胆管癌误诊和漏诊的影像学分析

目的：分析胆管癌误诊和漏诊的原因，评价不同检查方法对肝门区胆管癌诊断的价值，提高胆管癌的影像学诊断和鉴别诊断水平。方法：收集31例临床和病理诊断为胆管癌的病例(ERCP检查31例，B超检查31例，25例CT检查，11例行MRCP检查)，回顾性分析不同检查方法的影像学表现。结果：31例中发生在肝门区的胆管癌25例。2例初次ERCP显示胆管内出血，再次行鼻胆管造影后诊断为胆管癌，4例合并有总胆管结石。6例为总胆管中下段癌。初次诊断准确性为90．3％。11例MRCP中9例显示病变，2例显示不满意，7例显示胆管或胆囊结石。25例CT中23例显示肝内胆管扩张，9例显示肝门区肿块，2例见后腹膜转移淋巴结，1例见肝内多发性转移瘤。12例初次诊断正确(48％)。B超检查23例提示肝内胆管扩张，6例提示总胆管结石，18例诊断为胆囊炎、胆囊结石，8例提示胆管占位(25．8％)。结论：良好的直接胆管造影是诊断胆管癌的金标准，MRCP可以在一定程度上准确显示病变的范围，是ERCP的良好补充，很大程度上取代了诊断性ERCP；CT诊断的关键在于显示扩张的胆管和梗阻的定位，肝门区梗阻多为胆管癌所致。多种影像检查方法的结合明显提高了诊断的准确性，对胆管癌治疗方案的选择有重要价值。

Misdiagnosis and missed diagnosis of extrahepatic bile duct cholangiocarcinoma

Objective:To analysis the case of misdiagnosis and missed diagnosis of extrahepatic bile duct cholangiocarcinoma, and discuss the values of ERCP,CT,MRCP and US in order to improve the ability in diagnosing cholangiocarcinoma.Methods:Thirty-one patients with extrahepatic bile duct cholangiocarcinoma are evaluated.Thirty-one cases are examined with ERCP, 31 with US, 25 with CT,11 with MRCP.The signs are analyzed respectively.Results:Twenty-five cases are hilar type. Six cases are distal duct type.At first ERCP,2 cases show the filling defects because of blood clots in the bile ducts,next cholangiograms show the tumors by drainage catheter.Four cases accompany stones.Primary accuracy of the diagnosis is 90.3%.Eleven cases show the lesion with MRCP,and 2 lesins can not be shown clearly. In MRCP images stones of bile duct are present.Twenty-three (23/25) patients have dilated intrahepatic bile duct in CT.The mass is shown in 9 cases and 2 cases have retroperitoneal metastatic lymph node. One case shows liver metastases. Primary accuracy of the diagnosis is 48%. In US dilated intrahepatic bile duct are found in 23 patients, stones of common bile duct in 6 cases, cholecystitis and cholecystolithiasis in 18 cases, cholangiocarcinoma in 8 cases(25.8%).Conclusion:Direct cholangiography is the golden criteria in diagnosing cholangiocarcinoma. MRCP is now able to visualize the location and intraluminal extent of the lesion. The key of CT diagnosis is location and the intra- and extrahepatic biliary duct dilatation. The hilar obstruction is almost caused by cholangiocarcinoma.The combination of CT,ERCP,and MRCP is emphasized in evaluating cholangiocarcinoma.