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1、肝胆动态显像,1,显像剂,亚氨基乙酰乙酸衍生物(IDAs),吡哆醛氨基酸(PAA),HIDA、EHIDADISIDA、PIPIDABIDA、BrIDA,PMT,2,显像原理,肝细胞,胆小管,胆囊管,清除机制,主动转运,胆囊,总胆管,十二指肠,摄取分泌排出,胆管肠道,显像剂,蛋白质,3,血清胆红素对图像影响,4,显像方法,患者准备病史禁食424h停用对奥狄括约肌有麻醉的药物,5,成人剂量,儿童剂量0.2mCi/kg，1mCi,剂量,6,采集,即刻1F/1s，60s5、10、20、30、45、60m静态末次RLA、LLA胆囊不显影，34h延迟显像或吗啡介入胆总管梗阻、狭窄，24h延迟显像,7,介入
2、试验,促胆囊收缩素（ CCK）试验吗啡试验脂肪餐试验鲁米那试验,8,显像前注射，禁食超过24h、缩短时间显像中注射，评价奥狄括约肌功能显像后注射，功能性、机械性总胆管梗阻、 急性非结石性胆囊炎、胆囊排胆分数、 症状性慢性胆囊炎与无症状性胆石症伴 其他原因引起腹痛,60s注射，胆管痉挛23m注射，差异较大 1530m注射，胆囊完全排空,CCK,作用,应用,CCK试验,9,吗啡试验,应用 缩短确诊急性胆囊炎时间作用 引起奥狄括约肌收缩，使胆总管压力增加10倍方法 缓慢注射后30m显像绝对禁忌症 呼吸抑制、吗啡过敏相对禁忌症 急性胰腺炎,10,脂肪餐试验 油煎鸡蛋鲁米那试验作用 增加肝脏酶分泌，加快
3、胆红素及IDA分泌微胆管应用 婴儿先天性胆管闭锁,11,适应证,急性胆囊炎总胆管梗阻先天性胆管闭锁和先天性胆管囊性畸形肝管手术后随访，判断是否有胆囊管残留、胆总管结石复发或残留、奥狄括约肌功能紊乱及手术后胆汁漏等肝脏FNH 、肝腺癌、肝细胞肝癌慢性非结石性胆囊炎十二指肠胃反流胆管支架植入后随访,12,图像分析,正常图像脾、肾显影后68s肝显影510m，肝实质显影1015m，左、右肝管、肝总管、胆总管显影3060m，胆囊显影12h延迟显像。部分正常人胆肝通过时间延迟，CCK试验判断正常变异、不完全性胆总管梗阻,13,5min,10min,15min,20min,25min,60min,正常肝胆显
4、像,胆囊,14,正常肝胆显像,A图未进食,B、C图进食后胆囊未显影,15,异常图像,肝实质显像期，见肝形态异常肝功能受损，肝清除显像剂能力降低，心肾放射性增高肝胆系显影时相延缓或胆囊与胆道不显影肝内与肠道显影顺序发生异常,16,临床应用,急性胆囊炎 原因 结石嵌顿至胆囊管梗阻病理生理 胆囊壁水肿、白细胞浸润、出血、坏死，至坏疽、穿孔显影特点 肝脏、肝胆管、总胆管、肠道1h内显像，胆肝通过时间正常，但胆囊始终不显影,17,Rim征 胆囊窝血流增加，周边肝脏摄取增加灵敏度 1h延迟显像97.6 ，4h延迟显像99.2鉴别诊断,慢性胆囊炎禁食24h严重肝细胞病变肝功不全,18,Case1 DISID
5、A显像,1F/3s动态显像,1F/5m动态显像,3h静态显像,4h静态显像,19,Case2 Anterior dynamic imaging (0-60 minutes),20,Anterior dynamic images after morphine administration.,21,Full history:58-year old woman with abdominal pain, and a questionable calcification in the region of the gallbladder seen on an abdominal radiograph.,F
6、ollowup:Surgery performed the day after hepatobiliary scintigraphy revealed two large gallstones (one in the body and one in the neck of the gallbladder). The patient had acute cholecystitis at surgery.,22,胆总管梗阻,病因 胆石症、肿瘤、胆总管狭窄影像,肝脏摄取好，胆管排出受阻节段性狭窄、胆管显影中断、管腔内充盈缺损、狭窄部位上端胆管扩张、胆管动力学异常,23,优势,梗阻24h内，胆管未扩张
7、有胆总管梗阻、胆管手术者 不完全性胆总管梗阻,24,先天性胆管闭锁,影像 肠道始终无放射性出现鉴别诊断,新生儿肝炎，24h内可见肠道显影严重肝功能损害，胆肝通过时间明显延迟,25,Tc-EHIDA显像ANT 24h肠道持续未显影,Case 3 先天性胆道闭锁,26,Case 4 Biliary atresia,Findings:Sequential images obtained over 60 minutes after injection demonstrate prompt uptake of the radiopharmaceutical by the liver. There is
8、no evidence of excretion of the radiopharmaceutical into the biliary system or small bowel. Renal clearance into the bladder was noted. Additional imaging obtained at 4 and 24 hours demonstrated no bowel activity.,27,Full history:This is a 2-week old infant with elevated conjugated bilirubin and aco
9、lic, gray stools.,Followup:Repeat scintigraphy with phenobarbital pretreatment as well as liver biopsy were both most consistent with biliary atresia.,28,ANTTcEHIDA显像,Case 5 新生儿肝炎,29,术后随访,总胆管无梗阻、吻合口通畅 肝脏浓集迅速，肠道60m出现放射性不完全性梗阻 肝肠通过时间延长(60m)，伴胆管扩张完全梗阻 肝脏浓集正常，胆管不显影胆汁漏 漏出部位、走向及估计漏出速率,30,Case 6 Biliary Le
10、ak,Full history:This is a 51 year-old man who underwent liver transplantation for hepatitis C three months ago. The pateints T-tube was removed one day prior to this examination. After the tube was removed, the patient has had worsening abdominal pain.,31,原发性肝脏良性恶性肿瘤,肝细胞 肝癌,血流灌注增加肝脏摄取明显胆管清除延缓,不摄取显像剂,早期病区冷区延迟显像填充,32,慢性胆囊炎,图像多样化胆囊显影正常、延迟、不显影胆肝通过时间延长 优势慢性非结石性胆囊炎CCK胆囊排胆分数35%，预示慢性胆 囊炎病理诊断和术后可缓解症状,33,十二指肠胃反流,影像 近端肠道显影后胃内有放射性,34,
