胆系影像诊断学.ppt

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1、1,胆系影像诊断学,2,X线检查,X线平片：右上腹平片，显示钙化、气体以及被肠管气体影衬托的胆囊X线造影：口服胆囊造影，静脉胆道造影术后T形管造影：了解胆管内有无残余结石，胆管与十二指肠的通畅情况以及有无术后并发症ERCP：诊断胰腺疾病和确定胆系梗阻的原因。亦能进行胆总管取石和胆总管狭窄内支架置入术PTC：鉴别阻塞性黄疸的原因和确定梗阻的部位,3,“T”管造影,透视监视下注射对比剂时应避免将空气混入，以免造成假象,4,PTC,Percutaneous transhepatic cholangiography透视监视下将22G细针经皮穿入肝管后注入对比剂显示肝内胆管和胆总管,5,CT检查,平扫：

2、空腹，准备同肝脏扫描，若怀疑胆系结石，则不必口服碘对比剂。胆系扫描范围从膈顶至胰钩突区。层厚和间距通常为10mm，胆囊区和其它重点层面35mm薄扫增强扫描静脉内注射60%泛影葡胺80100ml后CT扫描，肝脏及其动静脉、胰腺强化，能更清晰的衬托出胆道影像静脉内注射60%胆影葡胺约2030ml后扫描，胆道和胆囊充盈对比剂，显示清晰口服胆囊对比剂后CT扫描，可特异性的显示胆囊梗阻性黄疸与胆囊病变的诊断与鉴别诊断平扫显示胆道系统梗阻的部位、含钙结石增强显示和区别肝内血管、胆道系统，更好地显示胆囊形态和胆囊壁的病变,6,MRI检查,检查时空腹。常用SE序列T1WI及T2WI，以横断面为主，辅之以冠状面

3、及矢状面，薄层扫描有助于胆囊内细微结构的观察Magnetic Resonance Cholangio-Pancreatography（MRCP）不需注射对比剂可清楚显示胰胆管全貌，对胰胆管梗阻性病变诊断颇有价值，敏感度、特异度和准确度均在90%以上,7,US检查,胆道系统超声检查时将探头置于腹直肌与右肋缘交界处纵切，剑突下横切、右肋间斜切，以及右上腹斜纵切等途径，可获得胆囊、肝内外胆管图象,8,正常X线表现,右上腹平片：肠道气体衬托下，可以观察到胆囊，位于右肝下缘造影：胆囊位于右第12肋附近，长710cm，宽34cm，茄子状胆囊管长约3cm，宽约3mm，与肝总管汇合成胆总管肝内胆管呈树枝状分布

4、，纤细、整齐，逐级汇合成左右肝管，再汇合成肝总管肝总管宽46mm，长34cm胆总管长610cm，宽48mm。走行于十二指肠和胰腺后方，先向内下再向外下走行，同胰管汇合，斜行进入十二指肠降段,9,胆囊造影,胆囊位于右第12肋附近，呈长茄子状,10,胆系CT正常表现,平扫肝内胆管通常不能显示。肝总管位于肝门区，门静脉主干的外侧，呈圆形低密度影，直径约3mm5mm，壁厚小于1.5mm，胆总管位于胰头上区域和胰头内后方，呈圆形低密度影，直径约36mm胆囊呈卵圆形，位于方叶下方的胆囊窝内，大小变异较大。内容物为水样密度，CT值为-515Hu，囊壁厚约2mm泛影葡胺增强扫描，肝外胆道显示为圆形低密度影，胆

5、道壁可强化，使胆道影更清晰。胆囊壁强化，胆囊内液体不增强胆影葡胺增强扫描，胆道及胆囊内充盈对比剂，呈高密度影像,11,胆系横断面,CT平扫呈低密度，卵圆形，胆汁密度均匀，CT值略高于水,12,正常胆囊,13,胆系MRI正常解剖,胆囊及胆总管T1WI呈均匀的低信号，T2WI上呈明显高信号MRCP可显示胆树全貌，呈均匀高信号。肝外胆管的显示率为100%胆总管直径0.8cm，肝总管直径约0.4cm，边缘光滑MRCP对无扩张的肝内胆管显示率达82%；对判断梗阻性胆管扩张的准确率为91100%，判断梗阻部位准确率为84100%,14,正常US胆系解剖,胆囊呈梨形或椭圆形，长经8，短经4。胆囊壁光滑清晰，

6、后壁回声增强，正常时胆囊壁厚度均匀一致，约为3以下。胆囊内为无回声区正常肝内胆管一般不显示，肝总管和胆总管上段显示为门静脉前方的管道结构，显示长度为4，内径小于伴行的门静脉的1/3，约为36,15,ERCP与PTC的异常表现,梗阻以上胆管扩张胆道结石时，梗阻端可见边缘光滑的充盈缺损影胆囊内蛔虫显示为长条状充盈缺损胆管受肿瘤侵润，梗阻端可表现为突然变细的外形不规则的狭窄胆结石、胆囊癌、胆管癌均表现为相应部位的充盈缺损。肝内外胆管扩张表现为增宽、迂曲呈蚯蚓状的高密度影,16,CT异常表现,形态及大小：平扫及增强见到肝内胆管即为肝内胆管扩张，表现为肝内增宽、迂曲的条状、树枝状低密度影，从肝门向肝的外

7、周延伸，胆管结石或肿瘤可致梗阻近端的胆管扩张。胆总管直径超过1cm为胆总管扩张。胆囊增大可为胆总管下端结石或肿瘤所致密度：胆囊、胆管结石表现为相应部位的高密度影，呈类圆形，边界清楚；软组织密度影可见于胆囊息肉、胆囊癌、胆道癌及泥沙状结石；胆囊及胆管内气体或阴性结石则表现为低密度CT增强扫描：泛影葡胺增强扫描：肝内外胆管扩张显示为无强化的低密度影，管壁明显强化；胆囊癌、胆管癌表现为轻中度强化胆影葡胺增强扫描：胆道及胆囊内充盈对比剂，呈高密度,17,MRI异常表现,胆管扩张及胆囊增大：胆系的梗阻性病变（如结石、炎症、肿瘤等）可使胆囊体积明显增大以及肝内外胆管扩张。梗阻越重，胆囊及胆管的扩张越明显数

8、目异常：见于先天变异如双胆囊、三胆囊、胆囊缺如、胆囊分隔、胆管囊肿等信号异常：T1WI多数结石信号与胆汁近似，呈低信号，部分结石比胆汁信号高，T2WI上结石在高信号胆汁的衬托下呈低信号；胆囊癌及胆管癌多为软组织信号；胆囊炎时胆囊壁增厚，周围可见水肿信号MRCP：胆系结石亦为圆形低信号充盈缺损，炎症引起的扩张胆管壁僵硬，呈阶段性或串珠样扩张，恶性梗阻时胆管壁光滑，胆管扩张明显,18,US异常表现,胆道系统扩张或缩小：二级以上的肝内胆管正常时不显示，扩张时与相应的门静脉呈“平行管征”，重度扩张时呈星状结构。肝外胆管扩张与门静脉伴行称为“双筒猎枪征”。胆管下段梗阻时肝内外胆管扩张，胆囊增大。高位肝门

9、部梗阻时肝内胆管及左右肝管扩张，胆囊缩小，肝外胆管不宽。壶腹水平梗阻胆管、胰管均扩张。回声改变：胆囊、胆管结石表现为相应部位强光团伴声影，可移动。胆囊息肉、胆囊癌、胆管癌及泥沙状结石表现为等回声或稍低回声，其中息肉及肿瘤无声影，不移动，泥沙状结石可有浅淡声影，移动后形态改变,19,胆石症,分为胆囊结石、肝外胆管结石、肝内胆管结石和复合结石胆石主要成分为胆色素和胆固醇，可分为胆色素结石、胆固醇结石，根据含钙多少，X线能否显示，分阳性结石和阴性结石胆系结石常引起右上腹疼痛和黄疸,20,CT,多数胆结石含有胆固醇或胆色素，呈不定形的钙化。单纯胆固醇结石，可见环状或中心部的钙盐沉着。大多数结石通过超声

10、可作出诊断，CT可对80%90%的胆结石作出诊断胆管内结石，应用薄层扫描可提高检出率,大的结石，CT可见典型的钙化影。胆汁的CT值根据其粘稠度的不同可在080HU范围内，胆汁与胆结石的密度差别不定，有时可呈等密度。胆固醇结石的CT值在-60140HU的范围内，根据钙盐含量的增加而增加。不伴钙化的结石，有时比胆汁的CT值低，较难诊断,21,胆囊结石（gallbladder stone）,在胆汁淤滞和胆道感染等因素影响下，胆汁中胆色素、胆固醇、黏液物质和钙盐析出、凝集而成结石根据化学成分不同，胆囊结石可分为胆固醇结石、胆色素结石、混合性结石西方国家多胆固醇类结石，我国胆红素类结石常见，近年胆固醇类

11、结石有上升趋势症状为发复、突然发作的右上腹痛，疼痛为持续性，并放射至后背和右肩胛下布，同时出现呕吐中年女性多见，表现为胆绞痛和阻塞性黄疸，伴有胆囊炎者可有胆囊炎的症状体征,22,Gallbladder Stone,X线平片可显示1020%的含钙结石，胆囊结石呈圆形、多边形或石榴籽状。阳性胆管结石可显示在胆管走行区域内高密度影阴性结石造影显示胆囊或胆管内充盈缺损CT检查，根据结石的化学成份不同，平扫可表现为高密度结石、等密度结石、低密度结石或环状结石。等密度结石平扫不易发现，采用胆影葡胺增强扫描可协助诊断，表现为胆囊内可移动充盈缺损,23,Gallbladder Stone,胆囊内见单个或多个圆

12、形或多边形异常密度密度可为均匀高密度，分层（多环）状混杂密度，等密度，低密度胆囊内分层样密度不均，上高下低，之间为一液平等或低密度结石者应做胆囊造影，以便更加清楚显示结石，随体位变化而变化胆囊壁增厚,24,Gallbladder Stone,T1WI上与胆汁信号相似，少数结石明显高于胆汁。T2WI胆汁显示为高信号，而结石在高信号胆汁的衬托下呈现低信号充盈缺损US可显示胆囊结石的三大特征胆囊内形态固定的强回声光团后方伴有无回声带即声影改变体位检查强回声团随体位变化而移动如胆囊内充满结石，胆汁缺乏，则出现增厚的胆囊壁弱回声带环绕强回声的结石，加上后方有声影，形成“囊壁、结石、声影”三合征，提示胆囊

13、结石伴有胆囊炎小的结石或泥沙样结石强回声影不明显，变换病人体位检查时强回声团可移动,25,胆管结石（biliary stone）,胆管结石分为肝外胆管结石和肝内胆管结石病因、病理和临床表现同胆囊结石当结石移动或嵌顿于胆管内时可引起绞痛症状，若结石停留于胆管内则引起梗阻产生黄疸US显示扩张的胆管内有强回声团，伴有声影,26,胆总管结石,CT表现为胆总管内高密度影，伴有或不伴有周围低密度胆汁影环绕。或为腔内软组织密度影，周围可环绕低密度区。管腔内中心低密度区，边缘为高密度影；或者是管腔内低密度区的中心见散在点状高密度影。胆总管梗阻，梗阻近肝侧的胆管扩张。肝内胆管结石CT表现为肝内管状、点状、不规则

14、状高密度影，沿胆管走行分布MRI可见肝内、外胆管走行区域信号异常，T1WI上结石表现为低于胆汁或高于胆汁信号，T2WI上结石在高信号胆汁的衬托下表现为低信号充盈缺损。MRCP的最大优点是能在一幅图像上充分展示整个胆系结石的分布、并能直观地显示结石的大小、形态、数目、位置以及梗阻部位和梗阻程度，较大结石梗阻端呈杯口状。对于泥沙样结石，MR无特异征象，容易漏诊,27,US appearance of gallstones,highly reflective echoes within the gallbladder,which indicate gallstonesmarked posterior

15、 shadowing after repositioning the patient shows mobility of the gallstones,28,gallstones,29,胆囊结石,结石呈多发性环状排列的钙化。结石呈两枚点状钙化,30,胆结石,31,胆结石,胆结石内真空现象，慢性胆囊炎导致胆囊壁肥厚,32,胆结石,33,胆囊多发性结石,34,胆囊阴性结石 口服法胆囊造影后扫描,35,胆囊阴性结石 口服法胆囊造影后扫描,36,胆管结石,37,胆管结石,38,胆管结石,CBD stones in a patient who had undergone cholecystectomy.

16、Coronal single-shot fast spin-echo MR cholangiopancreatogram shows multiple gallstones(arrows)within a markedly dilated CBD(30 mm wide),39,急性胆囊炎（acute cholecystitis）,常由胆囊结石嵌顿和蛔虫阻塞，引起胆囊管阻塞，胆汁淤滞，胆囊内压力增高，压迫胆囊壁血管和淋巴管，胆囊血供障碍导致炎症发生病理学表现三种类型：单纯性急性胆囊炎，胆囊黏膜充血、水肿，胆囊轻度肿胀；化脓性急性胆囊炎，为胆囊壁弥漫性白细胞浸润形成广泛蜂窝织炎，胆囊肿大，囊壁增厚

17、，浆膜纤维素性脓性渗出，发生胆囊周围粘联或脓肿等；坏疽性急性胆囊炎，胆囊高度肿大，胆囊壁缺血、坏死、出血甚至穿孔，引起胆汁性腹膜炎。如为产气细菌感染，则胆囊坏疽的同时，胆囊内和胆囊壁积气，为气肿性急性胆囊炎常见于45岁以下，男女比1:2。临床表现为急性发作的右上腹痛，放射右肩胛部，为持续性疼痛并阵发性绞痛，伴有畏寒、高热、呕吐等检查右上腹压痛，莫非（Murphy）征阳性，可扪及肿大的胆囊，重者出现黄疸,40,Acute Cholecystitis,X线平片多阴性，少数可见合并的胆囊结石或胆囊窝处有气体影，后者提示有坏死气肿性胆囊炎或穿孔CT平扫可显示胆囊增大，直径5cm，胆囊壁弥漫性增厚，可超

18、过3mm。胆囊周围组织水肿，胆囊周围常有一环形低密度带。胆囊坏死、穿孔，胆囊窝可见包含有液平面的脓肿。增强扫描时胆囊壁可见明显均匀一致性强化，且强化时间较长。可合并胆囊结石MRI可见胆囊增大、胆囊壁弥漫性增厚，超过3mm即有诊断意义。胆囊窝积液以及胆囊周围水肿带呈长T1WI低信号和长T2WI高信号，偶见胆囊积气、积液征象US显示胆囊增大，胆囊壁轮廓线模糊，胆囊壁弥漫性增厚，增厚的胆囊壁呈增强回声带，中间同时出现间断或连续的弱回声带，称为胆囊壁的双层回声，系黏膜下水肿、出血和炎性细胞浸润所致。胆囊窝显示无回声带，提示胆囊周围液体潴留或积脓,41,急性胆囊炎,胆囊壁增厚（4mm），增强显示胆囊内侧

19、粘膜层炎症引起的充血产生增强效应，呈致密细线条状阴影，浆膜层水肿形成低密度带环绕胆囊周围对比增强，沿胆囊内壁可见厚1-2mm的低密度带,42,急性胆囊炎,胆囊壁增厚，增强显示胆囊内侧粘膜层炎症引起的充血产生增强效应，呈致密细线条状阴影，浆膜层水肿形成低密度带环绕胆囊周围,43,慢性胆囊炎,注射造影剂后，可见胆囊壁呈不规则增厚，与肝脏分界不清,44,慢性胆囊炎（chronic cholecystitis）,多为发复发作的急性胆囊炎发展而来，也可没有明显的急性发作过程，发病过程常与胆囊结石并存和互为因果病理改变为纤维组织增生和慢性炎性细胞浸润，使囊壁增厚，胆囊收缩功能减退。常有结石并存临床症状不典

20、型，常出现腹胀不适、上腹部隐痛、消化不良等。右上腹局部压痛,45,Chronic Cholecystitis,X线检查多无异常，少数可见阳性结石影CT多表现胆囊缩小，为胆囊萎缩所致。少数也可增大，由胆囊积水引起。胆囊壁均匀或不均匀性增厚。增强扫描时增厚的胆囊壁可见明显均匀一致性强化。可合并胆囊结石MRI表现为胆囊腔缩小、胆囊壁均匀性增厚US显示胆囊增大，胆囊壁增厚，增厚的胆囊壁呈增强回声带。胆囊轮廓回声模糊，提示胆囊与周围组织粘连。胆囊收缩功能减弱,46,慢性胆囊炎,47,Chronic Cholecystitis,48,胆囊周围脓肿,胆囊炎伴有腹壁脓肿,49,胆囊肿瘤,胆囊造影表现为充盈缺损

21、的病变中，胆固醇息肉是仅次于胆结石的病变，常为35mm的多发病灶，也有达10mm者胆囊腺肌瘤病，表现为胆囊壁的局限性或弥漫性肥厚真性乳头状和大于4cm的腺瘤，发生率低,50,胆囊癌（gallbladder carcinoma）,原因不明，可能与胆囊结石和慢性胆囊炎的长期刺激有关70%合并胆囊结石。多发于胆囊底部或颈部，70%90%为腺癌，少数为鳞癌80%的肿瘤呈浸润性生长，早期在胆囊黏膜浸润性生长，胆囊壁增厚，随肿瘤的进展，胆囊壁呈环形增厚20%的肿瘤呈乳头状生长，表现为菜花样肿块突入胆囊腔内。肿瘤生长可充满整个胆囊好发于中老年，女性多，男女比1:3早期无症状，进展期出现右上腹部持续性疼痛、黄

22、疸、消瘦、肝大和上腹部包块。合并胆囊炎时发热、恶心、呕吐出现症状时，肿瘤多向胆囊床扩散，多侵犯肝十二指肠韧带和肝脏，局部淋巴结转移，预后不良,51,Gallbladder Carcinom,X线平片：对诊断无价值PTC：侵犯胆管时出现胆管不规则狭窄、充盈缺损及胆道梗阻晚期累及胆囊浆膜层时，动脉造影可显示胆囊动脉增粗、受压移位，可见肿瘤血管,52,Gallbladder Carcinoma:CT,胆囊壁增厚：15%22%，胆囊壁不规则或结节样增厚腔内结节：15%23%，胆囊腔内单发或多发结节状肿块肿块：41%70%，肿块可充满整个胆囊并侵犯邻近肝组织，肝内见边界不清的低密度区。出现胆道梗阻。增强

23、扫描则显示不规则增厚的胆囊壁或肿块有明显强化。可伴胆囊结石,53,Gallbladder Carcinoma：MRI,信号强度无特异性肿瘤组织在T1WI上呈不均匀性低信号，在T2WI上为不均匀性高信号增强后出现不均匀性强化胆囊癌多并发结石,54,Gallbladder Carcinoma：US,小结节型：突入胆囊腔内的乳头状肿块，表面不光滑，大小约1.01.2cm蕈伞型：宽基底的中等回声或弱回声之肿块，边缘不规则厚壁型：胆囊壁弥漫形或局限性的不均匀性增厚，表面欠光滑混合型：多见，表现为蕈伞型和厚壁型的声像图实块型：表现为胆囊增大，胆囊腔被肿瘤所闭塞，呈弱回声或粗而不均匀的实性回声,55,Gal

24、lbladder Carcinoma,56,胆囊癌,胆囊内软组织肿块向肝脏浸润，与肝脏境界不清，提示向肝脏的浸润性生长,57,胆囊癌,胆囊形态不规则，胆囊壁肥厚，向肝脏浸润形成不规则低密度区,58,胆囊癌,肿瘤向肝门部扩散，胆管引流术的适应症,59,胆囊癌,胆囊壁肥厚，境界不清。肿瘤向肝脏浸润，边缘轻度强化,60,Gallbladder carcinomas,Poorly differentiated adenocarcinomaResected gallbladder shows innumerable gallstones and diffuse neoplastic mural thic

25、kening.Papillary adenocarcinomagallbladder specimen shows the cauliflower-like intraluminal growth of a papillary adenocarcinoma,61,Gallbladder carcinomas,Porcelain gallbladder containing carcinoma and a fistula to the duodenum.Abdominal radiograph shows curvilinear calcification and an abnormal gas

26、 collection within the right upper quadrant of the abdomen.Image from an upper gastrointestinal series demonstrates a gallbladder-duodenal fistula,caused by invasive carcinoma of the gallbladder,62,Gallbladder carcinomas,Moderately well-differentiated adenocarcinoma,F70,right upper quadrant pain and

27、 a history of gallstoneswell-defined mass in the gallbladder fundus(*)that produces ill-defined posterior acoustic shadowingCT：tumoral calcifications in the soft-tissue mass within the gallbladderspecimen：the tumor mass(*)and numerous gallstones,63,胆道梗阻,胰头部狭窄性病变，导致肝内胆管明显扩张、变形。门脉系统等的相对位置关系，保持在正常位置,64

28、,胆管癌（cholangio-carcinoma）,发生在左右肝管以下的肝外胆管癌上段，又称肝门部胆管，左、右肝管及其汇合部、肝总管，50%中段，肝总管与胆囊管汇合部以下至胆总管中段下段，胆总管下段、胰腺段和十二指肠壁内段80%为腺癌，少数为鳞癌生长方式：结节型、浸润型、乳头型（常见）发病年龄在5070岁之间，男女比22.5:1早期症状为右上腹隐痛或胀痛，继而出现进行性黄疸。体检右上腹部包块，胆囊肿大,65,胆管癌,PTC和ERCP可直接显示胆管癌的部位和范围浸润型见胆管狭窄，狭窄呈突然性，边缘不规整结节型和乳头型显示胆管内不光整的充盈缺损，上部胆管扩张，肝内胆管扩张，呈现“软藤”征CT病变近

29、端的胆总管和肝内胆管扩张，于梗阻部位突然中断部分病例在中断处可见腔内软组织肿块。增强扫描肿块轻-中度强化肝门区胆管癌则表现为肝门区软组织肿块，肝内胆管扩张，增强扫描肿块呈轻中度强化,66,胆管癌,MRI：T1WI胆管走行区出现比肝实质稍低的肿块，T2WI上呈稍高信号MRCP见胆管狭窄或完全中断，梗阻端呈锥形或不规则形。肝内胆管扩张呈“软藤状”US结节型和乳头型见胆管远端有边缘不规整的软组织肿块，突入胆管内或阻塞于胆管，肿块呈强回声，无声影。与胆管壁分界不清浸润型表现扩张的胆管远端突然中断或狭窄闭塞，阻塞端为肿瘤部位，表现致密的强回声,67,Hilar cholangiocarcinomas,a

30、ccount for 50%of all large bile duct malignanciesThe middle and distal portions of the common bile duct are affected in about 17%and 18%Tumors originating from a large bile duct are in a critical location and are discovered early due to the presence of jaundice or cholangitisTumors originating from

31、small bile ducts do not cause significant biliary obstruction until the late stage,when the tumor itself or metastatic hilar lymphadenopathy causes obstruction of the common hepatic duct,68,Infiltrating hilar cholangiocarcinoma,tumoral involve the right secondary confluence and common hepatic ductCT

32、 reveals a high-attenuation tumor on the anterior aspect of the right portal vein On a subsequent CT scan,the tumor appears as a high-attenuation lesion on the right side of the portal veinCT scans at a lower level show the mucosa of the cystic duct with strong enhancement,a finding that suggests tu

33、moral involvement.Soft-tissue infiltration around the portal vein and lymphadenopathy are also noted,69,Exophytic hilar cholangiocarcinoma,Arterial and portal-phase CT show a 4-cm low-attenuation mass with peripheral enhancement at the hepatic hilum,mainly in segment IV.Both intrahepatic ducts are d

34、ilated.Two pigtail catheters were inserted for drainageCholangiogram reveals obliteration of the left hepatic duct,but the right secondary confluence is preserved.In such cases,it is difficult to ascertain whether the tumor originates from the left hepatic duct and demonstrates exophytic growth or o

35、riginates from a small branch of segment 4 and exhibits subsequent involvement of the hepatic hilum,70,Infiltrating hilar cholangiocarcinoma with early-stage exophytic growth,PTC shows hilar cholangiocarcinoma originating mainly from the right hepatic ductCT shows the tumor as a thin line of high at

36、tenuation anterior to the right portal veinResected specimen cut along the right hepatic duct shows a whitish tumor invading the hepatic parenchyma.This finding,which was not seen at CT,represents early-stage exophytic growth,71,Polypoid hilar cholangiocarcinoma,Delayed-phase CT scans show a soft-ti

37、ssue mass within a dilated left hepatic duct and common bile ductCholangiogram shows a polypoid mass at the confluence levelSpecimen reveals an extensive polypoid mass within the common bile duct,72,Polypoid hilar cholangiocarcinoma,M64Portal-phase CT scan shows diffuse dilatation of the intrahepati

38、c duct,a soft-tissue mass in the common bile ductPTC reveals a papillary mass at the level of the hepatic hilum,presumably arising from the right hepatic duct,73,Infiltrating extrahepatic cholangiocarcinoma involving the midportion of the common bile duct,74,Polypoid extrahepatic cholangiocarcinoma

39、with diffuse bile duct involvement,M65,CT scans show a dilated common bile duct filled with a papillary tumor;partial restoration of the ductal lumen in the intrapancreatic portion of the common bile duct.However,small papillary tumors are still evident.On a CT scan obtained at the level of the dist

40、al common bile duct,the lumen is again filled with an intraductal papillary tumor.Direct cholangiogram shows a large papillary tumor in the proximal two-thirds and the distal portion of the common bile duct,75,肝门胆管癌,76,肝管分叉水平肿瘤,肝管分叉水平，可见局限性病变，病变向左叶上方扩展，局部可见胆管狭窄和局部扩张，注射造影剂后CT值与肝脏大致相等,77,胰头癌肝内胆管扩张T1WI

41、,78,胰头癌肝内胆管扩张-T2WI,79,Adenomyomatosis,also termed adenomyomatous hyperplasia of the gallbladder,is a benign hyperplastic cholecystosisno definite racial or sex predilectionAge range is wide,most in their 50sincidental finding,has no intrinsic malignant potential,requires no specific treatmentfrequen

42、tly coexists with cholelithiasis,but no causative relationship has been provedoccasionally produces abdominal pain,and in some cases cholecystectomy may be indicated for relief of symptoms,80,Adenomyomatosis,The gallbladder wall is composed of four layers:mucosa,lamina propria,muscularis propria,and

43、 serosa.No muscularis mucosa or submucosa.The wall thickening of adenomyomatosis involves hyperplasia of both mucosa and muscularis propriaCholesterol accumulation in adenomyomatosis is intraluminal,as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses,intramural dive

44、rticula lined by mucosal epithelium,81,Adenomyomatosis of the Gallbladder,Longitudinal UStransverse US thickened gallbladder wall and echogenic intramural foci with comet tail reverberation artifacts,indicative of cholesterol crystals within Rokitansky-Aschoff sinuses,82,Adenomyomatosis:CT,thickened

45、 gallbladder wall and abnormally intense mucosal enhancementdiscrete hypoattenuating intramural lesions represent Rokitansky-Aschoff sinuses,83,adenomyomatosis,C-T2WI and c+T1WI show a diffusely thickened gallbladder wall and intramural cavities,which are hyperintense on the T2WI,hypointense on the

46、T1WI,and nonenhancingThe cavities represent Rokitansky-Aschoff sinuses containing fluid bile,84,Adenomyomatosis,Diffusely thickened wall and multiple cystic intramural cavities.The cavities correspond to Rokitansky-Aschoff sinuses and are filled with calculi,85,Adenomyomatous hyperplasia,F65chronic

47、right upper quadrant painmultiple,punctate,calcific opacities in the right upper quadrant,86,胆管内积气,胆管内积气，特别是由乳头切开术引起者，CT易于检出,87,先天性胆管扩张症,胆管囊状扩张症是由于先天性胆管壁发育不良、胆道不同程度梗阻，引起胆道内压增高，胆管增大形成囊状扩张按位置和形态，胆管扩张分为五种类型型为胆总管囊肿，多见，占80%90%型为胆总管憩室，占2%型为壁内段胆总管囊状膨出，占1.4%5%型为多发性肝、内外胆管囊肿，占19%型肝内胆管多发性囊肿，也称为卡罗里氏病（Carolis Di

48、sease）按发病部位分为肝外胆管囊状扩张（包括型、型、型）、肝内胆管囊状扩张（型）和肝内外胆管囊状扩张（型）,88,先天性肝内胆管囊样扩张,由Caroli于1958年首先报道，故也称为Carolis病，为先天性染色体缺陷引起。有两种类型，一种为单纯性肝内胆管扩张合并胆管炎和胆道结石，无肝硬化。另一种合并小胆管增生纤维化而致肝硬化和门脉高压，部分可能恶变Carolis病包括肝内胆管扩张、肝硬化门脉高压和囊性改变一组征候群，可单独存在或与胆总管囊肿并存本病罕见，主要见于儿童和青年。病理表现为肝内肝管囊性扩张，囊壁与肝胆管主支相通，形成交通性胆汁囊肿临床可出现腹痛、发热、黄疸,89,X线平片见肝内

49、多发小结石。PTC显示肝内胆管呈囊状扩张，左右肝叶均可受累，胆总管亦有扩张，但无明显阻塞CT显示肝内胆管囊状扩张，多呈节段性分布。平扫表现为分界清楚的条状、分支状低密度影，其内高密度影则为胆管内结石。增强扫描病变无强化，但注射胆影葡胺后病变成为分支状高密度影，可解释它与胆道系统的从属关系MR的表现与CT相似，为大小不等、边缘锐利的圆形或椭圆形长T1长T2信号。增强后无强化表现。肝内胆管扩张一般为多发性，扩张的胆管在MRCP图像上呈串珠状或藕节状高信号，彼此之间可见正常胆管与之相连US显示肝内的囊性肿物沿左右、肝管分布，呈圆形、类圆形无回声区，并与肝管相通，囊壁见边界清楚的强回声区,90,先天性

50、肝外胆管囊状扩张,先天性肝外胆管囊状扩张（choledochal cyst）病因未明，但胆管先天发育不全为主要原因胆总管囊肿系先天性胆管壁层发育不全所致，表现为胆总管呈梭形扩张，末端狭窄或胆总管呈憩室样膨出。囊性扩张可涉及胆总管的一段或全部，亦可位于胆囊管、肝管与胆总管连接处本病多见于女性儿童，男女发病比例为1:34临床可出现黄疸、腹痛，有时右上腹扪及包块,91,胆总管囊肿,X线胃十二指肠钡餐可见十二指肠弧也可扩大，胃窦压向腹侧，呈“垫压征”ERCP和PTC能显示囊肿的范围、大小、形态与正常段胆管的关系，可据此作出分型，能为手术前提供依据CT可见胆总管高度扩张，直径可达10cm或更大，管壁增厚