Radio-imagistica Colecistului Si Cailor Biliare
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Transcript of Radio-imagistica Colecistului Si Cailor Biliare
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RADIO-IMAGISTICA IN PATOLOGIA COLECISTULUI
SI CAILOR BILIARE
.©Rad/Imag-Iasi1999-2003
Catedra Radio-imagistica Catedra Radio-imagistica UMF GR.T POPA -IasiUMF GR.T POPA -Iasi
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COLECIST SI CAI BILIARECOLECIST SI CAI BILIAREMetode radio-imagisticeMetode radio-imagistice
1.RADIOGRAFIA STANDARD ABDOMINALA1.RADIOGRAFIA STANDARD ABDOMINALA
2. COLECISTOGRAFIA PER OS2. COLECISTOGRAFIA PER OS
3.ULTRASONOGRAFIA 3.ULTRASONOGRAFIA (US)(US)
4.COLANGIOGRAFIA PERCUTANA 4.COLANGIOGRAFIA PERCUTANA (CPT)(engl.PTC)(CPT)(engl.PTC)
5.COLANGIOGRAFIA- PANCREATOGRAFIA 5.COLANGIOGRAFIA- PANCREATOGRAFIA RETROGRADA ENDOSCOPICARETROGRADA ENDOSCOPICA(CPRE)(engl.ERCP)(CPRE)(engl.ERCP)
6.COLANGIOGRAFIA PER/POSTOPERATORIE6.COLANGIOGRAFIA PER/POSTOPERATORIE
7.COLESCINTIGRAFIA7.COLESCINTIGRAFIA
8.CT8.CT
9.COLANGIO-PANCREATOGRAFIA RM9.COLANGIO-PANCREATOGRAFIA RM
(CPRM)(engl.MRCP)(CPRM)(engl.MRCP)
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Radiografia ABDOMINALA STANDARD
Metoda de orientare:evidentiaza:
-calculi opaci (30%;70%=transparenti rx);
-vezicula “de portelan” (calcificari parietale);
-bila calcica (“milky bile”);
-aer in caile biliare (fistule,incompetenta Oddi)
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RADIOGRAFII STANDARD:RADIOGRAFII STANDARD:
CALCULI COLECISTICI OPACICALCULI COLECISTICI OPACI
Calcul unic,mixt: -centrul transparent Rx(colesterol); -
periferic opac (calciu)
Calculi opaci
Conglomerat litiazic
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RADIOGRAFIE ABDOMINALA STANDARDRADIOGRAFIE ABDOMINALA STANDARD
Vezicula”de portelan”Vezicula”de portelan” Aerobilie
-benzi radiotransparente dicotomizate in opacitatea hepatica
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COLECISTOGRAFIA ORALACOLECISTOGRAFIA ORALA
TEHNICA:TEHNICA:-s.contrast administrata -s.contrast administrata per osper os cu 12-16 ore cu 12-16 ore
inainte de radiografiereinainte de radiografiere (Razebil,Endocistobil,ac.iopanoic). (Razebil,Endocistobil,ac.iopanoic).
-Radiografia hipoc dr.-Radiografia hipoc dr.
-Prînz colecistokinetic -Prînz colecistokinetic (BOYDEN);(BOYDEN);
-radiografii seriate la 15’,30’,45’,60’.-radiografii seriate la 15’,30’,45’,60’.
METODA ESTE TOT MAI RAR FOLOSITAMETODA ESTE TOT MAI RAR FOLOSITA
(metoda “istorica”);(metoda “istorica”);
In prezentIn prezent -INLOCUITA DE ULTRASONOGRAFIE.-INLOCUITA DE ULTRASONOGRAFIE.
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COLANGIO-COLECISTOGRAFIA
Definitie:opacefiere cu contrast iodat hidrosolubil injectat intravenos a cailor biliare si colecistului.
Substante de contrast:-Iodipamida-(Biligrafin-Schering AG;)-dimer acid care ,injectat I.v. se elimina preferential prin bila;Iotroxat-meglumina(Biliscopin-Schering AG)-cu eliminare biliara mai crescuta si tolernta buna,
Tehnica:se administreaza in perfuzie I.v. 0,5ml/kgcorp.
-se executa radiografii hipocondrul drept
la 10,15,20,30 minute dupa sfirsitul infuziei.
Contraindicatii:icter,insuficienta hepatica,uremie.
METODA ESTE RAR FOLOSITA-SE PREFERA US SI MRCP –METODE NOI, NEINVAZIVE.
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COLECISTOGRAFIE PER OS:
A)NORMALA =>contractie dupa prinz Boyden
B),C).:LITIAZA VEZICULARA:
calculi transparenti Rx.
cistic
coledoc
duoden
Calculi”plutitori” (colesterol,mici)
Calculi mari radiotransparenti
A
B
C
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ULTRASONOGRAFIA (US)
METODA DE ELECTIE PENTRU EXAMENUL COLECISTULUI SI CAILOR BILIARE.ARE AVANTAJUL VIZUALIZARII DIRECTEARE AVANTAJUL VIZUALIZARII DIRECTE A: A: -peretilor,continutului colecistului.; -peretilor,continutului colecistului.;
-caii bilare principale si -caii bilare principale si - ficatului,pancreasului- cu posibile leziuni asociate;- ficatului,pancreasului- cu posibile leziuni asociate;
--primul examen in examinarea pacientilor cu icter;primul examen in examinarea pacientilor cu icter;
-metoda rapida,fara pregatire,in urgente=>colica biliara;-metoda rapida,fara pregatire,in urgente=>colica biliara;
-ieftina;-ieftina;
-rezolva > de 90% din patologia colecistului si c.biliare.-rezolva > de 90% din patologia colecistului si c.biliare.
DEZAVANTAJDEZAVANTAJ :metoda este operator –dependenta, :metoda este operator –dependenta, acuratetea depinde de calitatea/calificarea medicului acuratetea depinde de calitatea/calificarea medicului exaaminator. exaaminator.
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US:COLECISTITA ACUTA ALITIAZICA
SEMIOLOGIE: -perete gros,dedublat; -continut lichidian neomogen,sedimentat decliv,reflectogen (puroi,bila groasa-”noroi biliar”).
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USUS:HIDROPS VEZICULAR,COLECISTITA ACUTA:HIDROPS VEZICULAR,COLECISTITA ACUTA
SEMIOLOGIE: -marire volum -perete mult ingrosat -sediment gros,neomogen
puroi
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US:ABCES HEPATIC SECUNDAR COLECISTITEI ACUTE
A
SEMIOLOGIE COLECIST: -colecist voluminos; -continut reflectogen(puroi,calculi); -perete gros,interfata stearsa in patul vezicular;
ABCES HEPATIC: -zona hipoecogena neomogena,cu halou reflectogen in contaat cu capsula in patul vezicular
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US COLECIST:
A)COLECISTITA ACUTA ALITIAZICA
B)LITIAZA CU MICROCALCULI
A B
SEMIOLOGIE: -imagini intens reflectogene -mobilizabile cu postura; -vid sonic posterior
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ULTRASONOGRAFIE ,MOD B:
LITIAZA COLECISTICA
“Conuri de umbra”
SEMIOLOGIE: -imagini intens reflectogene -mobilizabile cu postura; -vid sonic posterior (“conuri “)
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US:LITIAZA COLECIST;
CALCUL UNIC,GIGANT
Vid sonic posterio
calcul
FICAT
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US;LITIAZA VEZICULARA;
COLECIST NEFUNCTIONAL
SEMNUL RAPTOPOULOS
SEMIOLOGIE: -colecist “ocupat”-fara lichid; -semiluna reflectogena si - vid sonic posterior masiv
Vid sonic
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US:CANCER VEZICULAR
SEMIOLOGIE: -masa reflectogena intraveziculara; -acolata parietal,baza larga de implantare; -impedanta acustica similara ficatului; -FARA VID SONIC POSTERIOR !
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US:STAZA VEZICULARA IN ICTER OBSTRUCTIV
SEMIOLOGIE: -vezicula dilatata(clinic nedureroasa la palpare cu traductorul)-semn COURVOISIER-TERRIER; -impedanta acustica crescuta,neomogenitate a continutului lichidian (“desicare” a bilei stagnante); - microzone hiperreflectogene=cristale colesterol
Dg.:cancer pancreas cefalic
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Colestaza extrahepatica(ICTER OBSTRUCTIV)
Colestaza extrahepatica(ICTER OBSTRUCTIV)
SEDIU OBSTACOL SEMNE US ETIOLOGIE
INTRAHEPATIC -cbih dilatate/asimetric -CHH -VB absenta/mica -hepatom
-coledoc normal -metastaze
-FEH prezenta -abces(e)
CBP- SUPRACISTIC -cbih dilat.simetric -colangiocarc.
-VB absenta;coled.N -adenop.hil -Tum/ggl.in hil ….cauta pancr,stom,LM
CBP-INFRACISTIC -VB MARE -Ca.Panc./CB
-CB I/eH dilatate -litiaza,Oddita
-”dublu canal”- -pseudochistANAST.BILI-ENTERALA -tum/calculi in CBP -adenopatii
SEDIU OBSTACOL SEMNE US ETIOLOGIE
INTRAHEPATIC -cbih dilatate/asimetric -CHH -VB absenta/mica -hepatom
-coledoc normal -metastaze
-FEH prezenta -abces(e)
CBP- SUPRACISTIC -cbih dilat.simetric -colangiocarc.
-VB absenta;coled.N -adenop.hil -Tum/ggl.in hil ….cauta pancr,stom,LM
CBP-INFRACISTIC -VB MARE -Ca.Panc./CB
-CB I/eH dilatate -litiaza,Oddita
-”dublu canal”- -pseudochistANAST.BILI-ENTERALA -tum/calculi in CBP -adenopatii
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Colangiografia percutanaCPT=Colangiografie Percutana Transhepatica = -metoda de opacefiere directa a cailor biliare intra/extrahepatice,prin punctie ghidata radio-imagistic
Indicatii:icter obstructiv;numai dupa dg. US !(cai biliare dilatate);preferabil dupa decizia de drenaj percutan nechirurgical,ghidat imagistic; Contraindicatii:ascita mare,diateze hemoragice Tehnica:-reperaj US/fluoroscopic;
-anestezie intercostala spatiul X-XI (xilina 1%);
-punctie cu ac fin,din otel superflexibil,0,6 mm diam(22Gauge (tipCHIBA);
-injectie contrast iodat-opacefierea cailor biliare;-radiografii/fluoro digitale;
CPT se practica ca prim-timp al tehnicilor de DRENAJ BILIAR/ENDOPROTEZARE A c.biliare.
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COLANGIOGRAFIA PERCUTANA TRANSHEPATICA
-TEHNICA-
Ac CHIBA
VB
Segm.VI
AVANTAJELE CPT: -vizualizare perefecta a c.biliare; -localizarea sediului obstructiei biliare; -precizarea naturii obstacolului (70%)
Tehnica de Radiol. Interventionala: -punctie percutana transhepatica cu ac fin a unui canal biliar dilatat si injectare de contrast iodat hidrdolubil,sub control fluoroscopic
Vezi si cap.”Rad.Interventionala”!
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Cl.rad.imag.-IasiCl.rad.imag.-Iasi
USUS:Boala Caroli:Boala Caroli:megacoledoc,-cai biliare cu :megacoledoc,-cai biliare cu dilatatii congenitale pseudochisticedilatatii congenitale pseudochistice
SEMIOLOGIE: -imagini lichidiene fuziforme, interconectate,intra-extrahepatice, reprezentind cai biliare malformate –transformate chistic.
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acac
acac
calculicalculi
Cl.radimag.Iasi
ColangiografieColangiografiePercutana TranshepaticaPercutana Transhepatica(CPT)(CPT)
Clinic:ICTER OBSTRUCTIV
Boala CaroliBoala Caroli:megacoledoc,-cai biliare cu :megacoledoc,-cai biliare cu dilatatii congenitale pseudochisticedilatatii congenitale pseudochistice
Coledoc gigant
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Cl.rad.imag.Iasi
calculicalculi
calculicalculi
Litiaza CBPLitiaza CBP
US –ICTER OBSTRUCTIV
SEMIOLOGIE: -coledoc dilatat(“dublu canal”); -stop coledoc aspect de cupa(concav); -calcul reflectogen+con umbra posterior
Clinic:ICTER OBSTRUCTIV
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CPTCPT
calculicalculi
Cl.rad/imag. IasiCl.rad/imag. Iasi
CPT: Litiaza canalara
SEMIOLOGIE: -lacune in popacifierea c.biliare; -stop complet cupuliform (calcul anclavat)
Clinic:ICTER OBSTRUCTIV
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acac
cycy
cy
cycy
CBP
Coledoc
Cl.radiol..IasiCl.radiol..Iasi
Pancreatita;pseudochist cefalic
PUNCTIE PERCUTANA ecoghidata,cu ac fin
US:compresiunea coledocului prin pseudochist pancreas cefalic(formatie expansiva transsonica)
Sectiune longitudinala
Sectiune transversala
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USUS:CHIST HIDATIC:CHIST HIDATIC
fisurat in cai biliare: in cai biliare: -chistul cu membrane -chistul cu membrane decolate,plicaturate; decolate,plicaturate; -material hidatic in calea -material hidatic in calea biliara principalabiliara principala
C.biliara obstruata
Cl.Cl.radiologica.Iasi.Iasi
ICTER OBSTRUCTIV secundar post-hidatic
Fistula biliara
chist
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Limfom non-hodgkinLimfom non-hodgkin
US:ICTER OBSTRUCTIV prin compresiune/invazie a caii biliare principale data de adenopatii in hilul hepatic
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CPT
T
TCBPCBP
acac
Cl.rad..IasiCl.rad..Iasi HEPATOM cu invazia cailor biliare in placa hilara HEPATOM cu invazia cailor biliare in placa hilara
ICTER OBSTRUCTIV NEOPLAZIC: -CPT:cai biliare stenozate la convergenta; -US:masa parenchimatoasa solida cu halou hipoecogen in hilul hepatic
tum
US
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ColedocColedoc
Colecist tumoral
Cl.rad..IasiCl.rad..Iasi
US:CARCINOM COLECISTIC cu invazia caii biliare
Clinic:ICTER OBSTRUCTIV
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drenaj biliar percutan transhepatic -extern
- intern transtumoral endoprotezare biliarã percutanã :
-proteze material plastic; -proteze metalice
drenaj biliar percutan transhepatic -extern
- intern transtumoral endoprotezare biliarã percutanã :
-proteze material plastic; -proteze metalice
METODE de Rad.Interventionala.Icter obstructiv neoplazic:
Vezi si cap.”Rad.Interventionala”!
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Drenaj biliar percutan transhepatic:Indicatii:-cai biliare dilatate (US); -caz inoperabil tehnic,riscuri majore; -icter recidivat dupa interv.chir;Contraindicatii:-metastaze hepatice; -diateza hemoragice necorectata;
-ascita cantitate mare -alergie majora(s contrast iodata)
Drenaj biliar percutan transhepatic:Indicatii:-cai biliare dilatate (US); -caz inoperabil tehnic,riscuri majore; -icter recidivat dupa interv.chir;Contraindicatii:-metastaze hepatice; -diateza hemoragice necorectata;
-ascita cantitate mare -alergie majora(s contrast iodata)
METODE deRad.Interventionala.Icter obstructiv neoplazic:
Vezi si cap.”Rad.Interventionala”!
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Drenaj biliar percutan transhepatic:
Tehnica:-colangiografie perutana ac fin(ghidata ecografic &/fluoroscopic;
-punctie ac-cateter si fir ghid in calea biliara ;
-extragere ac si introducere cateter-dren cu orificii multiple in calea biliara: -pretumoral(drenaj extern-bila colectata) sau -transtumoral(drenaj intern-bila trece in duoden).
Rezultate:-diminuarea/disparitia icterului (scade bilirubina) ,disparitia pruritului ,ameliorarea starii generale; Complicatii:-hematom ,dislocare cateter,hemobilie
Drenaj biliar percutan transhepatic:
Tehnica:-colangiografie perutana ac fin(ghidata ecografic &/fluoroscopic;
-punctie ac-cateter si fir ghid in calea biliara ;
-extragere ac si introducere cateter-dren cu orificii multiple in calea biliara: -pretumoral(drenaj extern-bila colectata) sau -transtumoral(drenaj intern-bila trece in duoden).
Rezultate:-diminuarea/disparitia icterului (scade bilirubina) ,disparitia pruritului ,ameliorarea starii generale; Complicatii:-hematom ,dislocare cateter,hemobilie
METODE deRad.Interventionala.Icter obstructiv neoplazic:
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V.biliara V.biliara dilatatadilatata
ColedocColedoc
TUTU
Cl.rad..Iasi
pancreaspancreas
US:ICTER OBSTRUCTIV NEOPLAZIC prinCANCER de PANCREAS CEFALIC
SEMIOLOGIE: -colecist dilatat; -coledoc dilatat -stop coledocian cu aspect stenotic; -nodul hipoecogen pancreas cefalic
Semnul Courvoisier-Terrier
STOP
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catetercateter
Drenaj percutan transhepatic extern
coledoccoledoc
Cl.rad..IasiCl.rad..Iasi
Rad.Interventionala in icterul obstructiv neoplazic:carcinom de pancreas cefalic
Ultrasonografie
Colangiografie percutana
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Cancer pancreasCancer pancreas
DRENAJ INTERN transtumoral
Cl.rad..IasiCl.rad..Iasi
Fir ghidFir ghid Foraj transTUForaj transTU
Rad.Interventionala in icterul obstructiv neoplazic:carcinom de pancreas cefalic
Cateter in duoden
Ultrasonografie
1
2
3
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US:Colangiocarcinom de cai biliare:US:Colangiocarcinom de cai biliare: indicatie majora indicatie majora pentru drenaj biliar si endoprotezare a cailor biliarepentru drenaj biliar si endoprotezare a cailor biliare
Cl.rad..IasiCl.rad..Iasi
Convergenta canale hepatice
Stenoza c.hepatic comun Masa intracanalara-coledociana
Nodul tumoral reflectogen
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Colangiocarcinom de convergenta: Colangiocarcinom de convergenta: -stenoze; -stenoze;-amputatie c.hepatic stang-amputatie c.hepatic stang
Colangiografie Percutana TranshepaticaColangiografie Percutana Transhepatica
Cl.rad.IasiCl.rad.Iasi
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Drenaj percutan Drenaj percutan intern- transtumoralintern- transtumoral
acac
Fir ghid trans- Fir ghid trans- stenozastenoza
Dren in Dren in duodenduoden
Colangiocarcinomde convergenta
Cl.rad..Iasi
Stenoza Stenoza tumoralatumorala
Colangiografie cu ac fin
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Endoprotezare biliara Endoprotezare biliara percutana transhepaticapercutana transhepatica
Colangiocarcinom de convergentaColangiocarcinom de convergenta
11
22
33
““pusher”pusher”
fir ghidfir ghid
protezaproteza
Dren temporarDren temporar
Cl.rad..IasiCl.rad..Iasi
Cateter-tutore
protezaproteza
TEHNICA:1-proteza se introduce pe fir ghid si cateter tutore, prin impingere cu un cateter-pusher- de acelasi calibru;2.cateterul pusher se retrage dupa pozitionarea protezei sub control fluoroscopic;3.se lasa un cateter-dren extern -pe care,la 24 h,se executa opacefierea de control:contrastul trece in duoden prin proteza permeabila;se extrage drenul temporar.
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ColangiocarcinomColangiocarcinom
Endoprotezare percutana transhepaticaEndoprotezare percutana transhepatica
Foraj transtumoralForaj transtumoral
Drenaj internDrenaj internProteza + dren temporarProteza + dren temporar
Cl.rad..IasiCl.rad..Iasi
Dren temporarDren temporar
Fir ghidFir ghid
Endoprotezare biliara Endoprotezare biliara percutana transhepaticapercutana transhepatica
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Endoproteza biliara-control dupa 9 Endoproteza biliara-control dupa 9
luni d le introducereluni d le introducere
Cl.rad..IasiCl.rad..Iasi
ColangiocarcinomColangiocarcinomEndoprotezare biliara Endoprotezare biliara percutana transhepaticapercutana transhepatica
proteza
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Colangiografia endoscopica
ERCP=Endoscopic Retrograde Colangio-Pancreatography
INDICATII:-litiaza canalara obstructiva-in scopul extragerii calculilor dupa sfincterotomie prealabila;
-icterele sec.pancreatitei cronice.
TEHNICA:-cateterism retrograd=>papila Vater sub control vizual & fluoroscopic (pe masa de scopie !);
-injectie contrast iodat diluat (120 mg Iod/ml);
-floroscopie/grafii tintite,pozitii PA-OAD-OAS.
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ERCP:
ASPECT NORMAL
ENDOSCOP
WIRSUNG
COLEDOC
CATETER
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Colangiografia per/postoperatorie
PER OPERATOR:-scop:evidentiere calculi in c.b.; TEHNICA:
-cateterizare cistic,dupa colecistectomie;
-injectie contrast iodat & radiografii=>pe masa op.;
POST-OPERATOR:-injectie contrast pe tub T (KEHR);
-scop:-evid.calculi restanti.
-se practica inainte de extractia percutana a calculilor restanti in caile biliare prin tehnica de radiologie interventionala.
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COLANGIOGRAFIE PE TUB T:
CALCULI RESTANTI POSTOPERATORVezi si cap.”Rad.Interventionala”!
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COLESCINTIGRAFIA
-Injectie de preparat izotopic-Tc-99-HIDA (imino diacetic acid) i.v.; -preparatul se concentreaza in hepatocite si este excretat in bila;
-scanare cu gamacamera la intervale de 10’;
-colecistul+c.b. apar normal la 30’;
-excretia in intestin la 60’.
In ictere obstructive,pasajul in intestin este absent si la 24h.
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COLESCINTIGRAFIA DINAMICA
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COMPUTER TOMOGRAFIA
INDICATII:-icter obstructiv,in cazul esecului US(10%);
-decelarea sediului & etiol.obstacolului biliar;
-extenzia loco-regionala a cancerului VB/CB;
-decelare metastaze hepatice
TEHNICA:-examen nativ +contrast
-sectiuni pt intregul ficat ,colecist,pancreas.
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CT, contrast i.v.:CARCINOM COLECISTIC+MTS.HEPATICE
Metastaze hepatice:noduli hipodensi hepatici cu dimensiuni variabile 5-20 mm
T
Tumora p.moi in lumenul v.biliare,captind neomogen contrastul
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COLANGIOGRAFIA cu RM
MRCP=Magnetic Resonance ColangioPancreatography
METODA NOUA DE VIZUALIZARE DIRECTA
ANATOMICA PRIN RECONSTRUCTIE COMPUTE-RIZATA A COLECISTULUI SI CAILOR BILIARE
AVANTAJE:-ULTRARAPIDA & NEINVAZIVA;
-FIDELITATE ANATOMICA;
-asociere cu ex.RM a ficatului,pancreasului.
DEZAVANTAJ:-pret prohibitiv;
-accesibilitate redusa.
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IRM:COLANGIO-PANCREATOGRAFIE(MRCP)
CALCULI IN COLECIST Tumora ampulara:dilatatie a cailor biliare si c.Wirsung
T
Post-procesare MIP & 3D
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MRCP:MRCP:OBSTRUCTIE COLEDOC PRIN AMPULOM
Wirsung
coledoc
TUM
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BIBLIOGRAFIE UTILA Hepatobiliary and pancreatic radiology,imaging
and intervention. G.S.Gazelle,S.Saini,P.R.Mueller, Thieme,1998.
Ghid practic de ecografie abdominala. G.Gluhovschi,I.Sporea,,Helicon(timisoara)1999
Alimentary Tract Radiology. A.R.Margulis,H.J.Burhenne,Mosby,1994