胰脾肾膀胱超声诊断

Ultrasonography of Pancreas,Spleen, and Urinary System,Chuan LU School of Radiology Taishan Medical University,Anatomy of pancreas,The pancreas is a long ,thin gland that lies posterior the stomach and the left lobe of the liver . An understanding of pancreatic anatomy is based upon the relationship of the pancreas,It is divided into the head ,neck , and body and a tail that usually abuts on the spleen,Technique and Normal measurement of pancreas,多采用切线测量法：于胰腺走行的弯曲度画一些切线，分别在其头、体、尾的测量处作垂直线来测量胰腺的前后缘距离,胰腺疾病的超声诊断,检查前准备与检查体位 检查准备 应禁食8小时以上，尤其在禁早餐后当日上午检查为好。胃肠气体过多者，于检查前三日口服消胀片，前一日进清淡少渣饮食，睡前服缓泻剂。检查中可饮水500至1000CC，以利观察。 患者的体位 ：一般取仰卧位，也可半卧位，上身与床面成30至45角。,正常声象图,正常人胰腺纵断面可为三种类型： 腊肠型胰腺头、颈与体尾部厚度相似。 哑铃型颈部细，头和体尾部增厚。 蝌蚪型正常人胰头厚度小于2.5CM，体尾部厚度小于2CM。正常胰腺内部回声均匀、细小而密集，较周围组织稍弱或相似，一般随年龄增大而回声增强。正常人胰管超声测量近头部可达3MM，体部一般2MM,胰腺超声检查测量方法与正常值,目前关于正常胰腺的超声测值尚无统一的标准，多数作者以测量胰腺的厚度（前后径）为标准。具体方法：一胰头的测量1选择切面。胰腺长轴切面，将胰头部显示清楚；2测量部位:在下腔静脉的前方测量，测量一般不包括钩突 3正常参考值（成人）：2.5二胰体的测量！选择切面：胰腺长轴切面，将胰体部显示清楚：2测量部位：在腹主动脉的前方垂直线进行测量。3正常参考值（成人）：2.0cm三胰尾的测量1选择切面：胰腺长轴切面，将胰尾部显示清楚：2测量部位：在腹主动脉的左缘或脊柱左缘进行测量；3正常参考值（成人）：2.0cm,Pancreatic diameter Head =1.5-3.0cm; Body=1.2-2.5cm; Tail= 1.0-2.5cm; Main pancreatic duct3mm,正常胰腺,箭头所指为正常胰腺，h胰头，u胰腺构突，n胰颈，b胰体，t胰尾，L为肝脏a腹主动脉，IVC下腔静脉，s肠系膜上动脉，sv脾静脉，pc门静脉，k肾脏,What do these pictures look like?Do they look like the transverse view of pancreas?,Main pancreatic duct：R anterior pararenal space, around left lobe of liver , in spleen, mediastinum, ilica fossa , along transverse mesocolon,Pseudocyst formation,急性胰腺炎,胰腺普遍性肿大，胰腺轮廓呈弧形膨出，边界线模糊。胰腺内为弱回声或无回声区，其后方回声增强。胰腺周围可有积液。,Focal tenderness Texture changes: less echogenic than normalEnlargement: may be focal or diffuse. The shape appears swollen with rounding off of the borders,Chronic panceatitis,Chronic panceatitis =continuing inflammatory disease of pancreas characterized by irreversible damage to anatomy and function Chronic calcifiying panceatitis :protein plugs /calculi with ductal systemChronic obstructive pancreatitis: secondary to slow growing tumor /surgical duct ligation,慢性胰腺炎,胰腺局部或普遍性肿大，少数亦可缩小胰腺与周围组织边界不清，其轮廓不规则、不整齐、局部可以突起胰腺内部回声多数增强，为粗斑点状，分布不均匀胰管可呈囊状扩张，增粗或粗细不均。,慢性胰腺炎,胰腺内广泛钙化,胰管扩张,Chronic pancreatitis:US/CT Findings,irregular/smooth/beaded/pancreatic ductal dilatationSmall atrophic glandPancreatic mostly intrductal calcificationsInhomogeneous gland with increased echogenicity Irregular pancreatic contour,Chronic pancreatitis:US/CT Findings,Focal /diffuse pancreatic enlargement Mostly mild biliary ductal dilatationIntra/periancreatic pseudocystsSegmetal portal hypertensionArterial pseudoaneurysm formationPeripancreatic fascial thickening +blurring of organ margins,Irregular pancreatic contour Pancreatic mostly intraductal calcificationsirregular/smooth/beaded/pancreatic ductal dilatation,Intra-/peripancreatic pseudocysts,Pancreatic carcinoma: Pancreatic ductal carcinoma胰腺癌,60%发生于胰头，其次为体、尾、全胰 胰腺局限性增大，内见异常回声，轮廓不规则，边界模糊，可向周围呈“蟹足样”浸润内部多呈低回声，可不均匀胰头癌压迫胆总管使肝内外胆管扩张、胆囊增大，主胰管扩张胰腺周围、肠系膜上动脉、腹主动脉、及下腔静脉周围可见椭圆形低回声的肿大的淋巴结超声引导下活检,Pancreatic ductal adenocarcinoma and its variants,Histological types Mucinous carcinoma Edenosquamous carcinoma Pleomorphic large cell carcinoma,Pancreatic Ductal Adenocarcinoma,Sonographic AppearancesHypoechoic pancreatic massFocal/diffuse enlargement of pancreasContour deformity of gland ; rounding of uncinate processDilatation of pancreatic +-biliary duct,Pancreatic Ductal Carcinoma,Transverse sonography upper abdomen demonstrates a hypoechoic mass (M) in head of pancreas and moderate dilatation of Wirsungian duct (W).,Pancreatic Ductal Carcinoma,Hypoechoic pancreatic massFocal enlargement of pancreasContour deformity of gland,Pancreatic Ductal Carcinoma,There is a marked dilatation of the common bile duct (CBD) due to compression of its terminal segment by tumoral mass (M). Note enlarged metastatic adenopathies (Ad).,Pancreatic carcinoma,脾脏的超声检查,正常声像图 脾的膈面呈弧形结构，光滑而整齐，脏面略凹陷，可见脾门切迹，回声较强。脾实质回声非常均匀，回声强度稍低于或接近肝脏，比肾皮质的回声略高。正常脾厚度小于4CM,Spleen,能了解脾的大小、形态以及直径在1cm以上的病变，是脾疾病的首选检查方法患者取右侧卧位，于左侧第911肋间隙，腋中、后线部位行肋间斜切扫查，测量脾厚度以及脾血管和血流状态。于左侧肋缘下锁骨中线纵行扫查，了解脾增大情况,Technique,Left side vies (coronal)Transverse views,肋间斜断面脾略呈半月形，长轴与左侧第10肋平行。脾包膜呈光滑的细带状回声。外侧缘呈孤形，内侧缘内陷，为脾门。脾v、脾A为管状无回声。脾实质呈均匀中等回声，光点细密。CDFI:脾门处及脾v的分支呈蓝色血流。胰腺后方脾V呈红色血流。脾门处脾A呈红色血流，腹腔干发出脾A分支处依不同的声束方向可呈蓝色或红色，脾A血流呈部分空窗型层流频谱。,正常脾声像图：,脾脏厚度,测量标准切面：左肋间脾脏斜切面，要求显示脾静脉出脾门部图像。测量位置：测量点选在脾门边缘至脾对侧缘之垂直距离测量。正常参考值（cm）：正常成年人不超过4cm。,脾脏长度,测量标准切面：左助间脾脏斜切面。尽量显示脾的全长，同时显示脾静 脉出脾门部图像。测量位置：测量点选在脾上下极的包膜处。正常参考值（cm）：正常成年人不超过12cm,Normal Sonographic Anatomy,Normal size of spleen : In adults:12cm length;7-8cm anteroposteror diameter,3-4 cm thick Texture: More echogenic than the liver or kidneyA group of high-level echoes in the center of the spleen at its medial aspect represents the splenic hilum at the entrance of the splenic artery and vein,More echogenic than the liver or kidneyA group of high-level echoes in the center of the spleen at its medial aspect represents the splenic hilum at the entrance of the splenic artery and vein,CDFI and Power Doppler,脾脏肿大的超声表现,男、女性脾厚度分别超过4CM和3.8CM，同时脾脏下缘超过肋缘线,Splenomagaly,Splenic cyst,临床与病理脾囊肿分为先天性和后天性，真性和假性。真性囊肿见于单纯性囊肿和多囊脾，假性囊肿见于外伤出血和炎症之后。脾包虫囊肿多见于流行病区。USG以其经济性为首选诊断方法,Simple cyst: echo-free area with smooth, well-defined borders, acoustic enhancement Polycystic spleen ： multiple cyst within spleen ,often with polycystic disorders of other organs,Splenic abscess,临床与病理由脾周围器官感染直接波及或经淋巴、血行感染可致脾脓肿，它亦可是脾梗死并发症。患者临床上可表现全身感染的症状并伴脾区疼痛,US表现 脾轻至中度增大。脾内出现无回声区，周边有较高回声带环绕，无回声区内可见光团、光带、光点回声。抗感染治疗后，无回声区范围明显缩小,脾破裂,脾增大，形态失常，包膜光带回声连续性中断 脾实质破裂处显示回声杂乱区，形态不规则，边界不清晰，其内常显示带状高回声出血量大时，脾实质内可出现混合回声图像，可见无回声区，境界欠清楚，无包膜回声，内有大小不一、形态不规则的强光团回声脾周围血肿时，显示脾周低回声带，其内有较多的光点回声腹腔内积血:少量积血时，肝肾间隙和陶氏腔内可探及细带状无回声。多量出血，肝肾间隙、脾周围、膀胱周围甚至肠间隙均可探及无回声区,The splenic trauma is the most frequently injured solid parenchymal organ within the abdomen!,Splenic Trauma,脾包膜下血肿：脾大小和形态尚正常。脾包膜光带下可见扁长形无回声区。脾实质回声显示受压表现。无回声区内可有散在分布的细小回声飘浮,Diagnosis and Differential Diagnosis 根据CT或USG表现，结合病史易作出脾破裂诊断，如果外伤时间不长，脾破裂和到血肿征象表现可能不明显，需动态观察。 脾破裂程度较轻而行保守治疗时，必须动态观察血肿大小有无变化，腹腔积血量有无增加。 此外，脾破裂伴肋骨骨折和皮下气肿可干扰USG的诊断，单凭CT表现不易区分陈旧性脾包膜下血肿和脓肿。,Splenic infarction,临床与病理脾梗死常见原因为左心系统血栓脱落，脾周围器官的肿瘤和炎症引起脾动脉血栓并脱落，某些血液病和淤血性脾增大等。大多数脾梗死并无症状，少数可有左上腹疼痛,脾实质内单个或多个楔形或不规则低回声区，楔形底部朝向脾包膜内部可呈蜂窝状回声或不均匀分布的斑片状高回声梗死灶坏死液化时，呈无回声或形成假性囊肿。陈旧性梗死灶纤维化钙化时，病灶回声明显增强，后方伴有声影,Splenic infarction,脾梗死,SPLEEN：脾脏箭头所指处为低回声区梗死灶,Splenic tumor,临床与病理 原发于脾的肿瘤少见，恶性肿瘤中以淋巳瘤多见，患者常伴有脾大和相应的临床症状。良性肿瘤以血管瘤多见，生长速度缓慢且多数患者无明显临床症状,脾恶性淋巴瘤,脾呈弥漫性增大;部分病人脾实质内单个或多个圆形低回声;多发性结节状淋巴瘤呈蜂窝状无回声箭头所指处为脾内多发弱无回声结节，边界尚清晰,脾海绵状血管瘤：境界清楚的圆形高回声，边缘锐利。高回声区内显示小的无回声和高回声间隔光带，呈网络状。 彩色多普勒显示血管瘤周围或其内部可有脾动脉或脾静脉的分支绕行或穿行，血管瘤内部无血流信号显示,肾 脏,Technique,Right kidney: The right kidney is best examined in the supine position through the liver. It may be necessary to role the patient into the right side up decubitus position and scan from a lateral approach Left kidney :Begin with the patient in the left-side up position .With the patients left arm extended over his or her head,and using a coronal approach, scan intercostally through the spleen,肾脏超声检查测量方法与正常值,肾脏长度（上下径）测量1测量切面：肾脏冠状切面或矢状切面的最长切面。2测量位置：将测量游标分别放置在肾脏上下极顶端的包膜处。3正常参考值（成年、cm）：男性：10.6土0.6：女性：10.4土0.6。肾脏宽度（左右径）测量1测量切面：肾门部短轴切面，或肾脏冠状切面2测量位置：测量游标分别放置在近肾门与肾脏最宽部的两侧包膜处。3正常参考值（成年、cm）：男性：5.6土0.5；女性：5.4土0.4肾脏厚度（前后径）测量1测量切面：肾门部短轴切面，或肾脏矢状切面。2测量位置：将测量游标分别放置在肾脏最厚部的两侧包膜处。3正常参考值（成年、cm）：男性：4.2土 0.4：女性：4.0土 0.5。,Sonographic Anatomy of kidney,Size and Shape The kidney is between 8 and 13cm in length and about 5cm wide. The parenchyma is 2.5cm thick;,正常肾的大小有较大出入。一般男性肾脏大于女性，左肾大于右肾。在实际超声诊断中，并不因为肾的大小略有出入而影响其诊断结果，只有当肾脏过分巨大或缩小时才有诊断意义。而对肾实质的厚度，尤其是肾皮质的厚度减薄意义较大。,肾脏的正常声像图,明亮的肾轮廓线。肾皮质为低回声区，仅有少量较淡的散在细光点肾锥体为三角形的暗区、内部回声少，在集合系统周围排列成放射状，可见到3到5个或7到8个不等到。肾的中部是集合系统回声，表现为密集的明亮光点，为肾盂的回声，还有肾窦内脂肪回声的组合。正常时，集合系光点占肾宽度的1/2到2/3。,正常肾脏,肾被膜：明亮回声线，清晰、光滑肾窦：不规则密集的强回声区肾实质：位于强回声的肾被膜与肾窦之间,正常肾脏二维与彩色多普勒对照,Sonographic Anatomy of kidney,Sinus and Capasular Echoes The kidney is surrounded by a well-defined echogenic line representing the capsule in the adult. At the center of the kidney are dense echoes ( the central sinus echo or sinus echo complex) due to renal sinus fat.,正常肾彩色多普勒血流显示,The normal kidney :CDFI and Power Doppler Imaging,Sonographic Anatomy of kidney,Parenchyma The renal parenchyma has two components . The centrally located pyramids ,or medulla ,are surrounded on three sides by the peripherally located cortex.,The echogenic area at the center of the kidney is due to renal sinus fatThe pyramids are less echogenic areas adjacent to the sinus The cortex is slightly more echogenic , and the capsule (perirenal fat ) is an echogenic line,Pathology,Renal Tumor benign /malignant/ cystHydronephrosisNephrocalcinosis / nephrolithiasis /Bladder tumorBladder calculi,Renal Tumor,Renal Cell Carcinoma/ Renal Adenocarcinoma Nephroblastoma / Wilms Tumor Angiomyolipoma,80-90% of all renal malignant primaries in adult Hyperchoic(50-60%),mostly in small tumors 3cmIsoechoic(30-86),mostly in large tumors Inhomogeneity due to hemorrhage , necrosis ,cystic degeneration Usually have an irregular border that expands the outline of the kidney,Renal Cell Carcinoma/Renal Adenocarcinoma,CDFI有四种表现抱球型 沿肿瘤周边彩色血流丰富仅肿瘤内部有上述星点状彩色血流丰富血流型 肿瘤内部血流丰富少血流型 肿瘤内部血流甚少,肾 癌,声像图一般是实性均质暗区，在其中可见散在细小光点，分布均匀。 肿物边界不如囊肿清晰，内部回声比正常肾实质回声强。有时肾实质内出现不均质暗区，是由于出血所致。,肾癌栓塞前肾和膀胱积血,左肾癌术前超声和术后照片,Blood flow around the tumor,Nephroblastoma / Wilms Tumor,A malignant lesion affecting children The tumor is usually unilateral , occupying only part of the kidney,Sonographic Features,They appear as subtle subcapsular hypoechoic / isoechoic / hyperechoic nodulesNephromegaly with decreased parenchymal echoes,Angiomyolipoma: AML,They are benign mesenchymal tumor of kidney Hist : They are composed of fat, smooth muscle, aggregates of thick-walled blood vessels,Angiomyolipoma: AML,Types Isolated AML(80%)+sporadic AML/solitary +unilateral (in80% on right side/no stigmata of tuberous sclerosis ;M:F=1:2.3-12.5 AML associated with tuberous necrosis (in 20%); commonly bilateral +multiple ; no sex predilection,Clinical Manifestations,Small lesions are asymptomatic Acute flank/abdominal pain (due to hemorrhage)Shock (duo to massive retroperitoneal hemorrhageHematuria,Sonographic Features,Intensely echogenic tumor (duo to high fat content)They tend to bleed , causing area of decreased echogenicity in or around the massLess echogenic areas due to hemorrhage ,necrosis ,dilated calyces,血管平滑脂肪瘤(错构瘤) （angiomyolipoma）,声像图上可见许多分布均匀的强回声团，边界清晰,Angiomyolipoma,肾囊肿,声像图特点：肾内可见边缘整齐的圆形无回声区边缘清晰，光滑、整齐囊壁后方回声增强囊肿可单发，也可多发,Renal Cystic Disease,Simple renal cystPolycystic renal dieeaseCystic medullary diseaseRenal dysplasiaNeurocutaneous dysplasia Cystic tumors Acquired renal cystic disease,Renal cyst,Renal cyst are rare in children , gradually becoming frequent with age. In the elderly , they are very common .They may be single or multiple,The sonographic features of a cyst are as follows:,Spherical/ovoid in shapeUsually fluid filled with no internal echoes Acoustic enhancement (good through transmission with a strong back wall)Usually a smooth spherical outline with thin walls,The sonographic features of a cyst are as follows:,Usually cysts may have irregular walls and may contain low-level echoed in a dependent position owing to debrisSepta dividing a cyst into compartment may be seen .Such septa prove that a cyst is fluid filled but may be difficult to visualize completely and may be mistaken for a mural mass Irregular borders , septations ,or debris should raise the question of malignancy or necrosis and require further investigation ,usually by CT or percutaneous puncture under ultrasound control,Renal cyst,Simple cortical renal cyst : Acquired lesion possibly secondary to tubular obstruction Age: peak incidence agter age 30 years ; increasing frequency with age Polycystic Disease :Renal cysts in patients with polycystic disease usually have an irregular outline and are of markedly varied size .This is always a biateral process ,although one side may be more severely affected than the otherMulticystic Disease :is a congenital process that involves only one kidney .The entire kidney ,which is small , is flled with multiple adjacent cysts Renal sinus cyst= peripelvic/parapelvic lymphangiectasia,Simple renal cyst,Spherical/ovoid in shape Fluid filled with no internal echoes Acoustic enhancement A smooth spherical outline with thin walls,Simple renal cyst,Spherical/ovoid in shape Fluid filled with no internal echoes Acoustic enhancement A smooth spherical outline with thin walls,肾囊肿,1,2,1,2,3,3,1.肾囊肿：内含囊液，为无回声，壁薄光滑2.囊肿后方回声增强 3.正常肾组织,Simple renal cyst,Spherical/ovoid in shape Fluid filled with no internal echoes Acoustic enhancement A smooth spherical outline with thin walls,Simple renal cyst,Spherical/ovoid in shape Fluid filled with no internal echoes Acoustic enhancement A smooth spherical outline with thin walls,多囊肾,声像图特点：肾外形普遍增大，肾内可见多个圆形无回声区，大小不等到，边缘整齐,Renal sinus cyst= peripelvic / parapelvic lymphangiectasia,肾结石,直径0.5CM以上的结石出现强回声光团或光点，其后方伴有声影。肾结石常伴有肾盂积水,Nephrocalcinosis /Renal Calculi / nephrolithiasis,If they are more than 3 or 4mm in size ,acoustic shadowing can be seen beyond a dense echo Small calculi appear as densely echogenic structures within the renal sinus echoes In nephrocalcinosis the calculi are often too small to cast shadows but are seen as symmetrically located echogenic areas where the pyramids normally lie,Nephrocalcinosis /Renal Calculi / nephrolithiasis,Medullary nephrocalcinosis absence of hyperechoic papillary structures (earliest stage) Hyperechoic rim at corticomedullary junction +around tip and sides of pyramids Solitary focus of hyperechogenicity at tip of pyramid near fornixIncreased echogenicity of renal pyramids +/-shadowing (no acoustic shadowing with small+light calcifications),肾结石,箭头所指强光团为肾结石，其后方有声影,s,Cortical nephrocalcinosis,Calculi, whether due to uric acid ,or calcium mixtures ,cause echogenic areas with shadowing if they are large .Associated cystic areas adjacent to the calculi may represent dilated calyces Smalle calculi may not show shadowing ,or shadowing may be seen only fleetingly with real-time.Homogeneously increased echogenicity of renal parenchyma,Calculi, whether due to uric acid ,or calcium mixtures ,cause echogenic areas with shadowing if they are large,Ureteral Calculi,Echogenic areas with shadowing Associated cystic areas adjacent to the calculi may represent dilated ureter and pelvis,输尿管结石,肾盂积水,声像图特点：主要改变为中心集合系统光点分离，中间出现无回声暗区，其宽度在8MM以上。中度肾盂积水时，肾盂无回声区呈椭圆形、长条形或菱形。巨大肾盂积水时，仅见大片暗区伴有分隔光带，肾实质变薄。,Hydronephrosis,Obstructive uropathy = hydronephrosis =dilatation of collecting structures without functional deficitObstructive nephropathy =dilatation of collecting system with renal functional impairment,Hydronephrosis,CauseAcute : passage of calculus with sites of stone impaction at points of ureteral narrowing /passage of blood clot /Chronic :most frequent cause of abdominal mass in first 6 months of life acquired: benign+ malignant tumors of the ureter ; ureteral strictures ;benign prostatic hyperplasis Congenital :,Hydronephrosis,In hydronephrosis the sinus echoes surround a fluid-filled center because the calyces , infundibula ,and renal pelvis are dilated . Usually the rena