胆囊管正常变异的X线分析及临床意义

目的　通过观察胆囊管正常变异的X线表现 ,探讨胆囊管正常变异的X线表现及临床病理学意义。方法　观察和测量84例直接法胆系造影中显影良好的胆囊管。结果　胆囊管变异发生率 78.6 %。其中胆囊管长度变异占 41.7% ,汇入位置变异占35 .7% ,汇入方向变异占 5 2 .4% ,与肝总管并、绕行占 47.6 %。 4种变异常有 2～ 4种同时存在。结论　胆囊管正常变异是一种发生率较高的先天异常 ,术前行直接法胆系造影对临床有重要意义。     

胆囊管残留过长的X线诊断（附33例报告）

本文报告直接法胆系造影发现的３３例胆囊切除术后胆囊管残端过长，均经再手术证实。对胆囊管残留过长的解剖学原因和临床病理表现进行了研究。并就如何避免胆囊管残留过长等问题作了讨论。     

胆囊管解剖变异的手术治疗体会

目的：探讨胆囊管解剖变异在胆囊切除术中的注意事项及手术方法。方法：回顾分析我院自1999~2009年200例胆囊切除术时所发现的32例胆囊管变异对其病理类型和手术处理技巧进行讨论。结果：胆囊管低位汇入肝总管下端者合并胆总管结石显著高于其他类型胆囊管变异者（P〈0.001）;术中医源性胆道损伤2例,皆发生在有胆囊管变异的患者,其发生率显著高于无胆囊管变异的患者,全组无死亡病例。结论：术前酌情选用ERCP或PRCP,可发现胆囊管变异,并有较高的准确性。术中探查及必要的术中胆道造影和胆道镜是发现和处理胆囊管变异的最好方法。     

MRCP诊断胆囊管低位汇入的价值(附30例分析)

目的探讨磁共振胰胆管成像(MRCP)诊断胆囊管低位汇入的价值。方法收集2012年10月~2014年3月期间行MRCP检查的271例患者的图像进行回顾性分析,测量肝总管的长度和胆总管的长度,二者的比值大于1时诊断胆囊管低位汇入,分析低位胆囊管的汇合部位及其有无胆囊炎、胆囊结石。结果 271例患者中胆囊管低位汇入者30例(11.1%),其中胆囊管低位汇入肝外胆管右侧壁者5例(17.7.0%),后壁者9例(30.0%),左侧壁者16例(53.3%)。结论 MRCP检查有助于发现和诊断胆囊管低位及其并发症,具有重要的临床应用价值。     

MRCP对胆囊管低位汇入及其相关并发症的诊断价值

目的：探讨MRCP对胆囊管低位汇入诊断及相关并发症分析,以提高对该病的认识。方法：回顾性分析107例经MRCP诊断为胆囊管低位汇入患者的MRI图像。结果：107例中,平行汇入组27例（25.2%）,螺旋汇入组80例（74.8%）,2组胆囊结石及胆囊炎发病率差异均有统计学意义（均P<0.05）,胆总管结石、胰腺炎发病率差异均无统计学意义（均P>0.05）。结论：MRCP在胆囊管低位汇入中有非常高的诊断价值,明确汇入分型可避免术中胆道损伤,指导相关并发症的预防。     

经胆囊管胆道镜检查取石56例

目的：探讨经胆囊管或其汇入部微切开行胆道镜检查的可行性及适应证。方法：对具有胆道探查指征的患者，施行经胆囊管或其汇入部切开约2mm后进行胆道镜检查和取石，探查完成后不放置T管，直接结扎或缝合胆囊管及汇入部微切口。结果：施行经胆囊管胆道镜检查22例，经胆囊管汇入部微切开检查34例，成功53例。术后住院时间7—10d，平均8．6d，无一例胆漏发生。47例得到随访，随访时间3月～4．5年，平均32月，无一例结石复发或胆道狭窄表现。结论：与传统的胆总管切开胆道镜检查相比，经胆囊管或其汇入部微切开胆道镜检查具有创伤小，术后反应轻，术后住院时间短，免除了术后带T管的痛苦，减少了术后并发症等优点，适应于大部分胆道结石患者。     

20例异位胆囊管MRCP诊断的临床分析

目的 探讨异位胆囊管磁共振胰胆管成像（MRCP）诊断的临床价值.方法 20例术前均进行了磁共振仪扫描,对磁共振图像进行回顾性分析,对异位胆囊管进行分型总结.结果 20例胆道系统均良好显示,其中高位汇入型7例,低位汇入型8例,螺旋汇入型5例.结论 MRCP能很好显示异位胆囊管,对腹腔镜胆囊切除术具有十分重要的指导意义.     

肝内外胆管及胆囊扩张程度和低位梗阻性黄疸病变的相关性

目的探讨肝内、外胆管及胆囊扩张程度、形式对低位梗阻性黄疸的诊断价值。方法回顾性分析105例低位阻塞性黄疸患者的CT和内窥镜逆行胰胆管造影（ERCP）的影像资料，将胆系扩张分为下列7种类型：Ⅰ型为肝内、外胆管及胆囊均重度扩张；Ⅱ型为肝外胆管、胆囊重度扩张伴肝内胆管轻度扩张；Ⅲ型为肝内、外胆管重度扩张伴胆囊不扩张或轻、中度扩张；Ⅳ型为肝外胆管重度扩张伴肝内胆管和胆囊不扩张或轻、中度扩张；Ⅴ型为肝内胆管重度扩张伴肝外胆管及胆囊不扩张或轻、中度扩张；Ⅵ型胆囊重度扩张伴肝内、外胆管不扩张或轻、中度扩张；Ⅶ型为肝内、外胆管及胆囊均不扩张或轻、中度扩张。结合手术和病理结果，分析各类型胆系扩展和其低位阻塞性黄疸病变的相关性。结果105例低位阻塞性黄疸中33例为肿瘤性病变，72例为非肿瘤性病变。肿瘤性病变中．Ⅰ型16例，Ⅱ型10例，Ⅲ型4例，Ⅳ型1例，Ⅶ型2例。非肿瘤性病变中，Ⅰ型4例，Ⅱ型4例，Ⅲ型9例，Ⅳ型33例，Ⅴ型2例，Ⅵ型11例，Ⅶ型9例。Ⅰ、Ⅱ型扩张和Ⅲ～Ⅶ型扩张在肿瘤和非肿瘤病变中差异有统计学意义（χ^2=47．33，P〈0．01）。结论低位阻塞性黄疸病变性质和肝内、外胆管及胆囊扩张程度密切相关：（1）Ⅰ型和Ⅱ型扩张提示绝大多数为肿瘤性病变，少数为嵌顿性结石。（2）Ⅲ～Ⅶ型扩张常为胆管、胆囊结石及炎症。     

胆囊管变异与胆囊结石相关性的MRI研究

目的:利用磁共振胰胆管造影(M RCP)及常规M R I序列,探讨胆囊管变异与胆囊结石发生的相关性。方法:回顾性分析符合纳入标准的382例患者的MRI及临床资料,比较常见变异胆囊管与正常胆囊管患者胆囊结石患病率差异。胆囊管变异由两位影像医师根据MRI常规及2D-MRCP序列独立盲法诊断,胆囊结石经手术或MRI和B超检查共同证实。结果:正常胆囊管154例,胆囊管变异228例(变异率59.7%),其中胆囊管高位汇合20例,汇合于肝总管前或后壁130例,中间汇合24例,低位汇合16例,平行胆囊管20例,胆囊管低位汇合伴胆囊管平行走行11例,短胆囊管7例。变异胆囊管中,胆囊管低位汇合和胆囊管低位汇合伴胆囊管平行走行患者结石患病率(分别为68.8%、63.4%)较正常胆囊管患者差异有统计学意义(P=0.000、0.003),胆囊管高位汇合、汇合于肝总管前或后壁、中间汇合、平行汇合、短胆囊管患者胆囊结石患病率(分别为20.0%、26.9%、25.0%、40.0%、0)较正常胆囊管患者差异不具有统计学意义(P>0.05)。结论:胆囊管变异率较高,变异胆囊管中,胆囊管低位汇合、胆囊管低位汇合伴胆囊管平行走行是促进胆囊结石形成的危险因素。     

原发性肝细胞癌侵犯胆管的影像学观察

目的：通过对原发性肝细胞癌侵犯胆管的影像学观察，提高对原发性肝癌侵犯胆管的准确诊断率。材料与方法：回顾性分析１９８１年至１９９４年期间本院经超声、ＣＴ和直接法胆系造影检查并经手术病理证实的此症１９例。结果：术前超声检查１５例，ＣＴ检查１１例，直接法胆系造影检查１２例，三项检查中无一例作出正确诊断。结论：影像检查过程中既需要将各种征象全面考虑，又要对不同影像手段所获信息进行综合分析，才能正确诊断。作者提出直接法胆系造影所见“网球拍征”和“凝絮征”为诊断本症的较特异性的征象。     

直接胆管造影时胆囊不显影的意义探讨

本文回顾性分析连续130例(ERCP 78例、PTC 52例)肝内外胆管显影好、技术上满意、未作胆囊切除而胆囊或胆囊管不显影的直接胆管造影片及手术结果。按使胆囊不显影病变的部位将所有病例分成3组:(1)胆囊和/或胆囊管病变(83例,63.8％):(2)胆总管中下段病变(37例,28.5％);(3)肝总管远端或胆总管近端病变(9例,6.9％)。分析胆囊和/或胆囊管不显影的原因及发病机制。 本研究证明:直接胆管造影中,(1)如果肝内外胆管显影好且无梗阻性病变,胆囊和/或胆囊管不显影可下“病理胆囊”的诊断;(2)如果肝内外胆管显影好,胆总管或肝总管远端有梗阻性病变,胆囊和/或胆囊管不显影不一定提示胆囊或胆囊管病变。     

胆石症胆囊管MRCP分析及临床意义

目的:利用MRCP观察胆囊管在肝总管的开口部位及其变异,探讨其临床价值。方法:应用MRCP检查240例拟行腹腔镜胆囊切除术的胆石症病例,重建后观察胆囊管在肝总管的开口部位并对其变异予以分析。结果:MRCP像上胆囊管显示154例(64.2%),胆囊管正常开口于肝总管右侧壁96例(62.3%)、变异开口于肝总管左侧壁、前壁、后壁及低位分别为8例(5.2%)、8例(5.2%)、22例(14.3%)及4例(2.6%),另有16例(10.4%)胆囊管部分显示,其开口部位未显示。结论:MRCP可以观察胆囊管在肝总管的开口部位,对于腹腔镜胆囊切除术前了解胆囊管的变异有一定的临床价值。     

The cystic duct: normal anatomy and disease processes.

The cystic duct can be depicted with a variety of imaging modalities but is optimally visualized with direct cholangiography or magnetic resonance cholangiopancreatography. Nevertheless, unrecognized anatomic variants of the cystic duct may cause confusion on imaging studies and complicate subsequent surgical, endoscopic, and percutaneous procedures. Primary entities involving the cystic duct include calculous disease, Mirizzi syndrome, cystic duct-duodenal fistula, biliary obstruction, neoplasia, and primary sclerosing cholangitis. The cystic duct may also be secondarily involved by adjacent malignant or inflammatory processes. Postoperative alterations are seen after liver transplantation or cholecystectomy when a portion of the cystic duct is left behind as a remnant. Recognized postoperative complications include retained cystic duct stones, cystic duct leakage, and malposition of T tubes in the remnant. Pitfalls encountered in cystic duct imaging include pseudocalculous defects from overlap of the cystic duct and common bile duct, underfilling of the cystic duct during direct cholangiography, and admixture defects at the cystic duct orifice. Pseudomass or pseudotumor defects may result from an impacted cystic duct stone or from a tortuous, redundant cystic duct. Familiarity with the imaging appearance of the normal cystic duct, its anatomic variants, and related disease processes facilitates accurate diagnosis and helps avoid misinterpretation.     

Using MR cholangiopancreatography to evaluate iatrogenic bile duct injury.

OBJECTIVE: The purpose of this study was to assess the role of MR cholangiopancreatography (MRCP) in the evaluation of iatrogenic bile duct injuries. SUBJECTS AND METHODS: In this prospective study, MRCP was performed in 10 postoperative patients (nine female and one male, ranging in age from 17 to 79 years) suspected of having bile duct injury as a result of surgery. Presence or absence of biliary dilatation, excision injury, stricture, fluid collection, and free fluid was noted. Excision injury was diagnosed if a segment of bile duct was not visible on any of the MRCP sequences. Positive cases were classified according to anatomic location and extent of injury. Results were compared with endoscopic retrograde cholangiopancreatography in five patients, percutaneous transhepatic cholangiography in one, surgery in four, and clinical follow-up in three. RESULTS: Three patients had normal findings on MRCP and remained asymptomatic on clinical follow-up. Four patients had bile duct excision injury on MRCP that was surgically proven, and one had stricture, confirmed by percutaneous transhepatic cholangiography. Of these five patients, one had Bismuth type I injury, two had type II, one had type III, and one had type IV. Two patients had findings suggestive of cystic duct leak on MRCP that were confirmed on cholangiography. CONCLUSION: MRCP can accurately diagnose postoperative biliary strictures and excision injuries and can characterize and anatomically classify these injuries for planning reparative surgery. It can also suggest the presence of cystic duct leaks in patients who have undergone cholecystectomy.     

Value of magnetic resonance cholangiography in benign and malignant biliary stenosis: comparative study with direct cholangiography

PURPOSE: Magnetic resonance cholangiography (MRC) is currently under investigation for imaging of biliary stenosis. The purpose of this study was to evaluate the diagnostic value of MRC compared with direct cholangiography in biliary duct diseases, with the exception of biliary-enteric anastomosis. METHOD: Forty-nine patients (26 men, 23 women; median age 60 years) with clinically suspected bile duct stenosis were prospectively included. Magnetic resonance cholangiography was performed within 7 days before direct cholangiography, considered to be the gold standard. Stenosis location, extension, and type according to Bismuth classification as well as diagnostic presumed causes were determined by 2 radiologists and 1 endoscopist. RESULTS: Magnetic resonance cholangiography correctly identified the level of biliary ductal obstruction compared with direct cholangiography findings in 96% patients. Excellent agreement between MRC and direct cholangiography was found for the stenosis location (kappa value, 0.89). Sensitivity and specificity of MRC to detect common bile duct stenosis were 88% and 100%, respectively. Sensitivity and specificity of MRC to detect biliary confluence stenosis were 96% and 93%, respectively. Precise location of the lesion according to Bismuth classification was correctly evaluated on MRC in 74% of patients (kappa value, 0.64). The overall interobserver concordance between radiologists for the level of stenosis was good (kappa value, 0.625). In 35 patients with intrahepatic bile ducts dilation identified on direct cholangiography, 97% of patients were identified on MRC. Moderate concordance between MRC and direct cholangiography was confirmed in the evaluation of the surgical management (kappa value, 0.55). CONCLUSION: Magnetic resonance cholangiography is able to replace diagnostic direct cholangiography to restrict the use of invasive procedures to cases in which therapeutic procedures are anticipated or MRC findings are equivocal, especially in biliary tract diseases.     

The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.

AIM: To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and ultrasound (US) in the diagnosis of choledocholithiasis in a large group of patients with bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stone characteristics using the three different investigations, endoscopic retrograde cholangiopancreatography (ERCP), MRCP and US. MATERIALS AND METHODS: 191 patients (M:F, 76:115; mean age, 66 years; range, 24-92 years) were investigated by direct cholangiography, MRCP and US. Their final diagnosis as determined at direct cholangiography were choledocholithiasis (n = 34), strictures (n = 47) and normal ducts (n = 110). The direct cholangiographic methods used for diagnosis of choledocholithiasis were ERCP (n = 29), intraoperative cholangiography (n = 3) and percutaneous transhepatic cholangiography (n = 2). The bile duct stone characteristics were compared using ERCP, MRCP and US in the 29 patients in whom stones were exclusively diagnosed by ERCP. RESULTS: Compared with the final diagnosis, MRCP had a sensitivity, specificity and diagnostic accuracy of 91%, 98% and 97%, respectively, in the diagnosis of choledocholithiasis. MRCP resulted in three false-negative and three false-positive findings, four of which occurred due to confusion with lesions at the ampulla. US had a sensitivity, specificity and diagnostic accuracy of 38%, 100% and 89%, respectively, in the diagnosis of choledocholithiasis. ERCP diagnosed more stones and the stones were more proximally distributed within the bile duct at ERCP when compared with MRCP. CONCLUSION: MRCP has a high diagnostic accuracy (97%), similar to that at direct cholangiography, in the diagnosis of choloedocholithiasis. It has the potential to replace diagnostic ERCP and select patients with choledocholithiasis for therapeutic ERCP.     

Preoperative diagnosis of the Mirizzi syndrome: limitations of sonography and computed tomography

Preoperative recognition of the Mirizzi syndrome permits avoidance of several serious pitfalls at surgery. The typical diagnostic signs of the Mirizzi syndrome are (1) dilatation of the common hepatic duct above the level of (2) a gallstone impacted in the cystic duct, with (3) normal duct width below the stone. Since jaundice is the leading clinical symptom, sonography and computed tomography (CT) are now the primary radiologic tests. The syndrome does not regularly have typical features, however, and therefore cannot be detected routinely on sonography or CT. Direct cholangiography is often necessary, especially since a cholecystobiliary fistula secondary to stone penetration into the common bile duct can be demonstrated only by cholangiography. On the other hand, direct cholangiography should follow either sonography or CT because these imaging methods are superior for demonstrating extraluminal signs of malignancy, which is the most important differential diagnosis. The findings at preoperative examinations (sonography, six; CT, four; endoscopic retrograde cholangiography, five) in seven patients with surgically confirmed Mirizzi syndrome are analyzed retrospectively.     

Typical radiologic findings in Mirizzi syndrome

In extrahepatic cholestasis it is necessary to include Mirizzi's syndrome in the differential diagnostic considerations. Characteristic findings in sonography and computed tomography are: a stone incorporated in the neck of the gallbladder or cystic duct with an extension of the common hepatic duct above the stone and normal width of the bile duct below the stone; in endoscopic retrograde cholangiography (ERC, direct cholangiography), a characteristic finding is a smooth-walled, segmental stenosis through external compression or an incorporated stone.