磁共振胰胆管造影临床应用的价值评价

目的：探讨磁共振胰胆管造影（MRCP）在胆胰疾病中的应用价值。方法：采用重T2加权MR水成像技术对73例患者行MRCP检查。图像经三维最大信号强度投影（3D-MIP）及三维表面遮蔽显示技术（3D-SSD）后处理。结果：73例患者,4例为正常胰胆管,69例胆胰疾病中,梗阻性黄疸者58例,其中恶性胆道梗阻43例,良性胆道梗阻15例,非梗阻性病变11例,在梗阻性黄疸病例中,MRCP定位准确率为100%,并清楚显示扩张胆管程度及断端形态,对于恶性胆阻性病变11例,在梗阻性黄疸病例中,MRCP定位准确率为100%,并清楚显示扩张胆管程度及断端形态。对于恶性胆道梗阻。结合常规MRI可明显提高定性准确率83.7%,同时可显示肿块大小、范围及周围脏器侵犯情况。良性梗阻MR-CP检查的定性准确率为92.9%。在非梗阻性病例中,MRCP可清楚描绘胆囊结石、胆系术后改变及含液丰富的病变（胰腺假性囊肿、总胆管囊肿、十二指肠憩室等）与胰胆管之间的毗邻关系。结论：MRCP可准确揭示胆管梗阻部位,明确病变性质,MRCP对于非梗阻性胆胰疾病则有助于了解病变与周围脏器的毗邻关系。但MRCP作为一种影像检查技术。不能脱离常规CT、MRI,而是对常规影像检查的一种有效补充。     

MR imaging of the abdomen and pelvis in infants, children, and adolescents

Recent developments in magnetic resonance (MR) imaging have profoundly changed the investigation of abdominal and pelvic disease in pediatrics. Motion reduction techniques, such periodically rotated overlapping parallel lines with enhanced reconstruction, or PROPELLER, have resulted in reliable imaging with quiet breathing. Faster imaging sequences minimize artifact and allow for more efficient studies. Diffusion-weighted imaging has become increasingly important in the evaluation of neoplastic disease, depicting disease with increased cellularity and helping to differentiate benign from malignant masses. MR enterography helps visualize intra- and extraluminal bowel pathologic conditions. MR cholangiopancreatography can depict congenital and acquired causes of pancreatic and biliary abnormalities. MR urography is an effective technique for a one-stop-shop evaluation of structural urinary tract abnormality and renal function. Three-dimensional acquisitions allow volumetric display of structures from multiple angles. Specialized techniques allow quantification of iron and fat in the viscera in children with hemolytic anemia and obesity, respectively. This article covers current techniques and strategies to perform and optimize MR imaging of the abdomen and pelvis in infants, children, and adolescents and describes important practical applications.     

Chronische Infektionen im Bereich des Gallensystems

Chronic inflammation of the gallbladder and the biliary tract due to infections are rare, compared to common cholelithiasis and acute biliary inflammation. This group of diseases includes, besides of chronic cholecystitis with cholelithiasis, also chronic gallbladder inflammation without stones, gallbladder hydrops and porcelain gallbladder. The most common form of chronic biliary tract infection is primary sclerosing cholangitis, while infection due to parasites like oriental cholangiohepatitis is very rare in Europe. Using imaging modalities like ultrasonography, computed tomography and magnetic resonance imaging, normally, besides of porcelain gallbladder, only indirect signs of the disease may be documented. However, when i.v. cholangiography, endoscopic-retrograde cholangiography, percutaneous transhepatic cholangiography or MR-cholangiography are performed, depiction, especially of the biliary tree, is feasible. Differentiation of benign stricture and malignant tumor stenosis is problematic unrelated to the imaging modality used. Due to the unspecific signs of the disease, diagnosis may not be made from imaging alone, but a clinical suspicion may be strengthened.     

Comparison of 2D and 3D sequences for MRCP. Clinical value of the different techniques

Magnetic resonance cholangio-pancreaticograpy (MRCP) is a non-invasive imaging modality of the pancreatico-biliary system which plays an increasingly important role in the clinical and diagnostic workup of patients with biliary or pancreatic diseases. The present review is designed to give an overview of the currently available and appropriate sequences, their technical background, as well as new developments and their relevance to the various clinical issues and challenges. The impact of the latest technical innovations, such as integrated parallel imaging techniques and navigator-based respiratory triggering, on the diagnostic capacities of MRCP is discussed. In this context, the individual value of RARE, T2w single shot turbo/fast spin echo (SSFSE) and the recently introduced 3D T2w turbo/fast spin echo sequences (T2w 3D-T/FSE) is reviewed. RARE imaging may be preferred in severely ill patients with limitations in cooperation, SSFSE is particularly effective in differentiating benign and malignant stenosis, and 3D-FSE offers additional advantages in the detection of small biliary concrements.     

Vergleich von 2D- und 3D-Sequenzen für die MRCP

Magnetic resonance cholangio-pancreaticograpy (MRCP) is a non-invasive imaging modality of the pancreatico-biliary system which plays an increasingly important role in the clinical and diagnostic workup of patients with biliary or pancreatic diseases. The present review is designed to give an overview of the currently available and appropriate sequences, their technical background, as well as new developments and their relevance to the various clinical issues and challenges. The impact of the latest technical innovations, such as integrated parallel imaging techniques and navigator-based respiratory triggering, on the diagnostic capacities of MRCP is discussed. In this context, the individual value of RARE, T2w single shot turbo/fast spin echo (SSFSE) and the recently introduced 3D T2w turbo/fast spin echo sequences (T2w 3D-T/FSE) is reviewed. RARE imaging may be preferred in severely ill patients with limitations in cooperation, SSFSE is particularly effective in differentiating benign and malignant stenosis, and 3D-FSE offers additional advantages in the detection of small biliary concrements.     

Endoscopic Ultrasound of the Upper Gastrointestinal Tract and Mediastinum: Diagnosis and Therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage—in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.     

Complications of percutaneous biliary drainage: benign vs malignant diseases

Percutaneous transhepatic biliary drainage is used to treat a variety of benign and malignant biliary diseases. Although several investigators have reported on the number of complications associated with the use of this procedure in malignant disease, none has determined specifically the number associated with its use in benign disease. Differences in the number of procedure-related complications and deaths were examined in 206 patients with benign or malignant biliary diseases who underwent percutaneous transhepatic biliary drainage at the Toronto General Hospital during a 40-month period. Of these, 54 had benign and 152 had malignant biliary diseases. The prevalences of procedure-related major complications and deaths were 2% and 0%, respectively, in the benign group vs 7% and 3%, respectively, in the malignant group. These differences can be attributed to the shorter periods of drainage required and the generally better health of patients in the benign group. These findings suggest that percutaneous transhepatic biliary drainage can be performed with substantially fewer complications in patients with benign biliary diseases compared to those with cancer. Previously reported data on complications were derived from patient populations with preponderantly malignant obstructions and cannot be extrapolated to patients with benign diseases.     

Chronic inflammatory pseudotumor arising in the hepatobiliary-pancreatic system: progressive multisystemic organ involvement in four patients.

OBJECTIVE: Inflammatory pseudotumor is a benign process that can involve most organ systems. The purpose of this report was to evaluate the imaging features of multifocal chronic inflammatory pseudotumor in four patients who presented with clinical, radiographic, and biopsy evidence of pancreatic or biliary malignancy. CONCLUSION: To our knowledge, this is the first report in the radiology literature describing the imaging features of progressive multifocal inflammatory pseudotumor originating from a primary pancreatic or biliary focus. Even on retrospective review, no distinguishing imaging features were identified that could discriminate benign from malignant disease. These findings emphasize the importance of histopathologic analysis in the diagnosis of malignancy, particularly in patients with previously diagnosed inflammatory pseudotumor.     

MRCP 3D FRFSE系列对良恶性胰胆管梗阻的诊断价值

目的探讨三维快速恢复快速回波脉冲系列磁共振胰胆管水成像(MRCP 3D FRFSE)对良恶性胰胆管梗阻的临床应用价值。方法对106例临床疑有胰胆管梗阻患者行MRCP 3D FRFSE系列检查,2位高年资放射科医师前瞻性分析图像,结果与手术病理或临床随访结果比较。结果106例MRCP检查均一次性成功,肝内外胆管显示率为100%,主胰管显示率为93.4%,其中80例良性梗阻包括肝内外胆管结石66例,乳头炎6例,十二指肠降段憩室炎2例,十二指肠腺瘤样增生1例,慢性胰腺炎5例;26例恶性梗阻包括肝外胆管癌9例,壶腹癌5例,胆囊癌4例,胰头癌8例。MRCP对胰胆管梗阻的定位诊断准确率为100%,在区分良恶性梗阻中,敏感性92.3%,特异性96.3%,准确性95.3%。结论3D FRFSE系列的MRCP是区分良恶性胰胆道梗阻病变较为理想的技术,在临床上有较大的应用价值。     

18F-FDG PET显像在胰腺恶性病变鉴别诊断及转移灶探查中的应用价值

目的研究18F-FDGPET显像在胰腺恶性肿瘤诊断与鉴别诊断中的应用价值。方法 40例临床疑为胰腺恶性病变的患者均行18F-FDGPET显像,对显像结果进行目测法及SUV值半定量分析,并结合CT,MRI等影像学检查进行综合诊断,最后诊断根据手术病理或经4个月以上随访证实。结果如果以SUV为2.5作为鉴别诊断胰腺病灶良恶性的阈值,24例证实为胰腺癌患者中18F-FDGPET显像正确诊断22例,16例胰腺良性病变患者18F-FDGPET检出13例,其灵敏度、特异度及准确性分别为91.7%（22/24）,81.3%（13/16）及87.5%（35/40）;而结合CT,MRI等其他检查结果进行综合诊断,其诊断灵敏度、特异度及准确性分别为91.7%（22/24）、87.5%（14/16）及90%（36/40）。恶性病变的SUV平均值为4.6±2.6,良性病变的SUV平均值为2.3±1.5,良恶性病变间SUV平均值差异有统计学意义（P〈0.01）。在转移灶的检出中,18F-FDGPET显像发现了全部38处转移灶,并发现6处CT,MRI未能发现的远处转移病灶,排除了1例CT认为是胰周转移性淋巴结肿大的病例。结论 18F-FDGPET对鉴别诊断胰腺良恶性肿瘤的灵敏度、特异性较高,尤其在远处转移灶的探查中有较高应用价值。     

Diagnostic and interventional procedures for the biliary tract

Various diagnostic imaging studies have been employed in the past year to evaluate the normal and abnormal biliary ductal system. Variations in the normal ductal drainage of the left lobe of the liver, in which the right lateral hepatic duct drained into the left hepatic duct, were studied because of the implications for the surgical resection of the left lobe. Choledochal cysts have been studied in adults using endoscopic retrograde cholangiopancreatography to evaluate the abnormal junction between the common bile duct and pancreatic duct and the long dilated common channel. An ultrasound study indicated that children with choledochal cysts also may have intrahepatic duct dilatation. An increased incidence of malignancy has been noted in adults with choledochal cysts, and their appearance on ultrasound, CT, and cholangiography were described. Cystic fibrosis produces abnormalities of the biliary tree, extrahepatic strictures, and more interestingly, intrahepatic ductal dilatation and abnormal contour without strictures. The usefulness of the preoperative ultrasonographic evaluation of the biliary tract in Oriental cholangiohepatitis was stressed. Bile duct abnormalities in fascioliasis were also noted on CT scans. Patterns of abnormality in the CT appearance of the thickened, contrast-enhanced, extrahepatic bile ducts were elucidated. Focal concentric, focal excentric, diffuse concentric, and diffuse excentric ducts were seen with various forms of pancreatic disease, choledocholithiasis, and various forms of cholangitis. An enhanced, thick-walled duct indicates disease, but is a nonspecific finding. Chronic cholecystitis was found to produce false-positive cholescintigram results in patients with suspected acute cholecystitis, but only in those with severe degrees of chronic cholecystitis. The results of multicenter trials using extracorporeal biliary lithotripsy in the United States have been published. They are somewhat disappointing and do not confirm the original excellent results reported in Germany for treatment of gallbladder stones. Much interest has been focused on the use of expandable metallic stents for the treatment of benign and malignant biliary obstruction. Preliminary data suggest good patency rates for benign lesions. Patency rates for malignant lesions are similar to those of previously available plastic stents.     

恶性梗阻性黄疸的ERCP与CT对照分析

本文对比分析了８２例恶性梗阻性黄疸（包括胆管癌４５例，转移性癌２６例，胰头癌６例及壶腹周围癌５例）的ＥＲＣＰ与ＣＴ表现，主要发现：恶性胆管梗阻部位多位于肝外胆管近侧段；肝外胆管近侧段梗阻所致的肝内胆管重度扩张的发生率，远多于远侧段阻塞，在反映肝内胆管扩张程度、扩张范围方面ＣＴ优于ＥＲＣＰ，而显示病灶肿块直接征象方面ＥＲＣＰ优于ＣＴ。     

Radiologische Diagnostik der Gallenblase und der Gallenwege – Teil 2

Upper abdominal pain, icterus and cholestasis are the symptoms leading to evaluation of the biliary tract. Together with its complications biliary stone disease is the main reason for inflammation of the biliary system. A distinction is made between acute and chronic variants. In chronic bile duct inflammation primary sclerosing cholangitis (PSC), primary biliary cirrhosis (PBC) and more recently IgG4-associated sclerosing cholangitis are of particular importance. Besides benign and tumor-like-lesions, malignant entities as gallbladder carcinoma and cholangiocarcinoma (CCC) in its three locations have to be mentioned. Despite all recent improvements, specificity of bile-tract imaging still remains limited, especially regarding malignant masses. Therefore the final diagnosis is made in many cases by histological analysis.     

磁共振胆胰管成像(MRCP)与ERCP或PTC临床诊断价值的比较

探讨磁共振胆胰管成像在临床上对不同胆胰管疾病的诊断价值。材料与方法：回顾分析２３例疑有胆囊病患者的ＭＲＣＰ图像，并与其对照的ＥＲＣＰ或ＰＴＣ的诊断结果相比较。ＭＲＣＰ在１．０Ｔ超导磁场中完成，采用快速自旋回波序列ＭＩＰ法重建。结果：２３例患者的ＭＲＣＰ成功率为１００％，１４周手术病例中，ＭＲＣＰ对胆胰管系统非肿瘤性病变和肿瘤性病变的诊断正确率分别为１００％和８３５，１例误诊。     

MR cholangiopancreatography: technique, potential indications, and diagnostic features of benign, postoperative, and malignant conditions

The objective of this article is to review technical aspects, discuss potential clinical indications for MR cholangiopancreatography (MRCP) and demonstrate the spectrum of diagnostic findings in benign, postoperative, and malignant conditions. We describe our current imaging protocol in comparison with other available techniques. Using a non-breath-hold, heavily T2-weighted fast-spin-echo (FSE) sequence with or without respiratory gating we obtained coronal and axial source images and maximum intensity projections (MIPs) in 102 patients with suspected abnormalities of the biliary or pancreatic ducts. Based on this series we demonstrate the diagnostic appearance of a variety of benign, postoperative, and malignant conditions of the biliary and pancreatic ducts and discuss potential clinical indications for MRCP. The non-breath-hold FSE technique enables a consistent image quality even in patients who cannot cooperate well. Respiratory gating increased the rate of diagnostic examinations from 79 to 95 %. Acquisition of coronal and axial source images enables detection of bile duct stones as small as 2 mm, although calculi that are impacted and not surrounded by hyperintense bile may sometimes be difficult to detect. The MIP reconstructions help to determine the level of obstruction in malignant jaundice, delineate anatomical variants and malformations, and to diagnose inflammatory conditions, e. g., sclerosing cholangitis, the Mirizzi syndrome and inflammatory changes in the main pancreatic duct. The MRCP technique also correctly demonstrates the morphology of bilio-enteric or bilio-biliary anastomoses. Because MRCP provides sufficient diagnostic information in a wide range of benign and malignant biliary and pancreatic disorders, it could obviate diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in many clinical settings. The ERCP technique may be increasingly reserved for patients in whom nonsurgical interventional procedures are anticipated. Received 25 July 1996; Revision received 1 October 1996; Accepted 5 November 1996     

The characterization of pancreatic and bile duct tumours by duplex Doppler.

Duplex Doppler imaging was used to study the effect of pancreatic and bile duct tumours on portal vein and hepatic artery blood flow and the specific Doppler signals recorded from these tumours. Chaotic portal vein flow occurred in 35% (14) of pancreatic and 20% (6) of biliary tumours and complete portal vein occlusion in 28% (11) and 10% (3) respectively. Twenty-eight per cent (11) of pancreatic and 7% (2) of bile duct tumours had high frequency shift Doppler signals and 22% (9) of pancreatic tumours had a signal indicating low impedence flow. Both signal types are suggestive of malignancy. The results suggest that pulsed Doppler imaging has a valuable place in the ultrasound assessment of portal vein wall invasion, is an important staging criterion for pancreatic and biliary tumours and may assist in differentiating benign from malignant lesions.     

Inflammatory diseases of the gall bladder and biliary system. II. Acute and chronic inflammation of the biliary system--primary biliary cirrhosis

Inflammatory diseases of the biliary tract are divided into acute and chronic forms. Acute inflammation of the biliary tree is ascending cholangitis. Among chronic forms of the disease, primary sclerosing cholangitis, parasitic infection of the biliary tract, AIDS cholangiopathy, and chemotherapy cholangitis are recognised. Primary biliary cirrhosis and chronic inflammation of the papilla are also categorized within this group of inflammatory diseases of the biliary tree. Cross-sectional imaging modalities, such as sonography, computed tomography and magnetic resonance imaging, offer numerous possibilities for depicting the biliary system with high diagnostic accuracy. In contrast to the gallbladder, invasive imaging modalities of the biliary tree are also used for diagnostic purposes in addition to their therapeutic aspects.     

Benign biliary strictures: a current comprehensive clinical and imaging review

OBJECTIVE: There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. CONCLUSION: Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.     

Magnetic resonance cholangiopancreatography in conjunction with 3D for assessment of different biliary obstruction causes

Objective

To assess the diagnostic value of magnetic resonance imaging in conjunction with 3D-MRCP, with maximum intensity projections and volume rendered images in different biliary obstruction causes.

Patient and methods

This study retrospectively reviewed the radiology records of 29 patients (18 females and 11 males) suffering from obstructive jaundice. All patients were subjected to magnetic resonance imaging (MRI), 3D-MRCP with maximum intensity projection (MIP) and volume rendered (VR) reformatted images for biliary obstruction diseases in Zagazig University Hospitals between November 2008 and January 2010. MR studies were performed with 1.5-T superconductive magnet (Philips Achieva, class II a). The patient ages were ranging from 23 to 66 years (mean age: 34 years). This study was done to evaluate the diagnostic value and accuracy of the new MRI techniques as a non-invasive tool to diagnose and differentiate between benign and malignant variants of biliary obstruction diseases and to facilitate the management planning. All cases were evaluated by clinical examination, laboratory values, grey and colored scale ultrasonography, conventional MRI, three-dimensional (3D-MRCP), MIP, and VR images. Our results were correlated with the histology of the resected specimen, operative (ERCP) or image-guided biopsy in inoperable patients.

Results

The mean age of benign patients was 30 years compared with 54 years in malignant biliary obstruction. Seventeen patients had benign cases 58.6% (6 cases of benign stricture and 11 cases with choledocholithiasis). The other 12 cases had malignant aetiology. Twenty-three patients were subjected to operative procedures, while the remaining six had ERCP/PTC and stenting. The MRI/MRCP images were of good quality in all patients. The intra- and extra-hepatic biliary radicals were visualized completely including the proximal and distal extent of the stricture. Regarding the benign cases (16/17) were satisfactorily diagnosed, however, one case was false negative, due to missed small stone at the MIP reconstructions. The 12 malignant biliary obstruction cases were as follows: five cases were cholangiocarcinoma (one peripheral type, one perihilar position, one Klatskin’s type, and two cases of the distal type), three pancreatic neoplastic lesions, two ampullary carcinoma, and two malignant lymph nodes. Regarding the benign cases 3D-MRCP had 94.1% diagnostic accuracy, otherwise more accuracy reported in malignant causes 100%.

Conclusion

3D-MRCP with MIP creates global images for pancreatico-biliary system. It is as effective as ERCP in detection of biliary obstruction and can precisely determine its level as well. Furthermore, it can provide a road map for management planning. By avoiding the flow artifacts, the false negative results that previously reported in past studies can be reduced.     

增强MRI诊断乳腺良恶性病变的价值

目的评价增强ＭＲＩ对乳腺良、恶性病变的诊断价值。方法对４８例乳腺病变患者进行ＭＲＩ平扫和增强扫描，并对照Ｘ线、Ｂ超及手术病理结果，分析比较了病变强化后形状、边界、内部信号、强化速度与程度以及强化消失快慢等特征。结果４８例乳腺病变患者８１个病灶的良、恶性诊断准确率为９２．６％。结论增强ＭＲＩ是鉴别乳腺良、恶性病变的一种有效的影像学诊断方法