膽道系統炎症之影像診斷
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膽道系統炎症之影像診斷

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膽道系統炎症之影像診斷 膽道系統炎症之影像診斷 Presentation Transcript

  • Biliary Anatomy
  • Biliary Calculi Milk of calcium bile Porcelain gallbladder Cholecystitis Mirizzi Syndrome, Gall stone ileus
  • Biliary lithiasis
  • Biliary lithiasis 最佳影像診斷線索 : Echogenic foci with posterior acoustic shadowing (10% stones: No acoustic shadow) in US Discrete & (movable) lower signal (density) filling defects within bile ducts in MRC and ERCP Opaque stones (20%) in plain radiography
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  • Gallbladder completely filled with calculi ~ Calculi are molded ( 鑄造 ) by the wall of the gall bladder : the acoustic shadow posterior to the Calculi that do not change with positional change
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  • Floating stone
  • Clinical issues
    • Primary CBD stones (5%) : Form within CBD
    • 2nd CBD stones (95%) : Gallstones into CBD
    • Treatment: stone < 3 mm : usu. spontaneously pass stone 3-10 mm : endoscopic sphicterotomy * stone retrieval balloon to sweep duct * basket to snare stones stone > 10-15mm : require fragmentation by mechanical lithotripsy
  • Clinical issues (CBD stones)
    • S/S: RUQ pain, Jaundice, pancreatitis
    • ↑ Alkaline phosphate & bilirubin
    • Gender: Females (middle age) > males
    • Pathology:
    • Bile stasis / infection ~
    • Bilirubinate stone formation (Cholesterol + Ca ++ bilirubinate)
    • Obstruction, dilatation, sclerosis, stricture.
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  • Crescent (meniscus) lucent sign Bull’s eye sign
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  • Milk of calcium bile Calcium carbonate precipitate within gall bladder lumen (calcium milk) 最佳影像診斷線索 : Identification of calcified liquid within gallbladder (echogenic fluid similar to sludges but with acoustic shadowing) Incidental finding: asymptom or RUQ pain Etiology: GB stasis ~ Ca++ carbonate in bile, thickness of GB wall
  • GB sludges (thick bile)
  • GB sludges ~ cholecystitis ~ stone
  • Milk of calcium bile (vs. sandy gall stone)
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  • Porcelain GB Calcification of gallbladder wall 最佳影像診斷線索 : Rim of calcification in RUQ conforming to GB shape Usually asymptomatic ; old age Rish factor for gallbladder carcinoma Prophylactic cholecystectomy is current consensus recommendation
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    • Acute inflammation of gall bladder
    • 95% calculous : 2°to obstructing stone in GB neck or cystic duct
    • 5% Acaculous : 2°to ischemia with secondary inflammation/infection
    Cholecystitis
  • Gallstones --> cystic duct obstruction Bile secretion  GB distention Wall edema / hypervascularity Intraluminal pressure  Compression on vessels --> Thrombosis/ ischemia --> GB wall necrosis --> Perforation / abscess Pathophysiology Gallstones (+) : 96 %
  • Color Doppler sonogram: marked Hyperemia & wall thickness of GB
  • Tc-HIDA scan: Acute cholecystitis without isotope filling of GB
    • 最佳影像診斷線索 :
    • GS impacted in neck / cystic duct
    • Sonographic Murphy sign (+)
    • GB wall thickness (> 4 mm)
    • Distended GB (> 4 cm trans. diameter)
    • Pericholecystic fluid/ /abscess
    • Intraluminal membranes
    • Gas in GB wall / lumen
    • Asymmetric GB wall thickness
    Cholecystitis
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  • Clinical issues
    • S/S: Acute RUQ pain, fever
    • Lab data: ↑WBC count, may have mild elevation in liver enzymes
    • Demographics
    • Age: typically > 25y, Gender: M:F = 1:3
    • Microscopic features
    • Lumen: GS, sludge; GB mucosa: Ulceration;
    • GB wall: Acute PMN infiltration;
    • Bacterial cultures positive in 40-70% of patient
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  • Acaculous cholecystitis ?
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  • Non-inflammatory GB wall thickness: Congestive heart failure with dilated IVC
  • Non-inflammatory GB wall thickness: Acute hepatitis Acute hepatitis s/p treatment
  • Clinical issues
    • Complications Empyema
    • Emphysematous, Gangrenous
    • Perforated with abscess
    • Chronic cholecystitis
    • Mirizzi syndrome
    • Bouveret syndrome (gall stone ileus)
  • Intraluminal membranes Empyema of gall bladder
  • Emphysematous cholecystitis
  • Intraluminal membranes Sloughed ( 蛻腐 ) mucosae (Asymmetrical wall thickness) Gangrene of gall bladder
  • Perforated GB with abscess localized peri-cholecystic complicated fluid collections
  • Perforated GB with abscess
  • Clinical issues
    • Treatment
    • Prompt or delayed lap. cholecystectomy Laparoscopic cholecystectomy for uncomplicated cases
    • Percutaneous cholecystectomy useful for poor operative risk patients with GB empyema or gangrene
    • Percutaneous drainage well-defined, well-localized pericholecystic abscesses
  • Chronic Cholecystitis Two appearance Small, contracted, sclerosed GB with/without stones (fasting state) Same imaging appearance as acute cholecystitis but without Murphy sign (terderness)
  • Small, contracted, sclerosed GB; even non-visualization of GB (during fasting state)
  • Mirizzi syndrome Partial or complete obstruction of common hepatic duct (CHD) due to gallstone impacted in cystic duct or gall bladder neck 最佳影像診斷線索 : Impacted cystic duct stone on US with proximal dilatation of intraheptic ducts
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  • Clinical issues
    • S/S: fever, jaundice, RUQ pain
    • D/D: Porta hepatis obstruction from nodes with proximal IHDs dilatation Porta hepatis obstruction by cholangiocarcinoma (Klatskin tumor) with proximal IHDs dilatation
    • Treatment: Cholecystectomy with careful dissection of cystic duct to avoid injury to CHD
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  • Porta hepatis nodes Klatskin tumor
    • 最佳影像診斷線索 : (Rigler triad)
    • Small bowel obstruction Gas in biliary tree Ectopic gallstone (> 2.5 cm) in bowel
    Gall stone ileus (Bouveret syndrome) Gall stone erodes into duodenum causing intestinal obstuction
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  • Clinical issues
    • Age: risk ↑with age; average 65-75 Y/O
    • Prognosis: high mortality, operative mortality 19 %
    • Treatment
    • Surgical therapy to relieve bowel obstruction
    • Cholecystectomy & biliary fistula excision; to prevent recurrence
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  • M/74
    • 主 訴: chills and fever for three days
    • 現 在 史 previous history of liver cirrhosis with ascites, started nausea, vomiting, fever and abdominal pain for three days before admission. He was brought to nearby hospital for hospitalization. However, signs and symptoms persist, and he was diagnosed to have peritonitis of unknown cause. He is then transferred to our hospital for further evaluation and management. At the ER, abdomen CT ~~~
    • Vital signs : Blood pressure 93 / 59 mmHg
    • Pulse rate 97 / minutes
    • Respiratory rate 19 / minutes
    • Body temperature 38.3 ℃
    • Abdomen : Distended ( + )
    • Tenderness ( + ) : RUQ ( + )
    • Rebounding pain ( + )
    • Murphy's sign ( + )
    • Shifting dullness ( + )
    • Bowel sound : Hypoactive ( + )
    • Lab. : WBC: 28230/cumm
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  • Pathological No.: 962230 Date of Arrival: 2007/8/7 Date of Report: 2007/8/8 Pathological diagnosis: Gall bladder, cholecystectomy ----- ----- Chronic cholecystitis with acute exacerbation and cholelithiasis Gross: The specimen consists of an opened gall bladder, measuring 9.2 x 4.5 x 3 cm in size. It is enlarged. The wall is thickened and measuring up to 0.5 cm in thickness. The mucosal folds are absent. There are several pieces of black stone in the lumen. Representative parts are embedded in one block. Microscopy: The sections show a picture of edema, neutrophilic infiltration, congestion, hemorrhage, abscess formation, fibrosis and focal chronic inflammatory cell infiltration in the lamina propria, muscular layer and perimuscular layer. Rokitansky-Aschoff sinuses are present.
    • 主 訴: Left abdominal pain off and on for 10 days
    • 病 史: This 52 years old woman, who had history of infertility s/p
    • laparoscopy > 25 years ago, Intestinal adhesion s/p OP
    • 25 years ago, left ovarian tumor s/p laparoscopy 15 years
    • ago.
    • According to the patient : she has left abdominal pain off
    • and on for 10 days, aggravated for 3-4 days, can not sleep
    • due tp severe pain with fullness. Associated with loss of
    • appetite, nausea was noted. The pain locates on left
    • abdominal area, subacute, duration 24 hours, dull pain and
    • fullness in character, aggravated by taken food, relief by
    • rest, no radiated, no change of bowel habit. She had been
    • treatment at 劉醫院 , but the treatment not effective, hence,
    • she sent to our GI OPD, KUB showed partial intestinal
    • obstruction, She was admitted.
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  • Spigelian hernia Lap. Port hernia
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  •