancer resection surgery, the initial diagnosis was: 1. After gallbladder cancer surgery, there is a possibility of metastasis to the hilar region and invasion of the edge of the pancreatic head; 2. The intrahepatic bile duct is dilated, and the obstruction plane is located in the hilar region; 3. The size of the pancreas and spleen is increased. Western medicine diagnosis: pancreatic cancer with jaundice, progressive stage. Chinese medicine syndrome differentiation: blood stasis and toxicity, liver depression and spleen deficiency, liver and pancreas dampness and heat Considering the patient's advanced age and the fact that he had undergone a gallbladder cancer resection surgery, surgical treatment was basically given up. Since radiotherapy has significant side effects, Chinese medicine treatment was used to assist in the treatment, in order to resolve blood stasis and detoxify, soothe the liver and strengthen the spleen, and clear away heat and dampness. After treatment and recuperation, the patient's jaundice symptoms gradually disappeared, his diet and sleep were good, and his mental state was getting better and better. Currently, Mr. Li Zhenguo is still receiving further treatment. |
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