经皮肝穿胆管造影(PTC)26例报告

图1　ａ)胆总管结石:梗阻以上肝管、胆囊管均扩张,肝内胆管呈“枯树枝”状,完全梗阻。　ｂ)胆总管结石:梗阻端呈凹面向上的弧形杯口状充盈缺损。　图2　胆总管中下段癌:梗阻为不完全性,胆总管中下段呈不规则线条状,肝内胆管扩张呈“软藤”状。ＰＴＣ不但可明确胆道梗阻部位、范围,而且对于胆道梗阻的原因也有较高的诊断价值。本文收集了经ＰＴＣ检查并手术证实的26例病例,对其Ｘ线表现进行了分析,提出ＰＴＣ检查在胆道梗阻诊断上的优越性,同时指出ＰＴＣ检查的局限性。材料与方法　本文26例包括胆管癌12例、胆总管结石8例、胆总管炎症粘连5…     

胆管癌的MRI诊断(附32例报告)

目的：探讨胆管癌的MR表现及鉴别诊断,方法：收集32例经手术,病理证实的胆管癌,回顾性分析其MR表现,结果：肝内胆管癌2例,MR表现为肝内块状长T1长T2信号,可见中心瘢痕,卫星结节,增强后呈中度环形强化,肝门胆管癌18例,MR表现为肝内胆管扩张,胆总管或左右肝管起始部狭窄,充盈缺损,肝门软组织肿块,中下段胆管癌12例,MR表现为肝内胆管扩张,病变以上胆总管扩张,病变胆总管狭窄,中断及周围软组织肿块,MRCP对扩张的肝内胆管,胆总管及狭窄端胆总管形态显示良好。结论：肝内胆管癌及肝门部胆管癌根据MR表现不难作出诊断,胆总管癌须认真分析MR及MRCP表现,鉴别其他低位梗阻性胆道疾病后作出诊断。     

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.     

肝内外胆管癌的螺旋CT诊断

目的:探讨肝内外胆管癌的螺旋CT表现及鉴别诊断。方法:收集23例经手术、病理证实的肝内外胆管癌,回顾性分析其螺旋CT平扫及动态增强表现。结果:肝内胆管癌5例,CT平扫为边缘欠清的低密度病灶中可有高密度钙化影,增强扫描随时间延长病灶由边缘向中央逐步强化,最后病灶强化高于正常肝实质,病灶周围可见扩张的肝内胆管。肝门胆管癌6例,CT表现为肝内胆管扩张,胆总管或左右肝管起始部狭窄、充盈缺损、轻中度强化的肝门软组织肿块。中下段胆管癌12例,CT表现为肝内胆管扩张、病变以上胆总管扩张、病变处胆总管狭窄、中断,梗阻近端胆管壁不均匀增厚、腔内见软组织结节影或周围软组织肿块。结论:肝内胆管癌及肝门部胆管癌根据CT动态增强表现不难作出诊断,胆总管癌须认真分析CT薄层放大增强表现鉴别其他低位梗阻性胆道疾病后作出诊断。     

肝外胆管癌的16层螺旋CT诊断

目的：探讨肝外胆管癌的16层螺旋CT征象及诊断价值。方法：对全部受检病例行16层螺旋CT平扫加动态增强扫描,然后进行多平面重组及胆管曲面重组;回顾性分析35例经手术（活检）病理证实的肝外胆管癌的各期CT表现。结果：胆总管癌19例,肝门区胆管癌16例。直接征象为胆管壁局限性不规则增厚、环状不均匀增厚、结节状或肿块状改变。胆管曲面重组可直观显示病变范围及狭窄或闭塞全貌。增强后肿瘤呈均匀或不均匀强化,以静脉期强化为主。结论：合理应用多平面重组、曲面重组等后处理技术,可以很好显示肝外胆管癌的直接征象,对确立诊断及指导临床治疗或手术具有重要意义。     

硬化性胆管炎与胆总管癌的影像鉴别诊断

目的探讨CT和胆道造影对硬化性胆管炎和胆总管浸润癌的影像特征并评价其诊断区别。方法对18例经手术病理证实的胆总管癌与4例临床诊断的硬化性胆管炎的CT和PTC、ERCP、MRCP的影像学表现进行分析。结果4例硬化性胆管炎表现胆总管壁较薄,边界更加光整,管壁向心性增厚,狭窄近段胆管轻度扩张;CT增强扫描呈明显强化,胆道造影表现管腔渐进性、均匀的狭窄,与胆管癌比较表现多灶性狭窄并有沙漏样改变。结论CT和胆道造影能有效区分硬化性胆管炎和胆总管浸润癌病变,密切结合临床综合分析,对于两种疾病的鉴别诊断有重要的价值。     

肝移植术后胆系并发症的T管造影表现

目的 探讨肝移植术后胆系并发症的T管造影表现及其意义。资料与方法 搜集52例肝移植术后T管造影病例中发生胆系并发症的患者24例，其中男20例，女4例，年龄21～64岁。所有病例均行T管造影，并将X线表现与肝穿刺病理所见对照。结果并发症发生率为46．1％(24／52)。T管造影表现：(1)9例早期胆汁淤积症，T管造影无胆管梗阻，但肝内胆树稀疏，分支细，有时呈“垂柳状”外观；(2)10例胆总管吻合口胆瘘，表现为吻合口对比剂外漏，形成不规则状阴影；(3)5例胆管吻合口狭窄，表现为胆总管吻合口的不规则形充盈缺损，对比剂经吻合口排人远段胆管困难；(4)5例胆管内结石／胆泥形成，表现为胆管内充盈缺损；(5)6例胆管炎，肝内胆管细小，走行僵硬，胆管炎严重者可表现为胆管近肝门段狭窄、远段扩张的独特外观；(6)3例肝外胆管吻合后过长，长度超过13cm。肝移植术后胆管并发症的患者T管造影表现可同时出现上述征象1～4种。结论 T管造影可以明确肝移植术后的胆管并发症，对肝移植术后胆系的评价具有重要的价值，是肝移植术后常规检查手段之一。     

MRCP结合MRI在胆管癌诊断和鉴别诊断中的应用

目的:讨论MRCP和MRI在胆管癌诊断和鉴别诊断中的应用。方法:回顾性分析18例胆管癌患者的MRI和MRCP表现,所有患者均行MR平扫及MRCP检查,其中4人做了MR动态增强扫描。18例中14例经手术病理证实,其余4例均经临床影像学资料全面综合分析确诊。结果:肝门部胆管癌9例,肝外胆管中段癌3例,肝外胆管下段癌6例。MRCP表现为胆管狭窄端呈不规则偏心性狭窄10例,向心性狭窄2例,阻塞或充盈缺损6例。MRI表现为扩张胆管末端不规则狭窄、软组织结节影或“双管征”,T1WI呈低、等信号,T2WI呈稍高信号,动态增强呈轻、中度强化。结论:MRCP是一种无创伤性的显示胰胆管腔形态的影像学方法,结合MR平扫加增强扫描,在胆管癌定位和定性诊断中有重要价值。     

恶性胆道梗阻的磁共振胰胆管造影诊断

目的 评价磁共振胰胆管造影（MRCP）对胆道恶性梗阻性疾病的诊断价值。材料与方法 43例恶性胆道梗阻患者（胆管癌15例,壶腹癌4例,胰头癌10例,转移性癌10例,原发性肝癌4例）行MRCP检查,结合PTC、ERCP检查、手术、病理结果、临床资料进行综合分析。结果 43例患者MRCP检查均一次成功,胆管及扩张胰管显示满意,定位诊断准确率为100％、定性准确率为83．7％。肝门区癌肿MRCP表现为肝门区不规则或类圆信号缺损,肝内胆管扩张以肝门区为中心呈“枯枝”状或“蟹足”样扩张;肝外胆管癌胆管断端呈模形或“鸟嘴”样截断;壶腹癌胆管断端呈横形、“鸟嘴”样或“鼠尾”状截断;胰头癌胆管断端呈“鸟嘴”样或“鼠尾”状截断,90％（9／10）伴“双管征”;转移性癌肿MRCP表现与转移部位有关;转移至肝门附近与肝门区癌肿相似,肝外转移者与相应部位胆管癌、胰头癌相似,常规MRI可见明显转移肿块或淋巴结。结论 MRCP是胆道恶性梗塞影像学检查的有效补充手段,可为恶性胆胰肿瘤术前可切除性提供评价,对不可切除的癌肿行介入治疗提供参考。     

胆管乳头状腺瘤的CT和MRI诊断

目的 探讨胆管乳头状腺瘤的CT和MRI影像特点,提高其诊断正确率.方法 回顾性分析10例经手术及病理证实的胆管乳头状腺瘤,10例均行CT平扫和增强扫描,其中8例同时行MR平扫和增强扫描检查,对其影像表现进行研究分析.结果 10例中发生于左侧肝内胆管6例,右侧肝内胆管2例,胆总管2例.CT上6例表现为乳头状、颗粒状或结节状肿块,呈低密度或等密度,增强后5例呈轻、中度强化,1例未见明显强化.4例CT未发现肿瘤占位,仅发现肝内胆管扩张伴胆管壁增厚,增强后胆管壁轻度强化.MRI上4例表现为等或稍长T1、稍长T2信号肿块,MRCP中发现胆管腔内类圆形或不规则形充盈缺损; 2例常规扫描中未见明显肿瘤,仅在MRCP上显示不规则充盈缺损; 2例仅表现为胆管壁增厚和胆管扩张.10例均伴有局限性或广泛性胆管扩张.结论胆管乳头状腺瘤CT、MRI表现具有一定特征性,可以做到术前正确诊断.     

The diagnosis of primary bile duct carcinoma (cholangiocarcinoma) in the jaundiced patient

One hundred and ten patients with obstructive jaundice were investigated in the established manner; an initial abdominal ultrasonic B scan was followed by fine needles percutaneous transhepatic cholangiography (PTC) and/or endoscopic retrograde cholangiography (ERC). This yielded 15 cases of histologically proven primary bile duct carcinoma (cholangiocarcinoma), which is an incidence of 13.6%. Primary bile duct carcinoma is suggested on ultrasonic examination by: (i) Attenuation of the ultrasound beam in the bile duct area especially if the shadowing is multiple and/or from the intrahepatic ducts. (ii) Delineation of a mass associated with the bile ducts. (iii) A high level of duct obstruction with a normal pancreatic appearance. On direct cholangiography a stricture of the duct system which is branched, short, multiple or tapering also suggests primary bile duct malignancy. It is possible to diagnose primary bile duct carcinoma on ultrasonic examination alone once this condition is recognised as occurring with significant frequency. PTC and ERC aid delineation of the extent of the tumour and exclude biliary duct stone as the cause of jaundice.     

MRI of portal cavernoma with biliary involvement

PURPOSE: To assess the value of MRI in the diagnosis of portal cavernoma with biliary obstruction. MATERIAL: and methods: six patients referred for clinical suspicion of biliary obstruction and portal cavernoma were explored with MRI. all patients were explored using a signa 1.5 t GE MR unit, with high gradient field strength and torso phased array coil. Biliary ducts were explored with ss-fse sequences of MR-cholangiopancreatography (MRCP), coronal and oblique coronal 20mm thick slices. Then, coronal T2w with shorter TE eff, MR-angiography and delayed T1w sequences were performed. CT scan and sonographic examinations of the liver were performed in all patients. Two patients were operated on and 2 underwent endoscopic retrograde cholangiography. RESULTS: Three different types of biliary involvement were found: in 3 cases findings that mimic cholangiocarcinoma spreading along the common bile duct and in 3 other cases multiple smooth extrinsic impressions along the common bile duct; in one patient MRCP demonstrated an irregular narrowing of the common bile duct mimicking chronic cholangitis. In all cases, the bile duct varices appeared of low T2W signal; in three cases, fibrosis was identified on delayed sequences. CONCLUSION: MRCP and MR-angiography can be proposed as a first imaging study in patients with portal cavernoma and cholestasis or bile duct dilatation.     

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     

Early bile duct carcinoma: comparison of imaging features with pathologic findings

PURPOSE: To retrospectively evaluate the imaging features of early bile duct carcinoma and to compare these features with histopathologic findings. MATERIALS AND METHODS: The institutional review board did not require its approval or informed patient consent for this study. Twenty-one patients (13 men, eight women; mean age, 60 years; range, 48-75 years) with early bile duct carcinoma that was surgically resected and histopathologically confirmed were included. Ultrasonography (US) was performed in 15 patients, computed tomography (CT) in 21, cholangiography in 18, and magnetic resonance (MR) cholangiography in six. Two radiologists retrospectively reviewed imaging features by consensus; they compared growth pattern of tumors, integrity of the bile duct wall that harbored the tumor, and periductal infiltration with histopathologic findings. RESULTS: Pathologic specimens showed intraluminal tumor growth in all cases. Tumors were confined to the mucosa in 11 patients and involved the fibromuscular layer in 10 patients. In four of the 10 intrahepatic cholangiocarcinomas, four of the five hilar cholangiocarcinomas, and six of the six extrahepatic cholangiocarcinomas, there were intraductal tumor masses and the wall of the tumor-bearing bile ducts was preserved without periductal infiltration on US and CT images. On cholangiograms and MR cholangiograms, tumors were better delineated but the wall invasion could not be evaluated. No difference in image findings was found between carcinoma confined to the mucosa and carcinoma involving the fibromuscular layer. CONCLUSION: Imaging features of early bile duct carcinoma are a tumor mass in the bile duct lumen and integrity of the tumor-bearing bile duct wall without infiltration outside the wall.     

Functional causes of the ductal obstructive pattern on hepatobiliary scans

Hepatobiliary imaging with Tc-99m IDA derivatives has proven value for evaluation of biliary disease. Prompt hepatocellular uptake with persistent nonvisualization of the common bile duct and bowel is usually indicative of a high-grade common bile duct obstruction, but is not pathognomonic. A functional abnormality due to hepatocyte dysfunction resulting in intrahepatic cholestasis can also cause this pattern. Two cases of hepatocellular excretory dysfunction, one due to E. coli endotoxemia with intrahepatic cholestasis and the other due to acute hepatitis A that produces ductal obstructive patterns on Tc-99m disofenin scintigraphy in patients with documented patent biliary ducts, are reported. Transhepatic cholangiography or endoscopic retrograde cholangiography may be useful when the diagnosis of biliary ductal obstruction is in doubt.     

Papillary neoplasms of the bile duct that mimic biliary stone disease.

Papillary tumors of the bile duct are intraductal tumors with innumerable minute, frondlike papillary projections. These tumors may be either fixed to or detached from the bile duct wall. However, because the papillary projections on the surface of papillary tumors are long and slender, the tumors are friable and slough easily. The sloughed tumor fragments may float within the bile ducts, resulting in intermittent partial biliary obstruction and mimicking bile duct stones at clinical examination and at ultrasonography (US), computed tomography (CT), and cholangiography. A tumor manifests radiologically as thickening and irregularity of the bile duct wall or as a fixed or sloughed intraductal mass. A nonshadowing intraductal echogenic cast seen at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening seen at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin seen at cholangiography are all appearances that suggest a papillary tumor and may be helpful in differentiating a tumor from a bile duct stone.     

Ampullary carcinoma: Demonstration by current MR techniques

The objective of this study was to demonstrate the appearance of ampullary carcinoma using current MR techniques, including fat suppression, gadolinium enhancement, and MR cholangiography. Nine patients with ampullary carcinoma were examined by MRI at 1.5 T. MR examinations included T1-weighted spoiled gradient echo, T1-weighted fat-suppressed, and immediate postgadolinium spoiled gradient echo images for all patients and MR cholangiography for three patients. The imaging features of ampullary carcinomas, including tumor size and morphology, signal intensity, and enhancement characteristics, were determined. Ampullary carcinomas shown on MR images ranged in size from 1.5 to 5.5 cm. Tumors were low in signal intensity on precontrast T1-weighted spoiled gradient echo and T1-weighted fat-suppressed images relative to normal pancreatic tissue and enhanced less than normal pancreas on immediate postgadolinium spoiled gradient echo images. Tumor conspicuity was greatest on immediate postgadolinium spoiled gradient echo images. MR cholangiography demonstrated high grade obstruction of the common bile duct and mild dilatation of the pancreatic duct at the level of the ampulla with abrupt termination of the ducts in two untreated patients and moderate dilatation of the common bile duct in one patient who had a biliary stent. Ampullary carcinomas can be demonstrated on MR images as small masses arising at the ampulla. Tumors are well defined on immediate postgadolinium spoiled gradient echo images.     

Diagnostic imaging of carcinomas of the gallbladder and the bile ducts

Early diagnosis and accurate staging of carcinomas of the gallbladder and the bile ducts are helpful in improving the prognosis. Ultrasonography (US), a useful initial modality when exploring the background of jaundice or non-specific gastrointestinal complaints, sensitively reveals bile duct obstruction in particular. In unclear cases, or if US suggests a resectable biliary malignancy, computed tomography (CT), magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC) and / or traditional cholangiography often provide additional information, and imaging-guided fine-needle biopsy or an endoscopic brush sample may verify the malignant nature of the tumor. Complementary modalities are usually needed for accurate staging, and traditional cholangiography is often performed for therapeutic purposes as well. Comparative studies of MRI with MRC and multidetector CT in biliary cancers would be welcome.     

Common bile duct obstruction: assessment by transcholecystic cholangiography

Percutaneous transcholecystic cholangiography was performed in 20 patients. Fifteen patients had normal-sized bile ducts on sonograms and computed tomographic scans, and five had partial common bile duct obstruction. Gallbladder pressures were measured in 14 patients. In all cases the intrahepatic and extrahepatic bile ducts were well visualized. Only one clinically significant complication, bile peritonitis, occurred, and it was relieved by inserting a cholecystostomy catheter. Techniques as well as the potential indications for transcholecystic cholangiography are discussed. The authors believe the transcholecystic approach is a useful alternative to transhepatic cholangiography.