疑难病例阻塞性黄疸鉴别诊断

1、http/http/http/疑难病例讲座疑难病例讲座 http/http/http/黄疸病人检查前的思路黄疸病人检查前的思路 真性黄疸与假性黄疸的鉴别 胡萝卜、南瓜、橘子汁、空心菜、甘蓝菜、芒果等蔬菜瓜果富含胡萝卜素，过多地摄入引起胡萝卜素血症，导致皮肤变黄，以手掌、足底最为明显，其次是面部、耳后，严重者可累及全身皮肤。http/http/http/黄疸病人检查前的思路黄疸病人检查前的思路 超声能确定外科外科阻塞性黄疸，判断阻塞位置，查明梗阻的原因如结石、肿瘤、蛔虫、狭窄。http/http/http/阻塞性黄疸鉴别诊断阻塞性黄疸鉴别诊断 有否外科阻塞性黄疸 阻塞位置判断 阻塞性质确定 ht

2、tp/http/http/黄疸的类型黄疸的类型 肝前性黄疸：溶血 肝性黄疸：肝损害 肝后性黄疸：胆管阻塞http/http/http/肝前性黄疸肝前性黄疸 表现间接胆红素升高，直接胆红素不升高 见于输血反应、毒蛇咬伤的溶血性黄疸http/http/http/肝性黄疸肝性黄疸 直接、间接胆红素均升高。 见于各种原因引起的肝细胞破坏如病毒性肝炎http/http/http/肝后性黄疸肝后性黄疸 直接胆红素升高，间接胆红素不升高 内科性：药物等引起的淤胆性肝炎，毛细胆管阻塞，超声检查未见异常。 外科阻塞性黄疸：各种原因引起的肝内或伴肝外胆管扩张，超声检查阳性。http/http/http/胆总管分段

3、及走向胆总管分段及走向 胆总管分为十二指肠上段，十二指肠后段、胰腺段、肠壁段。 胆总管上段与门静脉伴行，下段与下腔静脉伴行。 胆总管大多数穿过胰头与胰管汇合后进入十二指肠。少数在胰头后方行走，不与胰管汇合进入十二指肠。http/http/http/http/http/http/胆道胰管超声胆道胰管超声 超声能显示一级肝内胆管左右肝管，其分支一般不显示。正常左右肝管内径小于3mm，如大于3mm或二级胆管扩张呈“双管征”提示肝内胆管扩张。 肝外胆管因无法显示胆囊管，所以无法明确肝总管和胆总管的界线。肝外胆管大于8mm提示扩张。 http/http/http/胆道胰管超声胆道胰管超声 胰管大于3mm

4、提示扩张。 年龄较大者（60岁以上），胆管或胰管可能较宽，为退行性病变之故。 双管征：正常各级胆管为相应门静脉内径的1/3，在胆道梗阻时，胆管内径大于或等于门静脉内径时为双管征。http/http/http/http/http/http/http/http/http/肝内胆管肝内胆管http/http/http/主胰管超声图主胰管超声图http/http/http/外科阻塞性黄疸的确定外科阻塞性黄疸的确定 肝内胆管广泛性扩张是确定外科阻塞性黄疸的依据。http/http/http/http/http/http/http/http/http/阻塞部位的判断阻塞部位的判断 肝门部阻塞：表现为肝内胆

5、管广泛性扩张，主胰管及肝外胆管不扩张，胆囊不肿大。 肝门部阻塞最多见为肝门部胆管癌或肿瘤转移。http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/阻塞部位的判断阻塞部位的判断 共同开口以上阻塞，表现为肝内胆管广泛性扩张，肝外胆管扩张，胆囊肿大而主胰管不扩张。 原因可能为结石、蛔虫或肿瘤。http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/阻塞

6、部位的判断阻塞部位的判断 共同开口或壶腹部阻塞，表现为肝内胆管广泛性扩张，肝外胆管、主胰管扩张，胆囊肿大。 原因有胰头癌、胆管或壶腹部肿瘤、结石、蛔虫。http/http/http/阻塞原因的判断阻塞原因的判断 肿瘤：大多为低回声实性肿块，边界不清，不规则或蟹足样，cdfi上血供可能丰富，ri偏高。 患者年龄偏大，50岁以上，短期消瘦，无痛性黄疸及皮肤痒，位于肝门部或胆总管下段较多。http/http/http/阻塞原因的判断阻塞原因的判断 结石：扩张的胆管内见强回声团伴声影，在胆管中下段多见，多伴肝内胆管结石或胆囊结石。 年龄偏轻，有疼痛、发热、黄疸病史。 http/http/http/ht

7、tp/http/http/阻塞原因的判断阻塞原因的判断 蛔虫：扩张的胆管内见双线条样回声。 狭窄：手术损伤，壶腹部炎症后，结合临床。http/http/http/胆总管下段病变的超声诊断的讨论胆总管下段病变的超声诊断的讨论 胆总管下段病变如结石、肿瘤超声诊断的阳性率为4060。 如何提高显示率 1.饮水后检查， 2.加压探头扫查， 3.eus检查http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/http/h

8、ttp/http/http/http/http/http/http/http/http/http/http/http/http/http/胆囊超声若干问题讨论胆囊超声若干问题讨论http/http/http/http/http/http/胆囊超声特点胆囊超声特点 解剖结构简单 超声应用最早，效果最好的器官之一 问题不简单http/http/http/胆囊壁弥漫性增厚伴双壁征的鉴别胆囊壁弥漫性增厚伴双壁征的鉴别 胆囊炎急性发作或急性胆囊炎 急性肝炎 肝硬化或尿毒症http/http/http/胆囊急性炎症时的超声表现胆囊急性炎症时的超声表现 胆囊肿大 多伴胆囊结石（颈部嵌顿） 超声墨非氏征（）

9、增厚的胆囊壁病理基础是炎性水肿http/http/http/急性肝炎时胆囊超声表现急性肝炎时胆囊超声表现 胆囊缩小 胆汁透声差 严重时为实性胆囊 机理：胆汁分泌减少，毛细胆管渗透性增 提示急性肝炎http/http/http/肝硬化等引起胆囊表现肝硬化等引起胆囊表现 胆囊大小正常，壁增厚明显 机理：单纯性水肿 原因：可能是门静脉高压与低蛋白血症http/http/http/肝硬化等引起胆囊表现肝硬化等引起胆囊表现 不要诊断为胆囊炎 与腹水为同一原因引起的二种表现 少量腹水诊断先导 胆囊壁增厚可以作为腹水性质鉴别http/http/http/急性胆囊炎时假肿瘤样声像图急性胆囊炎时假肿瘤样声像图

10、胆汁透声降低，阻抗差减小 胆囊壁明显局限性增厚 建议：急性胆囊炎时，发现有胆囊癌样占位性病变，不要轻易诊断胆囊癌。消炎后复查。http/http/http/胆囊样息肉病变有关问题胆囊样息肉病变有关问题 胆固醇性息肉5060，炎性息肉510，腺瘤小于5。 大多数息肉逐步变成结石。 胆囊腺肌症：为非肿瘤非炎性的增殖性疾病，局部胆囊壁增厚，表面有粘膜覆盖http/http/http/胆囊样息肉病变有关问题胆囊样息肉病变有关问题 有下列情况建议手术： 大小大于1.0cm； 基底宽 表面不规则 单发性，位于颈部http/http/http/胆囊癌与胆囊结石的关系胆囊癌与胆囊结石的关系 以往认为1/3的胆囊结石为silence，不需要处理。 建议 胆囊癌75有胆囊结石。结石为胆囊癌的重要原因 50岁以上胆囊癌占82.3 胆囊结石病人，胆囊癌漏诊很高http/http/http/胆囊癌与胆囊结石的关系胆囊癌与胆囊结石的关系 5055岁以上，长期有胆囊结石特别是充满型胆囊结石病人，要多方位，多切面观察胆囊壁情况，对可疑