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。     

成人原位肝移植术后常见胆道并发症的诊疗

肝移植已成为治疗终末期肝病的有效方法,由于外科技术、供者选择、器官保存和运输、免疫抑制药、围手术期管理的长足发展,肝移植总体手术并发症明显下降,但胆道并发症发生率仍处于较高水平。当前,肝移植术后胆道并发症仍是导致移植物失功的重要原因,关于胆道并发症的发病机制及诊治仍存在争议,也是近年来器官移植领域的研究热点。本文尝试对成人原位肝移植术后胆道并发症的新突破和进展进行总结,为进一步解决胆道并发症相关临床问题提供理论基础。     

磁共振胰胆管成像在胆总管结石方面的临床应用价值

目的 探讨磁共振胰胆管成像(MRCP)在胆石症病人中的临床应用价值。方法 通过对87例术前行MRCP检查的胆石症病人和66例术前未行MRCP检查的胆石症病人的对比研究，比较两组术后胆道残石的发生率和胆道阴性探查率。结果 发现在有胆道相对探查指征的病人中，术前MRCP检查的阴性率为23％，术后残石率为1．5％，胆道阴性探查率为0；而未行MRCP检查的胆石症病人的残石率为9．1％，胆道阴性探查率为18．2％。结论术前MRCP检查可降低胆道阴性探查率，避免不必要的胆道探查，还可降低胆道残石发生率。     

MRI、CT诊断老年患者恶性梗阻性黄疸的差异

目的比较磁共振影像、CT两种影像学手段诊断恶性梗阻性黄疸的差异。方法选择经过磁共振影像（MRI、MRCP）、CT检查并经过病理证实为恶性梗阻性黄疸患者42例，分析两种影像学对于梗阻部位和疾病定性判定的准确性。结果MRI结合MRCP判定病变部位的准确率为：95．24％（40／42）；CT的准确率为：78．57％（33／42）。Mm（MRCP）、CT超判定疾病的准确率分别为：92．86％（39／42），83．33％（35／42）。两种影像学在定位方面具有统计学差异（x^2定位=5．124，P〈0．05），但在定性方面则不具有统计学差异（x^2定位=1．848，P〉0．05）。结论MRI（结合2维、3维的MRCP）判定疾病部位的准确率最高，CT则快速、方便，在临床上应结合不同的患者的实际情况进行不同的检查。如果二者结合判断梗阻性黄疸的病因十分精确。     

MRCP in the diagnosis of iatrogenic bile duct injury

Postoperative biliary tract lesions are becoming increasingly common. The diagnosis is made by direct cholangiography via endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). The present comparative study evaluates the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in application to iatrogenic bile duct injury. A prospective blind study was performed, contrasting MRCP and ERCP in 10 patients with suspected postoperative biliary tract lesions. MRCP was performed less than 72 h before ERCP. Final diagnosis was made on the basis of findings at surgery and ERCP. The presence of biliary dilatation, excision injury, stricture, fluid collection and free fluid was analyzed. The mean patient age was 66.5 years. There were three males and seven females. The type of postoperative lesion (Bergman classification) are five patients type C, three type D, one type B and one type A. Diagnostic failure was recorded in two cases with ERCP, while in five patients it was unable to define a therapeutic approach. In contrast, MRCP correctly diagnosed all patients. MRCP is effective in diagnosing postoperative biliary tract lesions, and can help decide the best therapeutic approach.     

肝外胆管梗阻病变MSCT曲面重建胆管成像与MRCP的比较研究

目的比较多层螺旋CT（MSCT）曲面重建（CPR）胆管成像与磁共振胰胆管成像（MRCP）对肝外胆管梗阻病变的诊断价值。方法66例经B超检查提示有肝外胆管梗阻病变的患者，采用单次激发快速自旋回波（SSFSE）序列，行MRCP检查，同期采用10mm层厚层距，使用血管对比剂，行MSCT增强扫描，将门静脉期图像采用2．5mm层厚、1．25mm层距重建，获得轴面源像（ASI），数据传输至图像工作站，作CPR胆管成像。比较CPR胆管成像、MRCP对肝外胆管梗阻病变的定位、定性诊断价值。结果CPR胆管成像、MRCP成功率为100％；CPR胆管成像、MRCP均对肝外胆管梗阻部位做出明确诊断，定位诊断率为100％；CPR胆管成像、MRCP定性诊断率分别为95．5％和80．9％。结论CPR胆管成像、MRCP对肝外胆管梗阻病变均能明确定位，CPR胆管成像定性诊断率明显高于MRCP，CPR胆管成像显示胆管及其周围病变与扩张胆管的关系更直观。     

中场磁共振胰胆管成像的临床应用研究

目的　研究中场磁共振胰胆管成像 (MRCP)对胆胰疾病的诊断价值。方法　对 12 5例患者进行检查 ,获得单纯MRCP(sMRCP)及联合MRCP(cMRCP)诊断结果 ,并与B超对比分析。结果　cMRCP、sMRCP及B超对胆胰管梗阻诊断敏感性及梗阻部位诊断符合率均很高 ,且相互间无显著性差别 (P >0 .0 5 ) ;对病灶数诊断符合率依次为 88.8%、5 8.9%及5 7.0 % ,与cMRCP相比均有高度显著性差别 (P <0 .0 1) ;对恶性肿瘤性梗阻诊断准确性分别为 97.6%、89.6%及 89.6% ,与cMRCP相比均有高度显著差别 (P <0 .0 1)。结论　中场cMRCP对胆胰管梗阻病因学诊断明显优于sMRCP及B超。     

Intraductal papillary adenoma: Usefulness of magnetic resonance cholangiopancreatography in the diagnosis of cystic branch-duct dilatation of the pancreas

A 70-year-old woman with gastric cancer was referred to our hospital for further evaluation of a cystic mass in the head of the pancreas. Endoscopic ultrasonography (EUS) showed a mural nodule in the cystic mass. Endoscopic retrograde cholangio pancreatography (ERCP) revealed a cystic lesion with a filling defect caused by obstruction with mucus. Magnetic resonance cholangiopancreatography (MRCP) allowed visualization of the entire configuration of the cystic lesion despite the presence of mucus. Pancreatic juice was positive for K-ras point mutation. Pancreatoduodenectomy was performed, with a diagnosis of intraductal papillary adenoma or adenocarcinoma with gastric cancer. Pancreatography of the resected specimen showed a cystic lesion in the uncinate process, consistent with the MRCP findings. Histological examination revealed an intraductal papillary adenoma. MRCP is very useful for demonstrating the total configuration of cystic lesions and is not impeded by impacted mucin. Nevertheless, because of its lower spatial resolution, this noninvasive modality is of limited value in detecting mural nodules. At present, therefore, surgical indications for cystic lesion of the pancreas should be determined by comprehensively analyzing: size and sequential changes in size of the cyst; presence of mural nodules, cytologic examination for presence of malignant cells, and/or K-ras point mutation in pure pancreatic juice.     

MRI平扫及MRCP显示十二指肠乳头腺癌合并胆道梗阻的研究

目的：分析与探讨MRI平扫及MRCP显示十二指肠乳头腺癌合并胆道梗阻的应用价值。方法选取100例2013年2月—2014年8月在该院接受诊断的十二指肠乳头腺癌合并胆道梗阻患者,以随机方式将其平均分为两组,即：对照组与观察组,对对照组患者实施常规诊断,对观察组患者实施MRI平扫及MRCP检查。两组患者诊断结果和病例相对照。结果对照患者病例,观察组患者病变诊断准确率为90.0%,对照组患者病变诊断准确率为50.0%,观察组明显优于对照组,差异有统计学意义(P<0.05)。结论研究表明,MRI平扫及MRCP能够有效显示十二指肠乳头腺癌合并胆道梗阻,该诊断方式对选择临床治疗方式具有重要价值,值得临床应用与推广。