IDUS对胆胰管疾病的应用体会.ppt

Advances of IDUS in Diagnosis for Advances of IDUS in Diagnosis for BilliaryBilliary Diseases Diseases Xiaoping Zou Department of Gastroenterology Nanjing Drum Tower Hospital Nanjing University School of Medicine Nanjing, China Intra-ductal Ultrasonography, IDUS Advantages of IDUSAdvantages of IDUS With a finer probe, can get approach to the With a finer probe, can get approach to the target site through working channel of the target site through working channel of the endoscopyendoscopy Get clearer images without the interference of Get clearer images without the interference of air and fatair and fat Probe with higher frequency is enabled with a Probe with higher frequency is enabled with a close distanceclose distance Images of high resolutionImages of high resolution IDUS vs. routine EUSIDUS vs. routine EUS The tubular structure of The tubular structure of pancreato-billiarypancreato-billiary duct duct facilitate the acoustical couplingfacilitate the acoustical coupling Fluid in duct can be used as medium of ultrasoundFluid in duct can be used as medium of ultrasound The diameter of the duct is slightly larger than The diameter of the duct is slightly larger than thantthant of the probeof the probe Higher frequencyHigher frequency (12-30MHz)(12-30MHz) Better image resolutionBetter image resolution Type of probeType of probe Electronic circular scanElectronic circular scan Synchronized double section scanSynchronized double section scan Mechanical radial scanMechanical radial scan Images of normal Images of normal billiarybilliary duct duct 2-3 layers2-3 layers Thickness: 0.31-0.79mmThickness: 0.31-0.79mm Smooth layer with homogenous Smooth layer with homogenous echoecho First layer: hyper-First layer: hyper-echogenicityechogenicity, , represents the represents the interphaseinterphase Second layer: hypo-Second layer: hypo-echogenicityechogenicity, , represents mucosal and represents mucosal and muscularismuscularis propriapropria layers layers Outer layer: hyper-Outer layer: hyper-echogenicityechogenicity, , the echo of fat and interface the echo of fat and interface between between serosaserosa and other organs and other organs Clinical applicationClinical application BilliaryBilliary duct duct Suspected stone in Suspected stone in billiarybilliary duct duct Differentiation for Differentiation for stenosisstenosis Tumor stagingTumor staging Pancreatic ductPancreatic duct Differentiation for Differentiation for stenosisstenosis Tumor stagingTumor staging Showing details of cystic Showing details of cystic neoplasmsneoplasms Localization of Localization of neuroneuro-endocrine tumors not -endocrine tumors not detcteddetcted by EUS by EUS Suspected stone in CBDSuspected stone in CBD CBD stonesCBD stones N=35 N=35 （with suspected stoneswith suspected stones） Of 21 patients with stones not detected by ERCP, IDUS Of 21 patients with stones not detected by ERCP, IDUS identified 8, in which 7 were proved by ESTidentified 8, in which 7 were proved by EST Of 5 patients with suspected stones under ERCP, IDUS Of 5 patients with suspected stones under ERCP, IDUS identified them as bubblesidentified them as bubbles IDUS changed the clinical strategies in 13IDUS changed the clinical strategies in 13 (37%) patients(37%) patients Catanzaro, A, Pfau, P, Isenberg, GA, Wong, RC. Clinical utility of intraductal US for evaluation of choledocholithiasis. Gastrointest Endosc 2003; 57:648. N=62N=62 Detect rate of Detect rate of cholangiographycholangiography : 87% : 87% IDUSIDUS combined with combined with cholangiographycholangiography: 97%: 97% IDUS in IDUS in cholangiocarcinomacholangiocarcinoma and and differentiation between benign and differentiation between benign and malignant stricturemalignant stricture Features of Features of cholangiocarcinomacholangiocarcinoma under IDUSunder IDUS Mass of hypo-echo, infiltrating the surrounding tissueMass of hypo-echo, infiltrating the surrounding tissue Heterogeneous echo inside the massHeterogeneous echo inside the mass Serrated or irregular marginSerrated or irregular margin Surface of papillary protrusionSurface of papillary protrusion Destruction of normal bile ductDestruction of normal bile duct Suspected Suspected lymphadenectasislymphadenectasis CholangiocarcinomaCholangiocarcinoma StagingStaging Detection of early lesionsDetection of early lesions Identify the margin along the ductIdentify the margin along the duct Determine the infiltration of pancreasDetermine the infiltration of pancreas Determine the infiltration of portal veinDetermine the infiltration of portal vein Determine the infiltration of right hepatic arteryDetermine the infiltration of right hepatic artery CholangiocarcinomaCholangiocarcinoma N=?, local staging, compared with N=?, local staging, compared with pTpT staging staging Accuracy of EUS: 54%Accuracy of EUS: 54% Accuracy of IDUS: 77%Accuracy of IDUS: 77% IDUS was especially useful for tumors in middle section of IDUS was especially useful for tumors in middle section of CBD and portal fissureCBD and portal fissure With poor penetration, unable to make M and N With poor penetration, unable to make M and N stagingstaging Unable to perform FNAUnable to perform FNA Menzel, J, Domschke, W. Intraductal ultrasonography (IDUS) of the pancreato-biliary duct system. Personal experience and review of literature. Eur J Ultrasound 1999; 10:105. Tamada, K, Kanai, N, Tomiyama, T, et al. Predict