肝外胆管细胞癌所致肝实质一过性密度差异研究

目的 探讨肝外胆管细胞癌所致胆系扩张的肝实质--过性密度差异(transient hepatic parenchyma)attenuation differences,THAD)的影像学表现.资料与方法 56例肝外胆管细胞癌致胆系扩张患者行肝脏三期动态扫描均可见THAD.分析THAD的影像学特征及THAD与胆系扩张程度的相关性.结果 56例共测量肝内胆管222段,其中轻度扩张46段,中度扩张98段,重度扩张78段.柱状或分枝状THAD(Ⅰ型)在胆管轻度扩张肝段的发生率明显低于胆管中、重度扩张肝段(X2=186.68,P<0.005).肝内胆管重度扩张时,扩张程度呈扇形或不规则片状THAD(Ⅱ型)发生率明显增高(t'=5.16,P<0.05)0 II型THAD阳性组95%可信区间下限为9.3mm.Ⅲ型THAD阳性组与阴性组胆囊横径均数存在差异,其差异具有统计学意义(t'=6.46,P<0.05).Ⅲ型THAD阳性组胆囊横径均数95%可信区间下限为28.2mm.结论 肝外胆管细胞癌所致胆系扩张的THAD的影像学表现主要有3种:(1) Ⅰ型.沿胆管分布的柱状或分枝状THAD,边界不清,肝内胆系扩张＞5mm时常见;(2) Ⅱ型.扇形或不规则片状THAD,边界清楚或不清楚,肝内胆系扩张＞9.3mm时常见;(3) Ⅲ型.胆囊旁肝实质内弧形片状THAD,边界不清,胆囊横径＞28.2mm时常见.     

肝吸虫病致肝内胆管及肝实质改变的CT表现

目的　探讨肝吸虫病致肝内胆管及肝实质改变的CT表现及其与临床症状和体征的关系。方法　收集 113例肝吸虫感染患者的临床及CT资料 ,对肝内Ⅱ、Ⅲ级胆管扩张进行分级。结果　肝内Ⅱ、Ⅲ级胆管分支直径轻微扩张 2 4例 ,轻度扩张 2 2例 ,中度扩张 31例 ,重度扩张 36例。无明显临床症状和体征者肝内胆管为轻微或轻度扩张。腹痛、畏寒、发热、黄疸及有并发症者以中、重度扩张为主 ;肝内胆管结石与胆管扩张无明显关系。 5例肝内胆管扩张伴肝实质小片状或小结节状低密度灶。结论　肝被膜下小胆管扩张为肝吸虫病的主要CT表现 ;肝内胆管扩张伴肝实质小片状或结节状低密度灶考虑肝吸虫病致肝实质炎性肉芽肿的可能 ;临床症状和体征明显程度与胆管扩张程度有关。     

肝外胆管梗阻病变CT诊断的评价

目的：通过分析良恶性肝外胆管梗阻病变的ＣＴ表现，总结出有鉴别诊断意义的征象。材料与方法：复查分析经手术和病理证实、术前均做了ＣＴ检查的肝外胆管梗阻病变１１７例，良性３８例，恶性７９例。结果：肝外胆管远段梗阻，梗阻部胆管呈漏斗样改变，肝外胆管壁呈环形弥漫型增厚，肝内胆管呈竹节状或小囊状轻、中度扩张，梗阻部肿块内钙化，边界清楚对良性病变诊断有重要意义；肝外胆管中、近段梗阻或肝外胆管未显影者，梗阻部胆管呈截断型或突然狭窄型并伴肿块，肝外胆管壁呈环形局限型增厚，肝内胆管呈藤状或蟹足状中度或重度扩张，梗阻部肿块边界不清，其内可见坏死等征象，高度提示恶性病变。结论：良恶性肝外胆管梗阻病变均有其特征性的ＣＴ征象，注意观察胆管的形态改变，以及与周围组织结构关系，并紧密结合临床综合分析，有助于提高诊断准确性。     

多层螺旋CT在肝外胆管梗阻病变诊断中的应用

目的：探讨多层螺旋CT（MSCT）在肝外胆管梗阻病变中的应用价值。方法回顾性分析经手术、病理以及临床随访证实的均做了CT检查的肝外胆管梗阻病变51例,其中良性41例,恶性10例。结果肝外胆管梗阻性病变中,良性多表现为肝内胆管呈枯枝状或残根状轻、中度扩张,梗阻部胆管呈漏斗样改变,肝外胆管壁呈环形弥漫性增厚;恶性多表现为肝内胆管呈软藤状中、重度扩张,梗阻部胆管呈截断型或突然狭窄并伴肿块,肝外胆管壁呈环形局限性增厚。结论良恶性肝外胆管梗阻病变均有其特征性的CT征象,注意观察胆管的形态改变,以及与周围组织结构的关系,结合临床综合分析,有助于提高诊断的准确性。     

胆囊管癌

肝内胆管、胆总管和胆囊癌的放射学表现已熟知,但胆囊管癌在放射学文献中还未见报告。作者报告2例。例1为58岁男性,阻塞性黄疸和体重减轻3个月。内窥镜逆行胆管造影显示总肝管向内弯曲,伴一短段管腔显著狭窄和肝内胆管扩张,胆囊     

梗阻性黄疸的病理、诊治进展

梗阻性黄疸是由肝内毛细胆管、小胆管、肝胆管、肝总管或胆总管的机械性梗阻所致。因梗阻部位不同，可分为肝外黄疸和肝内黄疸，前者常需手术，故又称为外科黄疸。梗阻性黄疸分：Ⅰ型(完全性梗阻)：常见于结石嵌顿，手术损伤以及胰腺癌，壶腹周围癌和胆管癌；Ⅱ型(间歇性梗阻)：常见于结石及壶腹周围肿瘤，     

胆道阻塞的CT诊断—与直接胆管造影的比较研究

本文对８２例手术病理证实的阻塞性黄疸作前瞻性ＣＴ诊断，并与直接胆道造影比较研究。发现胆管逐渐尖削，明显的肝外胆管壁环状增厚是良性阻塞可靠且特异的ＣＴ征象。肝内外胆管不一致扩张（内轻外重），扩张胆管腔内ＣＴ值大于２０ＨＵ对良性阻塞的判断有一定帮助。管突断伴或不伴肿块，胆管壁局根不规则增厚是恶性阻塞相对可靠且特异的ＣＴ征象。ＣＴ能清楚显示肝内胆管扩张及它们汇合处解部剖及变异。比较直接胆管造影，ＣＴ对肝     

螺旋CT扫描对低位性胆道梗阻的诊断价值

目的：分析低位胆道梗阻的备种CT表现．总结出具有定性诊断意义及鉴别诊断意义的CT征象。材料与方法：回顾分析经手术和病理证实，术前均做螺旋CT扫描的低位胆道梗阻病例106例，良性组59例，恶性组47例。扫描方式分为平扫和双期增强扫描，观察胆总管及胰管的梗阻和扩张情况。结果：直接征象：梗阻部位见高密度结石32例，由CT增强扫描辨出等、低密度结石13例；梗阻平面发现肿块42例，其中良性5例，均为慢性胰腺炎，其余为恶性。间接征象：梗阻平面以上胆、胰管扩张，胆囊增大。良性梗阻者肝内胆管及胰管多呈轻、中度扩张；胆总管壁轻度增厚，扩张的胆总管自上向下渐进性狭窄。恶性梗阻者肝内胆管多呈中、重度扩张(藤样扩张)，胰管扩张明显；梗阻部位肿块边界不清、扩张的胆总管突然截断。结论：低位性胆道梗阻良、恶性病变各有不同的特征性CT表现，螺旋CT平扫及双期增强扫描、梗阻部位薄层扫描的合理运用，对低位性胆道梗阻的发现和病因诊断、鉴别诊断具有十分重要的价值。     

MRCP在梗阻性黄疸中医辨证分型中的应用研究

目的:探讨磁共振胆胰管成像(MRCP)在黄疸中医辨证分型中的应用价值。方法:对72例梗阻性黄疸患者进行MRI及MRCP检查,同时进行中医辨证分型,并与临床诊断、化验结果或手术和病理结果对比分析。结果:72例梗阻性黄疸病例中医辨证阳黄30例,主要以结石、炎症、先天囊肿为主;阴黄42例,主要以肝内、肝外肿瘤为主,并发现肝外胆管扩张程度阴黄高于阳黄。前者以重度和中度黄疸为主,占38/42,且形态以软藤状为主,占38/42;后者以轻度和中度黄疸为主,占28/30,且形态以枯枝状为主,占17/24。结论:MRCP图像清晰,能清楚显示扩张肝内胆管、胆总管、胆囊的形态、部位以及与周围组织结构的关系,对梗阻性黄疸中医辨证分型的诊断具有一定指导价值。     

胆总管囊肿的分型和造影表现

胆总管囊肿是一少见胆系畸形,自1723年Vater首次描述本病以来,世界已报道3000例,在美国占住院人数1/13000,女性比男性多3～4倍。病因不明,有人认为系先天性病变,但Babbitt(1969)推论系胰胆管连接异常,引起胰酶慢性返流,进入胆系,导致炎症、扩张、瘢痕所致。作者介绍了常用的Todani分类法及PTC表现。共分五型。Ⅰ型(80%～90%)又分Ⅰ_A型:部分或全部肝外胆管囊状扩张,胆囊常发自于囊肿,肝内胆管如常。Ⅰ_B型:胆总管远端局限性扩张,囊肿与胆囊管之间常有一段正常胆总管,近端胆管正常。Ⅰ_C型:肝外胆管梭形扩张,胆囊发自扩张的肝外胆管,肝内胆管正常;Ⅱ型(2%):胆总管单发真性憩     

经导管肝动脉化疗栓塞术后胆管损伤的临床意义

目的 观察经导管肝动脉化疗栓塞术（TACE）治疗肝脏恶性肿瘤后继发胆管损伤的发生率、影响因素和临床过程.方法 对1240例患者做TACE 2 680次,术前影像学检查均无明确胆系异常表现,18例于术后3周～3个月出现胆管损伤并发症.采用回顾性调查,观察TACE术后胆管损伤的发生率、临床表现、转归以及影响因素.结果肝转移性肿瘤TACE后胆管损伤的发生率为8.8%（13/148）,肝细胞性肝癌（HCC）组为0.5%（5/1092）.胆管损伤的影像学表现有局灶性胆管扩张4例、多发性肝内胆管扩张8例、囊性病灶或胆汁瘤6例.3例多灶胆管损伤表现为轻度黄疸,2例对保守治疗反应良好,1例于出现黄疸后2周死于肝功能衰竭.4例胆汁瘤合并感染,3例采取经皮穿刺置管引流和抗生素治疗,其中2例死于感染囊腔破入腹腔、继发化脓性腹膜炎,1例治愈;1例仅用抗生素治愈.与胆管损有关的病死率为16.7%（3/18）.其余11例无相关症状.统计学分析显示：无肝硬变背景的肝转移瘤患者TACE术后胆管损伤发生率明显高于有肝硬变的HCC患者（P〈0.01）;其他高危因素有肿瘤为少血供型（P〈0.01）和用铂类制剂与碘油乳化后做超选择性栓塞（P〈0.01）.结论 认识TACE后继发胆管损伤的影像学表现可避免误诊,特别是肿瘤复发.对存在胆管损伤高危因素患者,适当减少碘油乳化的化疗剂（特别是铂类）剂量,有可能降低胆系缺血损伤并发症.     

肝细胞癌合并胆管癌栓的影像表现

目的 探讨胆管癌栓的影像表现,以提高影像诊断水平.方法 回顾性分析经手术病理证实的肝细胞癌(HCC)胆管癌栓13例患者资料,其中3例进行了CT和MR检查,2例仅行CT检查,8例仅行MR检查,7例进行了MR胰胆管成像检查,13例均进行了超声检查.采用四格表Fisher 确切概率检验方法比较超声与CT、MR诊断HCC胆管癌栓的准确性.结果 13例HCC肿瘤及胆管癌栓均在CT或MRI上显示.4例胆管癌栓在CT上表现为胆管内软组织块影,动脉期可见癌栓轻度增强,癌栓远端胆管扩张.11例胆管癌栓在T1 WI上均呈稍低信号,T2 WI为稍高信号,增强后可见轻、中度强化.MR胰胆管成像上胆管癌栓表现为:胆管阻塞中断、狭窄或不规则充盈缺损伴有梗阻上方胆管扩张,胆管突然截断或呈"鼠尾"状(5例);肝内胆管扩张,癌栓充满整个胆总管.胆总管不显示(2例).超声检查准确诊断胆管癌栓7例,误、漏诊6例.CT、MRI准确诊断12例,误诊4例,超声与CT、MRI诊断胆管癌栓差异无统计学意义(P=0.270).结论 CT或MRI对诊断HCC合并胆管癌栓及明确癌栓范围有价值.     

Comparison of percutaneous and endoscopic retrograde removal of postoperatively retained bile duct stones

Forty-one patients underwent nonsurgical removal of postoperatively retained bile duct stones in two nonrandomized groups. The endoscopic-retrograde technique was used in 21 patients, and succeeded in 19. The percutaneous approach through the T-tube tract was used in 22 patients, including the two in whom endoscopic stone removal had failed, and was successful in 21 patients. Individual preferences and prior history introduced a selection bias against the percutaneous technique. Auxiliary extracorporeal shockwave lithotripsy (ESWL) was used in 2 patients whose stones could not be fragmented mechanically by the percutaneous basket technique. ESWL was successful in one patient but failed in the second. Because endoscopy had also failed in this case, the patient subsequently underwent repeat surgery. Procedure-related complications were minor with both techniques and were readily treated by conservative measures. We conclude that both the retrograde and the percutaneous approaches are effective and safe. The endoscopic approach appears convenient because there is no need to await maturation of the percutaneous tract, but sphincterotomy carries a small but distinctive risk. Because the percutaneous approach uses an existing tract, is only minimally invasive and leaves the sphincter of Oddi intact, it is preferable in those patients who have T-tubes of approapriate size and position in place.     

Animal model of bile duct dilatation created with minimally invasive surgery

RATIONALE AND OBJECTIVES: The purpose of the study was to evaluate a method of producing obstruction of the common bile duct and concomitant biliary duct dilatation in an animal model. MATERIALS AND METHODS: Laparoscopic placement of a double-balloon occlusion device was used to produce common bile duct obstruction and bile duct dilatation in pigs. RESULTS: One week after the procedure, common bile duct obstruction and dilatation of the biliary tree were demonstrated with either percutaneous transhepatic cholangiography or percutaneous cholecystography. CONCLUSION: The use of this method is technically feasible and provides a useful subacute and chronic animal model of common bile duct obstruction and dilatation of the biliary tree for percutaneous interventional training and research purposes.     

Palliative bile duct irradiation

Carcinoma of the common hepatic bile duct or common bile duct were treated by interstitial irradiation with gold seeds using the percutaneous transhepatic drainage partly boosted by external irradiation. The interstitial dose of 50 Gy was given in two applications and 40 Gy by linac. Twice histological examination showed wide tumor destruction of local irradiation, but also much more tumor extension than seen before by diagnostic investigation. Mostly the therapy is only palliative because of the infiltration of liver and lymph nodes.     

正常成人肝外胆管声像图表现的再探讨

目的:观察正常成人肝外胆管的超声声像图特点,并获取各段肝外胆管内径的超声测值。方法:使用经腹超声扫查胆总管,分别观察肝门段、十二指肠后段、胰腺段胆管等段的走行、毗邻关系等特点,并测量各段肝外胆管的内径。结果:肝外胆管的形状各异,以梭形最常见,其他有蝌蚪形、管形等。肝外胆管内径最宽处位于十二指肠后段,最窄处位于胰腺段。肝门段内径及十二指肠后段内径男性和女性之间的差异无统计学意义,胰腺段内径差异具有统计学意义。结论:掌握肝外胆管的正常声像图特点及其内径的测值,对临床工作有重要参考意义。