3esvas超腹部肝胆管hepatobiliary us

Sonographyofthehepato-

biliarytract

肝胆管的超声检查

PatrickKircher,dipl.ECVDI

欧洲兽医诊断影像学学会认证医师

DivisionofclinicalRadiology

临床放射学部

VetsuisseFacultyBern

伯尔尼大学兽医学院

Whatcanweuse...

我们能使用的有...

RadiographyX线Contraststudies?

对比造影成像？Sonography

超声FNA,biopsy

细针抽吸，活检Contraststudies?

对比造影成像？EndoscopicSonography

内镜超声检查Technique技术Lateralordorsalrecumbency侧位或背侧位保定Ventralapproachlookingcranodorsalyoverxiphoid在剑突之后的腹部位置以头背向的方向放置探头Sagittalandtransverse纵向扫查和横向扫查Technique–intercostalapproach

技术－肋间进路Fromrightlateral从右外侧开始Betweenapprox.11thand12thrib大约在第11肋骨和第12肋骨之间Neededin:可用于以下对象deepchesteddogs胸腔深的狗casesofsmallliver肝脏小的病例Forvasculatureandbiliarytract可检查脉管系统和胆管

Wheretolookforit?

在哪里找它？Ltliver左肝叶Rtliver右肝叶Thenormalliver-Dog

正常肝脏－狗Thenormalliver-Cat

正常肝脏－猫Whatareindications?

适应症是什么？Hepatomegaly肝肿大Abdominalmasses有腹部包块Icterus/Jaundice黄疸Ascites腹水UnspecificGI-disease不能确定的胃肠道疾病FUO原因不明的发热Examinationofdiaphragm横膈膜的检查Searchformetastasis寻找转移灶GuidanceforFNA/biopsy引导细针抽吸/活检Normalliver正常的肝脏Midechogenicity回声强度中等Homogeneousarchitecture均质结构Smoothsurface表面光滑Sharpcontours轮廓清晰Normalliver正常的肝脏Portalvein:echo-rich„wall“门静脉：有强回声“血管壁”Livervein:anechoic„wall“肝静脉：无回声的“血管壁”DiameterincreasesindirectionofVCC

在VCC方向上时可见直径增加Lobuscaudatus:usuallyslightlyhypoechoiccomparedtootherlobes

尾状叶：同其他叶相比通常会显得回声较低Gallbladder胆囊:thinmildlyechoicwall有薄的低回声壁

anechoiccontent有无回声的内容物 sizevariable大小多变Normalliver

正常的肝脏Normalgallbladder

正常的胆囊IncourtesyofD.DellaSantaHepaticvessels

肝脏的血管Let‘sgoforpathologies

接下来让我们看看病理性的情况Biglesionsareusuallyobvious大的病变通常都很明显Likethisone....

比如说这一个病例....Appenzeller„Benno“,m.,11y

阿普策尔山地犬„Benno“,公犬,11岁Vomitussinceseveraldays

已呕吐好几天Bloodyvomitus

血性呕吐物Appenzeller„Benno“,m.,11y

阿普策尔山地犬„Benno“,公犬,11岁Appenzeller„Benno“,m.,11y

阿普策尔山地犬„Benno“,公犬,11岁Appenzeller„Benno“,m.,11y

阿普策尔山地犬„Benno“,公犬,11岁Whatwastheprimarylesion?

主要病变是什么？ tobefollowed!!!Butmostofthetime,itisnotsuchobvious

但是在大多数情况时，病变不是那么明显focal 局灶性 diffuse弥漫性hypo-mixed-hyper-hypo-hyper-低回声混合性回声高回声 低回声高回声 echoic echoic

Diffuselesions弥漫性病变hypoechoic:低回声 a淋巴肉瘤 Hepatitis,Congestion肝炎，淤血Ln.Ao.

腹主动脉淋巴结Diffuselesions弥漫性病变hypoechoic:低回声 a淋巴肉瘤 Hepatitis,Congestion?肝炎，淤血？ lookforhim找找他Liver:BugsBunny

肝脏：疯狂的兔子CourtesyDanieledellaSantaDiffuselesions弥漫性病变hyperechoic:高回声： Cirrhosis,Fibrosis肝硬化，纤维化 Lipidosis–steroidhepatopathy脂肪沉积－类固醇性肝病 a淋巴肉瘤Ratherobesecat

相当肥胖的猫Lipidosis

脂肪沉积Cirrhosissizediminished

肝硬化减小focal-multifocallesions局灶性-多病灶性病变

hypo-anechoic:低-无回声Neoplasia,primary,metastatic肿瘤，原发性，转移性a淋巴肉瘤FNH局灶性结节性增生Abscess,cyst脓肿，囊肿Hematoma血肿focal-multifocallesions局灶性-多病灶性病变

mixedechotexture混合性回声Neoplasia,primaryundmetastatic肿瘤，原发性和转移性a淋巴肉瘤focalnodularhyperplasia局灶性结节性增生Abscess脓肿Hematoma血肿Neoplasia?

肿瘤？CotondeTulear,m.,7y

棉花面纱犬，公犬，7岁No,parasitic

否，寄生虫Forradiologyitwasaprimaryneoplasia

从X光片上来看，这是一个原发的肿瘤Forcytology:从细胞学上来看：Forparasitology:从寄生虫学上来看：

Echinococcosis

包虫病Neoplasia

肿瘤CockerSpaniel„Hershey“,m.,12y

英国可卡犬„Hershey“，公犬，12岁Sometimesjustcomplex!!!

有时是非常复杂!!!Yorkie„Attila“,m.,11y.

约克夏„Attila“，公犬，11岁Didyourealize?

你注意到了吗？awasalwaysonthedifferentialslist!!!淋巴肉瘤一定会在鉴别诊断的目录中!!!Usuallydiffuse通常是弥漫性的Canbehyper-tohypoechoic可以是高到低的回声Canbenodular可以是结节化的Canbehomogeneous可以是均质的Canbe......可以是......Canevenlooknormal!!!甚至可以是看起来正常的!!!Primarymaligne:原发的恶性肿瘤：hepatocellularcarzinoma肝细胞癌a淋巴肉瘤Biliarycarzinoma胆管癌a血管肉瘤a骨肉瘤Primarybenigne:原发的良性肿瘤：Hepatocellularadenoma(hepatoma)肝细胞腺瘤（肝癌）Focalenodularhyperplasia(FNH)局灶性结节性增生Possibleprimarylivertumours

可能的原发性肝脏肿瘤Keytosuccess?

诊断正确的关键？Alwaylookatthesurroundingorgans

一定要看周围的器官Especiallylookforlymphnodes

特别要注意观察淋巴结And:

并且：Contrast

studies?

对比造影？FNA

细针抽吸Biopsy

活检Icterus黄疸hematocrit<20%血细胞比容<20%pre-hepatic

hemolyticdisease肝前性的溶血性疾病normalormildlydecreasedhematocrit血细胞比容正常或轻度降低post-hepaticorhepatic肝前性或肝性Ultrasonography超声检查biliaryobstruction胆道阻塞post-hepatic肝后性Surgery手术noobstruction无阻塞Hepatic肝性liverbiopsy肝脏活检Hepaticicterus:

肝性黄疸：impairedhepaticuptake,conjugationorexcretionofbilirubin

肝脏摄取，结合或排泄胆红素的能力受损seenindisorderswithsevereintrahepaticcholestasissuchas在如下的这些伴有严重肝内胆汁淤积的病症中可见felinehepaticlipidosis

猫的肝脏脂肪沉积inflammatoryhepatopathies

炎症性肝病liverfailure,severechronicliverdisease

肝衰竭，严重的慢性肝病severeextrahepaticinfections(cytokinesinhibitbilirubintransport)

严重的肝外感染（一些细胞因子抑制胆红素的转运）Gallbladder胆囊

biliaryducts胆道Obstruction!阻塞！ -gallbladder胆囊 -Ductuscholedochus胆总管 -Extrahepaticducts肝外导管 -Intrahepaticducts肝内导管Posthepaticicterus:

肝后性黄疸：obstructionofflowwithintheextrahepaticbileducts

肝外导管中胆汁的流动受阻choleliths胆结石pancreatitis

胰腺炎biliaryneoplasia

胆道肿瘤Thebiliarytree:

胆管结构图：gallbladder

胆囊胆囊管cysticduct总胆管commonbileducthepaticducts

肝胆管majorduodenalpapilla十二指肠大乳头minorduodenalpapilla十二指肠小乳头pylorus幽门pancreas

胰腺pancreaticduct胰管accessorypancreaticduct副胰管Duodenalpapilla:

十二指肠乳头：dog:

狗：cat:

猫：Dynamicsofbiliaryobstruction

胆道阻塞的动力学24hours:distentionofgallbladderandcysticduct24小时：胆囊和胆囊管扩张48hours:distentionofcommonbileduct48小时：总胆管扩张72hours:distentionofhepaticducts72小时：肝胆管扩张Differentialdiagnosesforbiliaryobstruction:

胆道阻塞的鉴别诊断：Intraductal

胆管内cholelith,biliarysludge,liverflukes

胆结石，胆泥，肝吸虫Intramural

胆管壁内cholangitis,biliaryadenocarcinoma

胆管炎，胆道腺癌Extraductal

胆管外pancreatitis,pancreaticpseudocyst,pancreaticcarcinoma,livermasses,lymphadenopathy

胰腺炎，胰腺假性囊肿，胰腺癌，肝包块，淋巴结病Duodenal

十二指肠foreignbody,IBD,intestinalneoplasia

异物，肠炎，肠道肿瘤Extrahepaticbiliaryobstruction(EHBO):

肝外胆管阻塞：mostcommoncausesindogs:狗最为常见的原因：pancreatitis

胰腺炎neoplasia

肿瘤mostcommoncausesincats:

猫最为常见的原因：biliaryorpancreaticneoplasia

胆道或胰腺肿瘤inflammatorydiseases(pancreatitis,cholangiohepatitis,cholecystitis)

炎性疾病（胰腺炎，胆管性肝炎，胆囊炎）cholelithiasis

胆结石Biliaryobstruction

胆道阻塞GoldenRetriever„Gipsy“,nf.,9y.

金毛寻回猎犬„Gipsy“绝育母犬，9岁Concurrenthepatic,splenicnodules(biliaryductcarcinoma?)

并发肝小结，脾小结（胆管癌？）Gallbladder胆囊DilatationundSediment扩张和沉积

"normal"inanorecticPatients

在厌食的病畜上是正常的Thickenedwall胆囊壁增厚 -Edema(ascites,hypoalb,etc...)

水肿（腹水，低白蛋白血症等...) -chronicCholecystitis慢性胆囊炎Cholethiasis胆汁淤积

-sometimesclinicallyinsignificant有时临床表现不明显 -DD:Polyps息肉Lastcase

最新病例CairnTerrier“Charlie”mc9y

凯恩梗“Charlie”去势公犬，9岁Presenteddiarrheaandvomitingafteratriptotheneighboursgarbagecan..在翻捡邻居家的垃圾桶后出现腹泻和呕吐..Clinicalexam:mildlethargy,abdominalpalpationfortable临床检查：轻度嗜睡，腹部触诊不适CBC,Chemistrywithinnormallimits血液常规，血液生化指标在正常范围内CaseincourtesyofG.Seiler,UniversityofPennsylvaniaAbdominalultrasound:

腹部超声：肝脏胆囊胆囊胆囊肝脏总胆管脾脏胆囊Diagnosis:biliarymucocele

诊断：胆道黏液囊肿gallbladderwallthickening胆囊壁增厚Inspissatedbileinastellateorkiwi-f