肝胆胰影像学PPT课件.ppt

肝胆胰影像学Radiologyofliver,biliarysystemandpancreas,1,.,了解肝胆胰常用影像学检查技术掌握原发性肝癌的CT表现掌握肝海绵状血管瘤的CT表现掌握胆石症的CT表现掌握急性胰腺炎的CT表现,学习目的与要求,2,.,MedicalImagingofliver,biliarysystemandpancreas,EchoCTMRIDSANuclearMedicine,3,.,肝血管造影angiography,普通血管造影DSA,4,.,经纤维胃镜导入导管导管进入十二指肠乳头透视监控下注造影剂胆胰管充盈,逆行性胰胆管造影ERCPendoscopicretrogradeCholangiopancreaticography,显示胆管腔内部轮廓,造影对比剂进入胆管,提高胆管腔内密度,5,.,CTofLiver，BiliaryandPancreas,6,.,CToftheliver，biliaryandpancreas,7,.,CTReconstructionofbileduct,8,.,2030秒,5060秒,110120秒,延长,1520秒,动脉期,门脉期,平衡期,肝脏螺旋CT多期扫描DynamicCT,9,.,MRIofLiver，BiliaryandPancreas,10,.,T1WI和T2WI为常规序列,11,.,脂肪抑制序列区别水和脂肪信号,TR/TE6000/90,12,.,DynamicMRI,动脉期,静脉期,13,.,成像原理,肝脾胰实质器官驰豫时间短重为低信号血液快速流动的大血管流空低信号脂肪为中等驰豫时间为高信号（脂肪抑制）静态水极长驰豫时间为高信号,利用重加权脉冲序列来展示具有非常长驰豫值结构的技术,3D,SS-FSE,14,.,肝正常影像学,密度或信号大小形态肝血管胆道,densityorsignalintensitysizestypebloodvesselbiliarysystem,15,.,正常影像学肝叶与肝段,右叶、尾叶、方叶、左叶,左外上下侧段,镰状韧带,左内侧段,右前上段右后上段右前下段右后下段,16,.,NormalCTofPancreas,胰头、体、尾、钩突部32.52cm,17,.,胰管内径24mm层厚10mm扫描不显5mm扫描可显示水平段,NormalCTofPancreas,18,.,Normalbileduct,19,.,AbnormalofLiver，BiliaryandPancreas,20,.,肝的大小异常,肝脏形态大小边缘异常,EnlargementliverLobulatedcontourofliver,21,.,肝实质改变,密度增高或降低Hyperorhypoattenuationofliverparenchyma,22,.,肝的MRI信号降低,T1WI和T2WI都表现低信号，“黑肝”GeneralizedreductioninsignalintensityonT1WI和T2WI“blackliver”,23,.,肝血管改变Abnormalofhepaticvessel,血管增粗，血管狭窄，病理血管，肿瘤染色动静脉瘘，门脉癌栓,24,.,胆系异常影像学,胆囊增大胆囊缩小胆囊密度改变胆囊壁增厚,CalcificationConstrictionThickenedbileductwallDilatationofgallbladerandbileduct,25,.,肝胆异常影像学,胆管扩张dilatationofbileduct胆管狭窄constrictionofbileduct胆管内充盈缺损fillingdefection,管腔改变,26,.,EnlargementpancreasshrunkenpancreasTumorinthepancreas,27,.,常见疾病影像学原发性肝癌hepatocellularcarcinoma临床症状多出现在中晚期，表现肝区疼痛，消瘦乏力，腹部包块。6090%肝细胞癌AFP阳性。晚期出现黄疸,28,.,原发性肝癌的分型,结节型5cm巨块型5cm弥漫型多发小结节小肝癌:1个结节3cm2个结节直径3cm,原发性肝癌主要由肝动脉供血,29,.,原发性肝癌的影像学检查方法选择,肝癌主要检查方法：对比增强多期CT扫描multiplestagesofcontrastenhancementMRI在鉴别诊断、小肝癌诊断血管造影：介入治疗前用来了解肿瘤血供情况,30,.,CT表现,肝癌平扫肝实质软组织肿块多数表现肝实质内单发或多发境界清楚或不清楚的低密度肿块肿瘤坏死中间则出现更低密度区,masswithhypo-attenuationonplainCT,31,.,“快显快出”,CT增强,平扫肿块低密度动脉期高密度强化门脉期强化密度迅速降低平衡期肿块强化进一步降低,masswithhypo-attenuationonplainCT,ObviouslyenhancementinarteryphaseThedensityReduceinginportalveinphase,32,.,CT表现,其它重要CT表现肿瘤假包膜pseudenvelope静脉癌栓thrombus腹腔淋巴结肿大lymphadenopathy,33,.,临床与病理肝海绵状血管瘤（Cavernoushemangiomaoftheliver）肝实质内异常血窦组成的团块状血管性肿块最常见肝的良性肿瘤,肝海绵状血管瘤(CavernousHaemangiomahepatic,34,.,螺旋CT和MRI对比增强多期扫描在肝癌诊断中具有非常重要的价值血管造影比较少用,肝海绵状血管瘤的影像学检查方法,35,.,平扫:圆形或卵圆形低密度灶，境界清楚，密度均匀。Avascularorglobularnodularwithasharpmarginandiso-indensity.动态增强:“早出晚归”现象：1、早期边缘强化earlyenhanceobviously2、增强区域进行性向心性扩展progressive“fill-in”ofthelesionfromtheperipherytowordsthesentre3、延迟扫描病灶等密度充填,肝海绵状血管瘤Cavernoushaemangioma,36,.,发生于胆道系统内的结石分为胆色素性结石（calculusofbilepigment)和胆固醇类结石(cholesterolcalculus)右上腹疼痛和黄疸为常见的症状影像学常表现阴性和阳性结石并发症为胆管梗阻和胆系炎症,胆石症,胆囊结石Cholecystolithiasis,肝外胆管结石Thecalculusofextrahepaticbileduct,肝内胆管结石Thecalculusofintrahepaticbileduct,胆管结石CalculusofBileDuct,37,.,USGCTMRI/MRCPPTCERCP,影像学检查方法,胆石症,38,.,X线平片显示高密度阳性结石(hightintensitypositivecalculi)环状、边缘密度高、中间密度低,胆石症(GallStones),39,.,PTC显示类圆形充盈缺损及胆管扩张,胆石症(GallStones),40,.,胆囊阳性结石(Cholecystpositivecalculus),胆石症,41,.,MRCP,胆石症,42,.,肝内肝外胆管结石,胆石症,43,.,MRCP,胆总管下端结石MRCP表现杯口状充盈缺损,胆石症,44,.,胆总管下端结石合并胆管梗阻StoneofbileductWithobstrution,45,.,胆石症影像学诊断依据,X线平片、CT胆管、胆囊高密度结石PTC、ERCP、MRCP胆管、胆囊内充盈缺损CT、MRI、MRCP胆管扩张,46,.,急性胰腺炎(AcutePancreatitis),病因和病理1、病因胆源性(choledocholithiasis)酒精性(alchohol)十二指肠梗阻、ERCP后等感染性(infectived)药物(drugs)性和代谢(metabolizable)性特发性,47,.,急性胰腺炎(AcutePancreatitis),2、病理(pathology)早期胰腺轻度肿胀（充血engorgement水肿edema）进展出血(haemorrhage)、坏死（nercrotize)（弥漫或局灶性）进展胰腺内、腺周、肠系膜、网膜、后腹膜脂肪坏死,48,.,急性胰腺炎(AcutePancreatitis),分型单纯水肿型：(simplyedematouspancreatitis)胰腺局部或全部水肿充、增大、发硬出血坏死型:(necrotizingpancreatitis)胰腺炎合并出血和坏死。,49,.,急性单纯水肿型胰腺炎(simplyedematouspancreatitis)胰腺增大多为弥漫性，少数局限于头部肿大。胰腺密度胰腺密度正常或下降，均匀或不均匀，反映水肿的程度。胰腺轮廓胰腺轮廓清楚，炎症渗出明显可出现轮廓不清楚。增强CT胰腺均匀强化，无坏死区。,AcutePancreatitis,50,.,增强：密度均匀无坏死区,胰管轻度扩张,平扫外形增大、轮廓清楚、少量渗出,51,.,胰腺体积改变弥漫性胰腺肿大(pancreaticenlargh)胰腺体积增大的程度一般与临床严重程度程正比。,急性出血坏死型胰腺炎,52,.,增强,平扫,密度改变胰腺水肿CT值低于正常胰腺的CT值（4045HU）坏死灶(pramchymalnecrotisis)胰腺实质囊状低密度区无强化出血CT值高达5070HU。,AcutePancreatitis,53,.,胰尾部大片坏死增强后不显影胰周大量积液,AcutePancreatitis,54,.,胰周改变胰腺周围积液fluidcollection常见部位：小网膜囊和左侧肾前间隙,AcutePancreatitis,55,.,胰周积液fluidcollection,小网膜囊内大量积液肝外缘少量腹水,AcutePancreatitis,56,.,胰腺大片坏死胰周及肾旁间隙大量积液肾旁筋膜增厚,AcutePancreatitis,57,.,蜂窝组织炎phlegmonousinflammation含胰蛋白酶的胰液外溢胰腺和胰周的脂肪、结缔组织坏死。部位：常见胰体胰尾、小网膜囊、左肾前间隙表现：大片状不规则、CT值高于水的低密度软组织。肾旁筋膜增厚。,AcutePancreatitis,58,.,蜂窝组织炎累及小网膜囊,AcutePancreatitis,phlegmonousinflammation,59,.,胰周蜂窝组织炎趋向于局限,蜂窝组织炎累及肾前旁间隙肾前筋膜增厚,AcutePancreatitis,phlegmonousinflammation,60,.,假性囊肿(pseudocyst)发生率为10%潴留液被纤维结缔组织包绕而成胰周或胰实质内境界清楚的囊性肿块可单发或多发CT值与水相同。,AcutePancreatitis,61,.,时间：99.