肝膽胰脾影像學(xué)

1、肝膽胰脾影像學(xué)肝 臟影像學(xué)檢查的目的：1. 確定病變的性質(zhì)，大小，位置2. 鑒別右上腹腫塊的起源3 . 了解肝的結(jié)構(gòu)和其他病變肝臟影像學(xué)檢查方法1. 普通X線檢查2. CT3. US 4. MRI5. 血管造影肝臟影像學(xué)檢查 CT檢查的適應(yīng)癥1. 凡是臨床或其它檢查方法懷疑肝臟占位性病變，都是CT檢查的適應(yīng)癥2. 確定病變部位、范圍、大小、性質(zhì)，有無(wú)轉(zhuǎn)移，門(mén)腔靜脈有無(wú)癌栓3. 手術(shù)后、導(dǎo)管化療后的復(fù)查4. 對(duì)上腹部情況作全面了解肝臟正常CT表現(xiàn)正常肝臟輪廓光滑，形態(tài)及解剖結(jié)構(gòu)依斷面位置不同而不同肝臟分左葉、右葉和尾葉。左葉以肝圓韌帶（縱裂）分為左內(nèi)和左外葉，右葉以肝右靜脈分為右前和右后葉肝實(shí)質(zhì)

2、密度均勻，5060HU，較脾臟高肝臟CT 肝臟CT肝臟 MR 檢查主要適應(yīng)證 主要適應(yīng)證 1肝良、惡性腫瘤（肝癌、肝血管瘤、肝轉(zhuǎn)移瘤）2肝囊腫和囊腫性病變（多囊肝、肝包蟲(chóng)?。?肝膿腫、肝結(jié)核和其他肝炎性肉芽腫等4肝局灶性結(jié)節(jié)狀增生（FNH） 一般適應(yīng)證 1.各種原因所致的肝硬化（肝炎后、酒精性、血吸蟲(chóng)性等肝硬化）2Budd-Chiari綜合征肝臟MR檢查禁忌證1裝有心電起搏器者2檢查部位鄰近體內(nèi)有不能去除的金屬植人物3使用帶金屬的各種搶救用具而不能去除者4MRI造影劑有關(guān)的禁忌證并發(fā)癥MRI造影劑有關(guān)的并發(fā)癥 肝臟正常MRI表現(xiàn)橫斷面解剖同CT肝實(shí)質(zhì)信號(hào)均勻，強(qiáng)度中等，略低于脾臟和背部肌肉肝外

3、和肝內(nèi)靜脈信號(hào)流孔，顯示良好肝臟 MRI 肝臟 MRITorso coil4 elements phase-array coil- huge anatomical coverage- high SNR- Asset compatible Patient preparationLiver and Pancreas:Dynamic Contrast- enhanced Scanning Protocol for CT or MRIEarly Phase: (delayed time:25-30s)Portal Phase: (delayed time:55-60s)Delayed Phase: (

4、delayed time:90-200s)肝臟的檢查技術(shù)-血管造影門(mén)靜脈造影脾門(mén)靜脈造影 左腋中線9-10肋間隙，76%泛影葡按40毫升，15秒內(nèi)攝3-4秒經(jīng)右網(wǎng)膜靜脈插管經(jīng)臍靜脈插管 肝臟常見(jiàn)疾病肝膿腫肝海綿狀血管瘤肝癌肝囊腫肝硬化 肝膿腫CT、MRI 表現(xiàn)典型膿腫CT表現(xiàn)為低密度灶，邊緣較清晰，增強(qiáng)掃描膿腫壁可表現(xiàn)為單環(huán)、雙環(huán)及三環(huán)，膿腔不強(qiáng)化可有輕微胸膜反應(yīng)，右下肺反應(yīng)性炎癥和盤(pán)狀不張MRI表現(xiàn)為長(zhǎng)T1和T2肝膿腫病因：細(xì)菌性、阿米巴性臨床表現(xiàn)：發(fā)熱、肝腫大和肝區(qū)痛CT表現(xiàn)： 膿腔 圓形低密度區(qū)，20-40Hu，不強(qiáng)化 膿壁環(huán)形帶， 膿腔 密度4mm) ，增強(qiáng)雙環(huán)影，粘膜高密度，漿膜低密

5、度。慢性膽囊炎膽囊癌85%腺癌，其余為鱗癌及類癌，腺癌分為乳頭狀、浸潤(rùn)型和粘液型CT表現(xiàn) 囊壁不規(guī)則增厚，腔內(nèi)不規(guī)則充盈缺損影，臨近肝組織低密度區(qū)，有增強(qiáng)MRI T2WI 高信號(hào)的膽汁內(nèi)充盈缺損影鑒別 慢性膽囊炎 囊壁均勻性 膽囊良性隆起性病變(息肉，肉芽腫、腺瘤) 大小、浸潤(rùn)膽囊癌Gallbladder CarcinomaHepatic Hilar CholangiocarcinomaBiliary ductal system23 sec Breath-holdBiliary ductal system SSFSE & 3D FRFSESl. thickness: 3 mm. Matrix:

6、 512 x 1922D SSFSE3D FRSFSE2D Fast GRE T1 w. Fat SatSl. thickness: 5 mm. Matrix: 512 x 256Sl. thickness: 2 mm. Matrix: 384x224Sl. thickness: 7 mm. Matrix: 512 x 256Sl. thickness: 20 mm. Matrix: 512 x 384High spatial resolution of the entire pancreaticobiliary tract and of the adjacent soft tissueAft

7、er Contrast Media InjectionFGRE T1 w. Fat SatFGRE T1 w. Fat SatBiliary ductal systemSSFSE & 3D FRFSE 3D FRSFSE3D FRSFSE2D SSFSE2D SSFSE2D SSFSEBiliary ductal system LAVA after mangafodipir trisodium administration (Teslascan ) Sl. Thickness 3 mm (ov -0.8 mm)Matrix: 256x224 ZIP 512Acq. time: 18 secHi

8、gh Resolution T1 w. 3D MRCP - Functional information -胰腺檢查方法平片：胰腺鈣化，胰管結(jié)石CT、MRI、超聲造影：胃腸鋇餐：胃前移，框擴(kuò)大ERCP選擇性腹腔動(dòng)脈造影PTC脾門(mén)靜脈造影 胰腺檢查方法胰腺疾病的影像診斷X線檢查方法1 普通檢查：平片-胰腺鈣化，胰管結(jié)石，用于慢性胰腺炎的診斷2 造影檢查： GI， ERCP， PTC，選擇性腹腔動(dòng)脈造影造影檢查GI胰頭增大引起十二指腸位置和形態(tài)改變顯示較大的胰腺腫瘤，多為低張?jiān)煊霸煊皺z查 ERCP對(duì)診斷慢性胰腺炎、胰頭癌、壺腹癌有幫助，同時(shí)可了解膽管病變正常胰管自胰頭向胰尾斜行向左上走行，管徑逐漸

9、變細(xì)，約35毫米寬，邊緣光滑整齊，有時(shí)可見(jiàn)副胰管胰腺造影檢查選擇性腹腔動(dòng)脈造影：胰島細(xì)胞瘤PTC：胰頭癌引起阻塞性黃疸CT 診斷CT是胰腺疾病診斷的首選方法檢查方法：檢查前口服陽(yáng)性造影劑以顯示腸管。仰臥位先平掃，后增強(qiáng)掃描（靜脈快速注射碘造影劑100ml）胰腺正常 CT 表現(xiàn)胰腺呈弓狀，周?chē)鸀橹窘M織，CT值455H密度均勻，胰頭為十二指腸包繞胰體后為腸系膜上動(dòng)脈脾靜脈居胰尾后胰頭25毫米，胰體19毫米，胰尾15毫米 T1WT1W脂肪抑制T2W正常胰腺M(fèi)R 動(dòng)態(tài)增強(qiáng)T1WT2W抑脂F(xiàn)SPGR動(dòng)脈期FSPGR門(mén)脈期胰腺常見(jiàn)病的CT表現(xiàn)急性胰腺炎：典型表現(xiàn)為胰腺體積增大，密度略底，可為彌漫性，也可

10、為局限性。胰腺周?chē)仔詽B出使胰腺輪廓不清左腎前筋膜增厚。滲出多時(shí)網(wǎng)膜囊、腎前間隙可見(jiàn)積液，液體積聚在胰腺內(nèi)形成假囊腫。水腫型（漿液-滲出型）胰腺炎病情較輕出血壞死型 胰腺炎病情危重，壞死低密度區(qū)內(nèi)可見(jiàn)高密度出血灶，增強(qiáng)掃描壞死區(qū)不增強(qiáng)，而一般水腫炎變的胰腺有增強(qiáng)。膿腫 是胰腺炎的重要并發(fā)癥，表現(xiàn)為局限低密度灶，出現(xiàn)氣體是其特征。急性胰腺炎Acute necrotic pancreatitisDepartment of RadiologyRetroperitoneal collection of fluid左腎旁間隙左結(jié)腸旁溝盆腔Department of Radiology胰腺膿腫慢性胰腺炎胰

11、腺局部增大，胰內(nèi)或胰外假囊腫，表現(xiàn)為邊緣清楚的囊性低密度影，水樣密度。部分病人可見(jiàn)鈣化，表現(xiàn)為沿胰管分布的斑點(diǎn)狀鈣化，是特征性表現(xiàn)。左腎筋膜常有增厚，胰管常有不規(guī)則擴(kuò)張，胰腺可有萎縮。Department of RadiologyChronic P胰腺囊腫真性：先天性、寄生蟲(chóng)性假性：胰腺炎、外傷胃腸鋇餐：胃腸移位、框擴(kuò)大CT：邊緣光滑、圓形低密度影、不增強(qiáng) Department of Radiology急性假性囊腫胰腺癌多數(shù)位于胰頭，起源于胰管或腺泡。鋇餐：十二指腸內(nèi)側(cè)壁粘膜平坦，消失，腸壁僵硬，框擴(kuò)大，雙邊緣，反3征，胃竇呈墊壓征。胰腺癌CT表現(xiàn)：胰腺局部或彌漫性增大或不規(guī)則增大平掃呈低密度

12、，密度多不均勻 增強(qiáng)掃描，腫瘤常不增強(qiáng)或增強(qiáng)不明顯其它改變：膽道梗阻，胰腺管擴(kuò)張，血管浸潤(rùn)，周?chē)址?，主?dòng)脈旁淋巴結(jié)增大，腹水胰腺癌MRI表現(xiàn)：胰腺局部或彌漫性增大，形態(tài)不規(guī)則T1WI 腫瘤呈低信號(hào)，T2WI呈不均勻高信號(hào)其他 肝管擴(kuò)張，胰腺管擴(kuò)張等SASVMRA胰體尾部癌 MRI with the combination of MRA and MRCP technique has the unique capability of allowing a noninvasive comprehensive examination within a single diagnostic modali

13、ty for evaluation of the full range of pancreatic diseases.PANCREASMultidetector row helical CTPancreas SSFSE & 2D FGRE Slice thickness: 5 mm Matrix 512x224No In-Plane interpolationSSFSE2D Fast GRE2D Fast GREAfter Contrast Media InjectionHigh contrast resolution pancreatic examination Internal septa

14、Pancreas SSFSE & 2D FIESTA Fat Sat2D FIESTA Fat satResp. TriggerSlice thickness: 5 mm Matrix 224x224Zip 5121 sec / sliceSSFSE Fat Sat2D SSFSEPancreas LAVASl. thickness: 1.6 mm (ov -0.8 mm)Matrix: 256x256 ZIP 512Acq. time: 23 sec Comprehensive Pancreatic examination - Parenchyma & adjacent soft tissu

15、e - Intra and extra pancreatic ducts - Abdominal arteries & veins 2D SSFSEArterial MIPPortal & veins MIPLAVA: Arterial phase (MinIP)LAVA: Portal phase (MIP)LAVA: Venous phasePancreas LAVA2.6 mm (ov-1,3)Matrix: 256x256 Acq. time: 16 secPancreas Comprehensive Pancreatic examination - Vascular presurgi

16、cal mapping + 2D SSFSE: Portal phase (MinIP): Portal phase (MinIP): Portal phase (MIP) Porto-systemic derivations Anatomical variation of the left gastric artery CancerDepartment of RadiologyPortal Vein Invaded by Pancreatic Carcinoma（MPR and CTA）Ca of the body and tail of pancreasCT dynamic enhance

17、mentDepartment of RadiologyPancreatic carcinomaMSCT thin scanningDepartment of RadiologyDouble tube signMPRMSCT“Political power grows out of the barrel of a gun”-MAO TSE-TUNGLanguage is the dress of thoughtThe world is a book, and those who dont travel read only a pageWell, remember that you took a wrong way to a place, and you can have a smooth trip homeThe tragedy of life is not so much what men suffer, but what they miss. T. Carlyle脾臟影像學(xué)檢查方法USCTMRI常見(jiàn)疾病脾腫大脾破裂脾腫瘤脾