慢性胰腺炎及并发症ppt课件.ppt

MRIofPancreatitisandItsComplications ChronicPancreatitis 慢性胰腺炎及其并发症的MRI表现 1 Chronicpancreatitisisaninflammatorydiseasecharacterizedbyprogressiveandirreversiblestructuraldamagetothepancreasresultinginpermanentimpairmentofbothexocrineandendocrinefunctions ERCPisthegoldstandardforearlychronicpancreatitis butitisinvasive MRImaybeanalternativeforpatientsinwhomCTorERCPiscontraindicatedornottolerated MRIprovidesnoninvasivebiliaryandpancreaticductimagingandaccuratecharacterizationofpancreaticandperipancreaticpathology 慢性胰腺炎是一种炎症性疾病 其特征是对胰腺逐步和不可逆转的结构性损坏 导致外分泌和内分泌功能的永久性受损 ERCP是诊断早期慢性胰腺炎的金标准 但它是侵入性检查 在CT或ERCP为禁忌或不能耐受时 MRI可作为替代 MRI提供非侵入性胆胰管成像和胰腺及胰周病变的征象 2 ThediagnosisofchronicpancreatitisonMRIisbasedonsignalintensityandenhancementchangesaswellasonmorphologicabnormalitiesinthepancreaticparenchyma pancreaticduct andbiliarytract Theimagingfeaturesofchronicpancreatitiscanbedividedintoearlyandlatefindings 慢性胰腺炎MRI诊断是基于信号强度和增强的变化 以及胰腺实质 胰管和胆道形态的异常 慢性胰腺炎的影像特征可分为早期表现和晚期表现 3 Earlyfindingsincludelow signal intensitypancreasonT1 weightedfat suppressedimages decreasedanddelayedenhancementafterIVcontrastadministration anddilatedsidebranches Latefindingsincludeparenchymalatrophyorenlargement pseudocysts anddilatationandbeadingofthepancreaticductoftenwithintraductalcalcifications 早期表现包括T1加权脂肪抑制图像上呈低信号 延迟强化或强化程度减低 侧支扩张 晚期表现包括实质萎缩或肿大 假性囊肿 胰管扩张或呈串珠样 导管内常伴钙化 4 MRIallowsearlyrecognitionofchronicpancreatitisbasedonchangesinpancreaticsignalintensity thesechangesarebestvisualizedonunenhancedandgadolinium enhancedT1 weightedfat suppressedimages Fig 1A 1B 1C 1D MRI可以早期识别慢性胰腺炎胰腺信号强度的变化 平扫和增强T1加权脂肪抑制图像显示信号变化最佳 图1A 1B 1C 1D 5 Fig 1A 1B Fig 1A 24 year oldwomanwithsmallpancreaticductstonecausingductobstructionandsegmentalpancreatitis AxialT2 weightedHASTEimageshowsslightlyincreasedsignalintensityofpancreatictail arrow withmilddilatationofpancreaticduct AxialT1 weightedfat suppressedspoiledgradient echoimageshowsabnormallowsignalintensityofpancreatictail arrow whileremainderofpancreashasnormalbrightsignalintensity 24岁 女 小胰管结石引起胆道梗阻和节段性胰腺炎 T2WI胰尾信号轻度升高 胰管轻度扩张 箭头 T1WI显示胰尾异常低信号 箭头 胰腺其余部分信号强度正常 为高信号 6 AxialenhancedT1 weightedfat suppressedspoiledgradient echoimageobtainedduringarterialphaseshowsdelayedenhancementofpancreatictail arrow relativetonormalpancreasduetofibrosis Patientlaterdevelopedatrophicchangesinthisareathatledtoresectionofpancreatictail Contrast enhancedCTscanshowspunctatehigh densityfocus arrow inpancreaticductrepresentingsmallintraductalstone ThisexampleillustratestheadvantageofCTinshowingtinyintraductalstonethatwasnotseenonMRI It however alsoillustratestheadvantageofMRIinshowingchangesofsignalintensityassociatedwithchronicpancreatitisthatarenotvisibleonCT 动脉期增强T1WI示因纤维化胰尾较正常胰腺强化延迟 箭头 此处后来呈萎缩性改变 导致实行胰尾切除术 对比增强CT扫描显示胰管内小结石 这个例子说明了CT的优势在于显示微小的管内结石 而在MRI未显示 然而 它也显示出磁共振成像的优点 可显示出慢性胰腺炎信号强度的变化与关系 此在CT上是不可见的 Fig 1C 1D 7 Chronicinflammationandfibrosisdiminishtheproteinaceousfluidcontentofthepancreas resultinginthelossoftheusualhighsignalintensityonT1 weightedfat suppressedimages Thenormalpancreasenhancesuniformlyandintenselyonearlyarterialphasecontrast enhancedT1 weightedimagesandexhibitsrapidwashoutofgadoliniumonsubsequentimages 慢性炎症和纤维化减少胰腺的蛋白质含量 使得在T1加权脂肪抑制图像上高信号消失 正常胰腺动脉期均匀明显强化 并快速廓清 8 Incontrast apancreaswithchronicfibrosisandglandularatrophyexhibitsdecreasedandheterogeneousenhancementonearlyarterialphaseimagesandincreasedrelativeenhancementondelayedimages Fig 2A 2B 2C 相比之下 慢性纤维化并腺体萎缩的胰腺在早动脉期强化程度减低并强化不均匀 延迟图像上强化程度相对升高 图2A 2B 2C 9 Fig 2A 2B Fig 2A 46 year oldmanwithhistoryofchronicpancreatitisduetoalcoholabuse AxialT1 weightedfat suppressedspoiledgradient echoimageshowsatrophyofpancreaticparenchymaandirregulardilatationofmainpancreaticduct arrows changessuggestiveofchronicpancreatitis CalcificationsarenotaswellseenonMRIasonCT AxialenhancedT1 weightedfat suppressedspoiledgradient echoimageobtainedduringarterialphaseshowsdiffuselydecreasedpancreaticenhancementrelativetomarkedenhancementseennormally Thisdecreasedenhancementrelatestofibrosisduetochronicpancreatitis Dilatedpancreaticduct arrows isvisualizedmoreclearlyaftercontrastadministration 46岁 男 因酗酒致慢性胰腺炎 T1WI显示胰腺实质的萎缩和不规则扩张的主胰管 箭头 提示慢性胰腺炎的变化 钙化在MRI和CT上都没有看到 动脉期增强T1WI显示胰腺因慢性炎症引起的纤维化而强化弥漫性降低 而非通常看到的显著增强 胰管扩张 箭头 显示更清 10 DuctAbnormalities胰管异常 MRCPishighlyaccurateforidentifyingpancreasdivisum Fig 6 However itsassociationwithpancreatitisremainscontroversial Ductabnormalitiessuchasdilatation irregularity andstonesandcomplicationsofchronicpancreatitissuchaspseudocystsarebestdepictedbythin sectionT2 weightedHASTEorsingle shotfastspin echoandthick slabT2 weightedhalf FourierRAREMRCPimages MRCP发现胰腺分裂的准确度很高 图6 然而 它与胰腺炎的关系仍存在争议 胰管异常 如扩张 不规则 结石和并发症如假性囊肿 在薄层T2加权HASTE或MRCP显示最佳 11 Fig 6 53 year oldwomanwithhistoryofcholecystectomywhopresentedwithjaundice abnormalresultsonliverfunctiontests andpancreasdivisum AxialT2 weightedimageshowsnoncommunicatingmainpancreaticduct straightarrow andaccessoryduct curvedarrow drainingseparatelyintoduodenum 图6 53 女 胆囊切除术后 黄疸 肝功能异常 胰腺分裂症 轴位T2WI显示轴向T2加权图像显示 互不沟通的主胰管 直箭头 和配胰管 弯箭头 分别进入十二指肠引流 Fig 6 12 MRCPisaccurateindepictingstricturesofthepancreaticductorbiliarytract Fig 7 Inequivocalcases ductaldistentionbycontrastinjectionduringERCPmaybehelpful Thebeadedmainpancreaticductwithitsdilatedsidebranchesmayhaveachain of lakesappearancewhenmoreextensive Fig 8 MRCP可准确的描绘胰管或胆管的狭窄 图7 在模棱两可的情况下 在ERCP过程中导管注射造影剂扩张胰胆管可能会有帮助 当病变广泛时 串珠样主胰管和扩张的侧枝 可能有连锁湖样改变 13 Fig 7 62 year oldwomanwithhistoryofchronicpancreatitisandpseudocysts CoronalT2 weightedthick slabRAREimageshowsstricture straightarrow ofpancreaticductatlevelofpancreatichead Upstreampancreaticductisdilatedandirregular andthereismilddilatationofsidebranches Notediverticulum curvedarrow arisingfromduodenum 图7 62 女 慢性胰腺炎 假性囊肿 冠状T2WI显示胰头水平胰管狭窄 直箭头 上游胰管不规则扩张 侧枝轻度扩张 注意十二指肠憩室 弯箭头 Fig 7 14 Fig 8 69 year oldmanwithchronicpancreatitis AxialT2 weightedHASTEimageshowsirregulardilatedmainpancreaticductandsidebranchesgivingchain of lakesappearance Noteatrophicchangesinpancreasandsignal voidareas arrows relatedtocalcificationsfromchronicpancreatitis 图8 69岁 男 慢性胰腺炎 轴向T2WI显示不规则扩张的主胰管和侧枝 连锁湖外观 可见胰腺萎缩及无信号钙化区 箭头 Fig 8 15 CTismoresensitivethanMRIforthedetectionofcalcificationsassociatedwithchronicpancreatitis however MRIbestdepictsintraductalstonesandductobstruction Figs 9A 9Band10 UnlikeERCP MRCPcanshowthedilatedductupstreamfromanobstructingstone Nevertheless visualizingintraductalstonesnotsurroundedbyfluidmaybedifficultonMRI Fig 1A 1B 1C 1D 对慢性胰腺炎的钙化检测 CT比MRI敏感 然而 MRI显示管内结石和胰胆管阻塞最佳 图9A 9B和10 不同于ERCP MRCP能显示上游扩张导管 然而 MRI诊断不被液体包围的导管内结石困难 图1A 1B 1C 1D 16 Fig 9A 46 year oldmanwithhistoryofchronicpancreatitisduetoalcoholabuse Axialcontrast enhancedCTscanshowsmultiplecalcificationsinpancreatichead Itisdifficulttodeterminethatastoneisinpancreaticduct Calcificationsareseencommonlyinchronicalcohol relatedpancreatitis asinthispatient AxialT2 weightedHASTEimageshowsstone arrow inmainpancreaticductdelineatedbyhigh signal intensityfluid 图9A 男 46岁 酗酒史 慢性胰腺炎 轴向增强CT扫描显示胰头多发钙化 从CT很难确定胰管内有无结石 钙化在慢性酒精相关性胰腺炎中很常见 此例即如此 轴向T2WI的显示主胰管内结石 箭头 被高信号液体包绕 Fig 9A 9B 17 Fig 10 45 year oldwomanwithhistoryofabdominalpain CoronalT2 weightedHASTEimageshowspancreaticductstone straightarrow andgallstone curvedarrow GB gallbladder CBD commonbileduct PD pancreaticduct DUOD duodenum 图10 45岁 女 腹痛 冠状T2WI的显示胰管内结石 直箭头 和胆结石 弯箭头 GB 胆囊 CBD 胆总管 PD 的胰管 DUOD 十二指肠 Fig 10 18 Complications 1 Pseudocysts假性囊肿2 Vascular血管相关并发症3 Biliary胆管相关并发症 19 1 Pseudocysts Pseudocystsareencapsulatedcollectionsofpancreaticsecretionsthatoccurinoraroundthepancreas Althoughmostresolvespontaneously complicationssuchasinfection hemorrhage andgastricorbiliaryobstructionmayoccur Fig 11A 11B Pseudocystscanbecommunicatingwiththemainpancreaticduct Fig 12 ornoncommunicating MRIcandepictpseudocystsandcanbeusedtocharacterizetheircontentandthustoguidedrainage 假性囊肿是发生在胰腺内或胰腺周围被包裹的胰腺分泌物 虽然大多数可自发吸收 但也可发生并发症 如感染 出血 胃或胆道梗阻 图11A 11B 假性囊肿与主胰管可连通 图12 或不连通 图13 MRI可以描绘假性囊肿并检测内容物成分以指导引流 20 52 year oldmanwithhistoryofrecurrentpancreatitis AxialT2 weightedHASTEimageshowslargethick walledmultiloculatedcysticcollectionlocatedprimarilyinlessersac representingpseudocyst P Itdoesnotcommunicatewithpancreaticduct AxialT1 weightedfat suppressedspoiledgradient echoimageshowshigh signal intensityfluidwithinpseudocyst suggestiveofcomplicatedpseudocyst P Internalconsistencyofpseudocystsmaybealteredbecauseofpresenceofproteinaceousmaterial hemorrhage orinfection anditmayrequirepromptdrainage 52岁 男 复发性胰腺炎 轴向T2WI的显示主要位于小网膜囊的巨大厚壁多房假性囊肿 P 不与胰管沟通 轴位T1WI显示囊肿内为高信号 提示其为复杂性假性囊肿 P 因存在蛋白性物质 出血 或感染 假性囊肿内部一致性可被改变 提示需要尽快引流 Fig 11A 11B 21 Fig 12 55 year oldwomanwithabdominalpain weightloss andhistoryofpancreatitis AxialT2 weightedHASTEimageshowshigh signal intensitypseudocyst P inpancreaticheadwithdilatedandirregularpancreaticduct Pseudocystcanbeseencommunicatingwithmainpancreaticduct arrow 图12 55岁 女 腹痛 体重减轻 胰腺炎 轴位T2WI显示胰头部高信号假性囊肿 P 及不规则扩张的胰管 可以看出假性囊肿与主胰管 箭头所示 连通 Fig 12 22 2 Vascular Arterialpseudoaneurysms hemorrhageintopseudocysts arterialbleeding andsplenicorportalveinthrombosisarevascularcomplicationsofchronicpancreatitisthatmaybeseenonMRI Inpatientswithchronicsplenicveinthrombosis theveinmaynotbevisualized Fig 14A 14B 假性动脉瘤 假性囊肿内出血 出血 脾静脉或门静脉血栓为慢性胰腺炎的血管相关并发症 MRI可检测出 但当有慢性脾静脉血栓时 静脉可能无法显示 图14A 14B 23 Fig 14A 46 year oldmanwithhistoryofchronicpancreatitisduetoalcoholabuse AxialenhancedT1 weightedfat suppressedspoiledgradient echoimageobtainedduringvenousphaseshowschronicocclusionofportalveinwithcollaterals arrow cavernoustransformationofportalvein Fig Bshowscollateralvessels arrows whichissuggestiveofsplenicveinocclusion 46岁 男 慢性胰腺炎 酗酒史 静脉期轴向增强T1WI示门静脉慢性闭塞 箭头 呈海绵样变 图B显示侧支循环形成 箭头 提示脾静脉阻塞 Fig 14A B 24 3 Biliary Thebiliarycomplicationsofchronicpancreatitisincludecholedocholithiasis fistulas anddilatationofthecommonbileductduetoinflammatorystrictures ThetypicalappearanceofbenignstricturesonMRCPisgradualtaperingwithafunnellikenarrowedsegment Fig 15 慢性胰腺炎的胆道并发症 包括胆总管结石 瘘管 由于炎性狭窄而致的胆总管扩张 良性狭窄的典型MRCP表现为逐渐变细的漏斗样狭窄 图15 25 Fig 15 59 year oldmanwithhistoryofchronicpancreatitis MRimagewasobtainedtoevaluatebiliarytractandcomplexpseudocystsseenonpriorCTscan notshown CoronalT2 weightedthick slabRAREimageshowsdilatedcommonbileductwithfunnel shapednarrowing arrowhead Pancreaticductisdilatedandcontainscalculus arrow atpancreaticheadlevel Alsoseenaremultiplepseudocysts P extendingbothsuperiorandinferiortopancreas GB gallbladder 男 59岁 明显胰腺炎 行MRI检测以明确CT所示复杂假性囊肿并评价胆道情况 冠状T2WI显示扩张的胆总管 漏斗样狭窄 箭头 胰管扩张 胰头处可见结石 并可见多发假性囊肿 P 延伸至胰腺前后方 GB 胆囊 Fig 15 26 ChronicPancreatitisVS PancreaticCarcinoma慢性胰腺炎VS 胰腺肿瘤 27 ChronicPancreatitisVS PancreaticCarcinoma Differentiatingbetweenaninflammatorymassduetochronicpancreatitisandpancreaticcarcinomaonthebasisofimagingcriteriaremainsdifficult DecreasedT1signalintensitywithdelayedenhancementaftergadoliniumadministrationaswellasdilatationandobstructionofthepancreaticobiliaryductscanbeseeninbothdiseases Irregularityofthepancreaticduct intraductalorparenchymalcalcifications diffusepancreaticinvolvement andnormalorsmoothlystenoticpancreaticductpenetratingthroughthemass ductpenetratingsign favorthediagnosisofchronicpancreatitisovercancer Fig 16A 16B 16C Indistinction asmoothlydilatedpancreaticductwithanabruptinterruption dilatationofbothbiliaryandpancreaticducts double ductsign andobliterationoftheperivascularfatplanesfavorthediagnosisofcancer 鉴别慢性胰腺炎引发的炎性包块和胰腺肿瘤 从影像学上尚属困难 两者均可出现延迟强化和胰胆管的阻塞扩张 不规则的胰管 胰管内或实质内钙化 弥漫性胰腺受累 光滑狭窄的胰管从肿块内穿过 穿透症 更支持慢性胰腺炎的诊断 图16A 16B 16C 相反的 平滑扩张的胰管突然中断 胆管和胰管同时扩张 双管征 以及血管周围脂肪间隙消失则支持肿瘤的诊断 28 Fig 16A 58 year oldwomanwithbreastcancerandchronicpancreatitisrelatedtoalcoholabuse Patienthad50 lb 23 kg weightloss ERCPimage notshown revealedstoneinpancreaticduct whichwasremoved Fine needleaspirationwassuggestiveofadenocarcinoma Whippleprocedureindicatedchronicpancreatitiswithoutcancer AxialT1fat suppressedspoiledgradient echoimageshowslow signal intensitypancreasduetochronicpancreatitis AxialenhancedT1 weightedfat suppressedspoiledgradient echoimageobtainedduringarterialphaseshowsdiffuselydecreasedenhancementofpancreasduetochronicpancreatitis Notedilatedpancreaticduct 图16A 58岁 女 乳腺癌 酗酒相关的慢性胰腺炎 发病以来体重下降23kg ERCP图像 图中未示出 显示胰管石并去除 细针穿刺提示腺癌 胰十二指肠切除术提示慢性胰腺炎无癌变 轴向T1WI显示因慢性胰腺炎而呈低信号的胰腺 动脉期增强T1WI示胰腺弥漫性强化减低 注意胰管扩张 Fig 16A B 29 Fig 16C AxialT2 weightedHASTEimageshowsmarkedlydilatedmainpancreaticduct arrow penetratingthroughpancreaswithchronicinflammatoryandfibroticchanges ductpenetratingsign Thisfindingsuggestschronicpancreatitisoveradenocarcinoma 图16C 同一病例 轴向T2WI示明显扩张的主胰管 箭头 穿过具有慢性炎症和纤维化的胰腺 穿透征 这一征象提示慢性胰腺炎可能性大 Fig 16C 30 MRImaybesuperiortoMDCTfortheevaluationofpancreaticadenocarcinoma especiallyifthelesionissmallandnon contour deforming ThetumorisbestdelineatedonunenhancedT1 weightedfat suppressedimagesandmultiphasicenhancedsequences Fig 17A 17B 17C 17D MRI在对胰腺腺癌的诊断上优于MDCT 特别是病变较小且胰腺外形没有异常时 平扫T1WI及多期增强序列上图17A 17B 17C 17D 显示最佳 31 71 year oldwomanwithweightlossduetoadenocarcinomaofpancreaswithassociatedchronicpancreatitis Axialcontrast enhancedCTscanshowsatrophyofpancreatictailandductdilatation arrow tolevelofsuspectedmass whichisdifficulttosee AxialT2 weightedHASTEimageshowsdilatationofpancreaticductwithabrupttermination arrow duetotumor 71岁 女 慢性胰腺炎并腺癌 轴向增强CT示胰尾萎缩和胰管扩张 箭头 无法判断是否有肿块 轴向T2WI示由于肿瘤扩张的胰管突然终止 箭头 Fig 17A B 32 Fig 17C AxialT1 weightedfat suppressedspoiledgradient echoimageshowslow signal intensitymass arrowhead measuringlessthan1cm Noteatrophyanddecreasedsignalintensityofpancreatictail curvedarrow relatedtoassociatedchronicpancreatitis Normallyhighsignalintensityofpancreatichead straightarrow ispreserved AxialenhancedT1 weightedfat suppressedspoiledgradient echoimageobtainedduringlatevenousphaseshowsdelayedenhancementoftumor arrowhead ThisexampleshowsvalueofMRItodepictnondeformingpancreaticmass 同一病例 轴向T1WI示低信号肿块 箭头 小于1厘米 注意慢性胰腺炎引起的胰尾信号减低并萎缩 弯箭头 胰头仍为正常高信号 直箭头 静脉期轴向增强T1WI示延迟强化的肿瘤 箭头 这个例子显示MRI在诊断不伴有胰腺外形失常的胰腺肿瘤中的价值 Fig 17C D 33 GroovePancreatitis沟部胰腺炎 Groovepancreatitisisatypeoffocalchronicpancreatitisaffectingthegroovebetweentheheadofthepancreas duodenum andcommonbileduct ThepredominantMRIfindingofgroovepancreatitisisasheetlikefibroticmassbetweenthepancreaticheadandthickenedduodenalwallassociatedwithduodenalstenosisandcysticchangesintheduodenalwall Fig 18A 18B 18C 18D Therecognitionofgroovepancreatitisisimportantfordifferentiationfrompancreaticandd