《胆系影像诊断学》PPT课件

1,胆系影像诊断学,2,X线检查,X线平片：右上腹平片，显示钙化、气体以及被肠管气体影衬托的胆囊X线造影：口服胆囊造影，静脉胆道造影术后T形管造影：了解胆管内有无残余结石，胆管与十二指肠的通畅情况以及有无术后并发症ERCP：诊断胰腺疾病和确定胆系梗阻的原因。亦能进行胆总管取石和胆总管狭窄内支架置入术PTC：鉴别阻塞性黄疸的原因和确定梗阻的部位,3,“T”管造影,透视监视下注射对比剂时应避免将空气混入，以免造成假象,4,PTC,Percutaneoustranshepaticcholangiography透视监视下将22G细针经皮穿入肝管后注入对比剂显示肝内胆管和胆总管,5,CT检查,平扫：空腹，准备同肝脏扫描，若怀疑胆系结石，则不必口服碘对比剂。胆系扫描范围从膈顶至胰钩突区。层厚和间距通常为10mm，胆囊区和其它重点层面35mm薄扫增强扫描静脉内注射60%泛影葡胺80100ml后CT扫描，肝脏及其动静脉、胰腺强化，能更清晰的衬托出胆道影像静脉内注射60%胆影葡胺约2030ml后扫描，胆道和胆囊充盈对比剂，显示清晰口服胆囊对比剂后CT扫描，可特异性的显示胆囊梗阻性黄疸与胆囊病变的诊断与鉴别诊断平扫显示胆道系统梗阻的部位、含钙结石增强显示和区别肝内血管、胆道系统，更好地显示胆囊形态和胆囊壁的病变,6,MRI检查,检查时空腹。常用SE序列T1WI及T2WI，以横断面为主，辅之以冠状面及矢状面，薄层扫描有助于胆囊内细微结构的观察MagneticResonanceCholangio-Pancreatography（MRCP）不需注射对比剂可清楚显示胰胆管全貌，对胰胆管梗阻性病变诊断颇有价值，敏感度、特异度和准确度均在90%以上,7,US检查,胆道系统超声检查时将探头置于腹直肌与右肋缘交界处纵切，剑突下横切、右肋间斜切，以及右上腹斜纵切等途径，可获得胆囊、肝内外胆管图象,8,正常X线表现,右上腹平片：肠道气体衬托下，可以观察到胆囊，位于右肝下缘造影：胆囊位于右第12肋附近，长710cm，宽34cm，茄子状胆囊管长约3cm，宽约3mm，与肝总管汇合成胆总管肝内胆管呈树枝状分布，纤细、整齐，逐级汇合成左右肝管，再汇合成肝总管肝总管宽46mm，长34cm胆总管长610cm，宽48mm。走行于十二指肠和胰腺后方，先向内下再向外下走行，同胰管汇合，斜行进入十二指肠降段,9,胆囊造影,胆囊位于右第12肋附近，呈长茄子状,10,胆系CT正常表现,平扫肝内胆管通常不能显示。肝总管位于肝门区，门静脉主干的外侧，呈圆形低密度影，直径约3mm5mm，壁厚小于1.5mm，胆总管位于胰头上区域和胰头内后方，呈圆形低密度影，直径约36mm胆囊呈卵圆形，位于方叶下方的胆囊窝内，大小变异较大。内容物为水样密度，CT值为-515Hu，囊壁厚约2mm泛影葡胺增强扫描，肝外胆道显示为圆形低密度影，胆道壁可强化，使胆道影更清晰。胆囊壁强化，胆囊内液体不增强胆影葡胺增强扫描，胆道及胆囊内充盈对比剂，呈高密度影像,11,胆系横断面,CT平扫呈低密度，卵圆形，胆汁密度均匀，CT值略高于水,12,正常胆囊,13,胆系MRI正常解剖,胆囊及胆总管T1WI呈均匀的低信号，T2WI上呈明显高信号MRCP可显示胆树全貌，呈均匀高信号。肝外胆管的显示率为100%胆总管直径0.8cm，肝总管直径约0.4cm，边缘光滑MRCP对无扩张的肝内胆管显示率达82%；对判断梗阻性胆管扩张的准确率为91100%，判断梗阻部位准确率为84100%,14,正常US胆系解剖,胆囊呈梨形或椭圆形，长经8，短经5cm，胆囊壁弥漫性增厚，可超过3mm。胆囊周围组织水肿，胆囊周围常有一环形低密度带。胆囊坏死、穿孔，胆囊窝可见包含有液平面的脓肿。增强扫描时胆囊壁可见明显均匀一致性强化，且强化时间较长。可合并胆囊结石MRI可见胆囊增大、胆囊壁弥漫性增厚，超过3mm即有诊断意义。胆囊窝积液以及胆囊周围水肿带呈长T1WI低信号和长T2WI高信号，偶见胆囊积气、积液征象US显示胆囊增大，胆囊壁轮廓线模糊，胆囊壁弥漫性增厚，增厚的胆囊壁呈增强回声带，中间同时出现间断或连续的弱回声带，称为胆囊壁的双层回声，系黏膜下水肿、出血和炎性细胞浸润所致。胆囊窝显示无回声带，提示胆囊周围液体潴留或积脓,41,急性胆囊炎,胆囊壁增厚（4mm），增强显示胆囊内侧粘膜层炎症引起的充血产生增强效应，呈致密细线条状阴影，浆膜层水肿形成低密度带环绕胆囊周围对比增强，沿胆囊内壁可见厚1-2mm的低密度带,42,急性胆囊炎,胆囊壁增厚，增强显示胆囊内侧粘膜层炎症引起的充血产生增强效应，呈致密细线条状阴影，浆膜层水肿形成低密度带环绕胆囊周围,43,慢性胆囊炎,注射造影剂后，可见胆囊壁呈不规则增厚，与肝脏分界不清,44,慢性胆囊炎（chroniccholecystitis）,多为发复发作的急性胆囊炎发展而来，也可没有明显的急性发作过程，发病过程常与胆囊结石并存和互为因果病理改变为纤维组织增生和慢性炎性细胞浸润，使囊壁增厚，胆囊收缩功能减退。常有结石并存临床症状不典型，常出现腹胀不适、上腹部隐痛、消化不良等。右上腹局部压痛,45,ChronicCholecystitis,X线检查多无异常，少数可见阳性结石影CT多表现胆囊缩小，为胆囊萎缩所致。少数也可增大，由胆囊积水引起。胆囊壁均匀或不均匀性增厚。增强扫描时增厚的胆囊壁可见明显均匀一致性强化。可合并胆囊结石MRI表现为胆囊腔缩小、胆囊壁均匀性增厚US显示胆囊增大，胆囊壁增厚，增厚的胆囊壁呈增强回声带。胆囊轮廓回声模糊，提示胆囊与周围组织粘连。胆囊收缩功能减弱,46,慢性胆囊炎,47,ChronicCholecystitis,48,胆囊周围脓肿,胆囊炎伴有腹壁脓肿,49,胆囊肿瘤,胆囊造影表现为充盈缺损的病变中，胆固醇息肉是仅次于胆结石的病变，常为35mm的多发病灶，也有达10mm者胆囊腺肌瘤病，表现为胆囊壁的局限性或弥漫性肥厚真性乳头状和大于4cm的腺瘤，发生率低,50,胆囊癌（gallbladdercarcinoma）,原因不明，可能与胆囊结石和慢性胆囊炎的长期刺激有关70%合并胆囊结石。多发于胆囊底部或颈部，70%90%为腺癌，少数为鳞癌80%的肿瘤呈浸润性生长，早期在胆囊黏膜浸润性生长，胆囊壁增厚，随肿瘤的进展，胆囊壁呈环形增厚20%的肿瘤呈乳头状生长，表现为菜花样肿块突入胆囊腔内。肿瘤生长可充满整个胆囊好发于中老年，女性多，男女比1:3早期无症状，进展期出现右上腹部持续性疼痛、黄疸、消瘦、肝大和上腹部包块。合并胆囊炎时发热、恶心、呕吐出现症状时，肿瘤多向胆囊床扩散，多侵犯肝十二指肠韧带和肝脏，局部淋巴结转移，预后不良,51,GallbladderCarcinom,X线平片：对诊断无价值PTC：侵犯胆管时出现胆管不规则狭窄、充盈缺损及胆道梗阻晚期累及胆囊浆膜层时，动脉造影可显示胆囊动脉增粗、受压移位，可见肿瘤血管,52,GallbladderCarcinoma:CT,胆囊壁增厚：15%22%，胆囊壁不规则或结节样增厚腔内结节：15%23%，胆囊腔内单发或多发结节状肿块肿块：41%70%，肿块可充满整个胆囊并侵犯邻近肝组织，肝内见边界不清的低密度区。出现胆道梗阻。增强扫描则显示不规则增厚的胆囊壁或肿块有明显强化。可伴胆囊结石,53,GallbladderCarcinoma：MRI,信号强度无特异性肿瘤组织在T1WI上呈不均匀性低信号，在T2WI上为不均匀性高信号增强后出现不均匀性强化胆囊癌多并发结石,54,GallbladderCarcinoma：US,小结节型：突入胆囊腔内的乳头状肿块，表面不光滑，大小约1.01.2cm蕈伞型：宽基底的中等回声或弱回声之肿块，边缘不规则厚壁型：胆囊壁弥漫形或局限性的不均匀性增厚，表面欠光滑混合型：多见，表现为蕈伞型和厚壁型的声像图实块型：表现为胆囊增大，胆囊腔被肿瘤所闭塞，呈弱回声或粗而不均匀的实性回声,55,GallbladderCarcinoma,56,胆囊癌,胆囊内软组织肿块向肝脏浸润，与肝脏境界不清，提示向肝脏的浸润性生长,57,胆囊癌,胆囊形态不规则，胆囊壁肥厚，向肝脏浸润形成不规则低密度区,58,胆囊癌,肿瘤向肝门部扩散，胆管引流术的适应症,59,胆囊癌,胆囊壁肥厚，境界不清。肿瘤向肝脏浸润，边缘轻度强化,60,Gallbladdercarcinomas,PoorlydifferentiatedadenocarcinomaResectedgallbladdershowsinnumerablegallstonesanddiffuseneoplasticmuralthickening.Papillaryadenocarcinomagallbladderspecimenshowsthecauliflower-likeintraluminalgrowthofapapillaryadenocarcinoma,61,Gallbladdercarcinomas,Porcelaingallbladdercontainingcarcinomaandafistulatotheduodenum.Abdominalradiographshowscurvilinearcalcificationandanabnormalgascollectionwithintherightupperquadrantoftheabdomen.Imagefromanuppergastrointestinalseriesdemonstratesagallbladder-duodenalfistula,causedbyinvasivecarcinomaofthegallbladder,62,Gallbladdercarcinomas,Moderatelywell-differentiatedadenocarcinoma,F70,rightupperquadrantpainandahistoryofgallstoneswell-definedmassinthegallbladderfundus(*)thatproducesill-definedposterioracousticshadowingCT：tumoralcalcificationsinthesoft-tissuemasswithinthegallbladderspecimen：thetumormass(*)andnumerousgallstones,63,胆道梗阻,胰头部狭窄性病变，导致肝内胆管明显扩张、变形。门脉系统等的相对位置关系，保持在正常位置,64,胆管癌（cholangio-carcinoma）,发生在左右肝管以下的肝外胆管癌上段，又称肝门部胆管，左、右肝管及其汇合部、肝总管，50%中段，肝总管与胆囊管汇合部以下至胆总管中段下段，胆总管下段、胰腺段和十二指肠壁内段80%为腺癌，少数为鳞癌生长方式：结节型、浸润型、乳头型（常见）发病年龄在5070岁之间，男女比22.5:1早期症状为右上腹隐痛或胀痛，继而出现进行性黄疸。体检右上腹部包块，胆囊肿大,65,胆管癌,PTC和ERCP可直接显示胆管癌的部位和范围浸润型见胆管狭窄，狭窄呈突然性，边缘不规整结节型和乳头型显示胆管内不光整的充盈缺损，上部胆管扩张，肝内胆管扩张，呈现“软藤”征CT病变近端的胆总管和肝内胆管扩张，于梗阻部位突然中断部分病例在中断处可见腔内软组织肿块。增强扫描肿块轻-中度强化肝门区胆管癌则表现为肝门区软组织肿块，肝内胆管扩张，增强扫描肿块呈轻中度强化,66,胆管癌,MRI：T1WI胆管走行区出现比肝实质稍低的肿块，T2WI上呈稍高信号MRCP见胆管狭窄或完全中断，梗阻端呈锥形或不规则形。肝内胆管扩张呈“软藤状”US结节型和乳头型见胆管远端有边缘不规整的软组织肿块，突入胆管内或阻塞于胆管，肿块呈强回声，无声影。与胆管壁分界不清浸润型表现扩张的胆管远端突然中断或狭窄闭塞，阻塞端为肿瘤部位，表现致密的强回声,67,Hilarcholangiocarcinomas,accountfor50%ofalllargebileductmalignanciesThemiddleanddistalportionsofthecommonbileductareaffectedinabout17%and18%TumorsoriginatingfromalargebileductareinacriticallocationandarediscoveredearlyduetothepresenceofjaundiceorcholangitisTumorsoriginatingfromsmallbileductsdonotcausesignificantbiliaryobstructionuntilthelatestage,whenthetumoritselformetastatichilarlymphadenopathycausesobstructionofthecommonhepaticduct,68,Infiltratinghilarcholangiocarcinoma,tumoralinvolvetherightsecondaryconfluenceandcommonhepaticductCTrevealsahigh-attenuationtumorontheanterioraspectoftherightportalveinOnasubsequentCTscan,thetumorappearsasahigh-attenuationlesionontherightsideoftheportalveinCTscansatalowerlevelshowthemucosaofthecysticductwithstrongenhancement,afindingthatsuggeststumoralinvolvement.Soft-tissueinfiltrationaroundtheportalveinandlymphadenopathyarealsonoted,69,Exophytichilarcholangiocarcinoma,Arterialandportal-phaseCTshowa4-cmlow-attenuationmasswithperipheralenhancementatthehepatichilum,mainlyinsegmentIV.Bothintrahepaticductsaredilated.TwopigtailcatheterswereinsertedfordrainageCholangiogramrevealsobliterationofthelefthepaticduct,buttherightsecondaryconfluenceispreserved.Insuchcases,itisdifficulttoascertainwhetherthetumororiginatesfromthelefthepaticductanddemonstratesexophyticgrowthororiginatesfromasmallbranchofsegment4andexhibitssubsequentinvolvementofthehepatichilum,70,Infiltratinghilarcholangiocarcinomawithearly-stageexophyticgrowth,PTCshowshilarcholangiocarcinomaoriginatingmainlyfromtherighthepaticductCTshowsthetumorasathinlineofhighattenuationanteriortotherightportalveinResectedspecimencutalongtherighthepaticductshowsawhitishtumorinvadingthehepaticparenchyma.Thisfinding,whichwasnotseenatCT,representsearly-stageexophyticgrowth,71,Polypoidhilarcholangiocarcinoma,Delayed-phaseCTscansshowasoft-tissuemasswithinadilatedlefthepaticductandcommonbileductCholangiogramshowsapolypoidmassattheconfluencelevelSpecimenrevealsanextensivepolypoidmasswithinthecommonbileduct,72,Polypoidhilarcholangiocarcinoma,M64Portal-phaseCTscanshowsdiffusedilatationoftheintrahepaticduct,asoft-tissuemassinthecommonbileductPTCrevealsapapillarymassatthelevelofthehepatichilum,presumablyarisingfromtherighthepaticduct,73,Infiltratingextrahepaticcholangiocarcinomainvolvingthemidportionofthecommonbileduct,74,Polypoidextrahepaticcholangiocarcinomawithdiffusebileductinvolvement,M65,CTscansshowadilatedcommonbileductfilledwithapapillarytumor;partialrestorationoftheductallumenintheintrapancreaticportionofthecommonbileduct.However,smallpapillarytumorsarestillevident.OnaCTscanobtainedatthelevelofthedistalcommonbileduct,thelumenisagainfilledwithanintraductalpapillarytumor.Directcholangiogramshowsalargepapillarytumorintheproximaltwo-thirdsandthedistalportionofthecommonbileduct,75,肝门胆管癌,76,肝管分叉水平肿瘤,肝管分叉水平，可见局限性病变，病变向左叶上方扩展，局部可见胆管狭窄和局部扩张，注射造影剂后CT值与肝脏大致相等,77,胰头癌肝内胆管扩张T1WI,78,胰头癌肝内胆管扩张-T2WI,79,Adenomyomatosis,alsotermedadenomyomatoushyperplasiaofthegallbladder,isabenignhyperplasticcholecystosisnodefiniteracialorsexpredilectionAgerangeiswide,mostintheir50sincidentalfinding,hasnointrinsicmalignantpotential,requiresnospecifictreatmentfrequentlycoexistswithcholelithiasis,butnocausativerelationshiphasbeenprovedoccasionallyproducesabdominalpain,andinsomecasescholecystectomymaybeindicatedforreliefofsymptoms,80,Adenomyomatosis,Thegallbladderwalliscomposedoffourlayers:mucosa,laminapropria,muscularispropria,andserosa.Nomuscularismucosaorsubmucosa.ThewallthickeningofadenomyomatosisinvolveshyperplasiaofbothmucosaandmuscularispropriaCholesterolaccumulationinadenomyomatosisisintraluminal,ascholesterolcrystalsprecipitateinthebiletrappedinRokitansky-Aschoffsinuses,intramuraldiverticulalinedbymucosalepithelium,81,AdenomyomatosisoftheGallbladder,LongitudinalUStransverseUSthickenedgallbladderwallandechogenicintramuralfociwithcomettailreverberationartifacts,indicativeofcholesterolcrystalswithinRokitansky-Aschoffsinuses,82,Adenomyomatosis:CT,thickenedgallbladderwallandabnormallyintensemucosalenhancementdiscretehypoattenuatingintramurallesionsrepresentRokitansky-Aschoffsinuses,83,adenomyomatosis,C-T2WIandc+T1WIshowadiffuselythickenedgallbladderwallandintramuralcavities,whicharehyperintenseontheT2WI,hypointenseontheT1WI,andnonenhancingThecavitiesrepresentRokitansky-Aschoffsinusescontainingfluidbile,84,Adenomyomatosis,Diffuselythickenedwallandmultiplecysticintramuralcavities.ThecavitiescorrespondtoRokitansky-Aschoffsinusesandarefilledwithcalculi,85,Adenomyomatoushyperplasia,F65chronicrightupperquadrantpainmultiple,punctate,calcificopacitiesintherightupperquadrant,86,胆管内积气,胆管内积气，特别是由乳头切开术引起者，CT易于检出,87,先天性胆管扩张症,胆管囊状扩张症是由于先天性胆管壁发育不良、胆道不同程度梗阻，引起胆道内压增高，胆管增大形成囊状扩张按位置和形态，胆管扩张分为五种类型型为胆总管囊肿，多见，占80%90%型为胆总管憩室，占2%型为壁内段胆总管囊状膨出，占1.4%5%型为多发性肝、内外胆管囊肿，占19%型肝内胆管多发性囊肿，也称为卡罗里氏病（CarolisDisease）按发病部位分为肝外胆管囊状扩张（包括型、型、型）、肝内胆管囊状扩张（型）和肝内外胆管囊状扩张（型）,88,先天性肝内胆管囊样扩张,由Caroli于1958年首先报道，故也称为Carolis病，为先天性染色体缺陷引起。有两种类型，一种为单纯性肝内胆管扩张合并胆管炎和胆道结石，无肝硬化。另一种合并小胆管增生纤维化而致肝硬化和门脉高压，部分可能恶变Carolis病包括肝内胆管扩张、肝硬化门脉高压和囊性改变一组征候群，可单独存在或与胆总管囊肿并存本病罕见，主要见于儿童和青年。病理表现为