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  分子影像学杂志  2018, Vol. 41 Issue (2): 147-151  DOI: 10.3969/j.issn.1674-4500.2018.02.03
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张遇乐, 王娜, 关步云, 陈金卫 . 婴儿先天性肝门部囊性占位的超声鉴别[J]. 分子影像学杂志, 2018, 41(2): 147-151. DOI: 10.3969/j.issn.1674-4500.2018.02.03
ZHANG Yule, WANG Na, GUAN Buyun, CHEN Jinwei . Ultrasonic differential diagnosis of infant congenital cystic mass in the hepatic hilar[J]. Journal of Molecular Imaging, 2018, 41(2): 147-151. DOI: 10.3969/j.issn.1674-4500.2018.02.03

基金项目

广东省科学技术厅自筹经费类科技计划(2017ZC0391)

作者简介

张遇乐,副主任医师,E-mail: octopus883@163.com

通信作者

王 娜,副主任医师,E-mail: 423352651@qq.com

文章历史

收稿日期:2018-01-12
婴儿先天性肝门部囊性占位的超声鉴别
张遇乐, 王娜, 关步云, 陈金卫     
广州市妇女儿童医疗中心超声科(儿童院区),广东 广州 510120
摘要目的 探讨超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值。方法 随机选取2016年6月~2017年6月我院收治的肝门区囊肿患儿31例,所有患儿均接受超声检查及手术治疗,依据手术结果将这些患儿分为囊肿型胆道闭锁组(n=15)和胆总管囊肿组(n=16),对两组患儿的肝内胆管扩张、肝门部纤维块、胆囊内胆泥沉积、胆囊形态异常、胆囊收缩不良发生情况、肝动脉内径、胆囊大小、囊肿体积进行统计分析。结果 囊肿型胆道闭锁组患儿的肝内胆管扩张、胆囊内胆泥沉积发生率0%、6.7%(1/15)均显著低于胆总管囊肿组75.0%(12/16)、50.0%(8/16)(P<0.05),肝门部纤维块、胆囊形态异常、胆囊收缩不良发生率80.0%(12/15)、86.7%(13/15)、73.3%(11/15)均显著高于胆总管囊肿组0%、6.3%(1/16)、12.5%(2/16)(P<0.05),肝动脉内径长于胆总管囊肿组(P<0.05),囊肿体积小于胆总管囊肿组(P<0.05),胆囊宽径短于胆总管囊肿组(P<0.05),但两组患儿的胆囊长径之间的差异无统计学意义(P>0.05)。结论 超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值高。
关键词:超声    先天性囊肿型胆道闭锁    胆总管囊肿    
Ultrasonic differential diagnosis of infant congenital cystic mass in the hepatic hilar
ZHANG Yule, WANG Na, GUAN Buyun, CHEN Jinwei     
Department of Ultrasound,Guangzhou Women and Children’s Medical Center, Guangzhou 510120, China
Abstract: Objective To investigate the value of ultrasound in the diagnosis of infant congenital cystic biliary atresia and choledochal cyst. Methods 31 children with cystic mass in the hepatic hilar admitted to our hospital from June 2016 to June 2017 were randomly selected, all of which received ultrasound examination and operation. Subjects were divided into cystic biliary atresia group (n=15) and choledochal cyst group (n=16) according to the surgical results. Factors including intrahepatic bile duct dilatation, fibrotic tissue around porta hepatis, the incidence of biliary sludge in the gallbladder, deformed gallbladder, contractile dysfunction of gallbladder, the inside diameter of hepatic artery, gallbladder size and cyst volume were statistically analyzed. Results The incidences of intrahepatic bile duct dilatation and gallbladder biliary sludge in the cystic biliary atresia group (0%; 6.7%, 1/15) were significantly lower than those in the choledochal cyst group (75.0%, 12/16; 50.0%, 8/16)(P<0.05); the incidences of fibrotic tissue around porta hepatis, deformed gallbladder and contractile dysfunction of gallbladder in the cystic biliary atresia group (80.0%,12/15; 86.7%, 13/15; 73.3%, 11/15)were significantly higher than that of the control group (0%; 6.3%,1/16; 12.5%, 2/16) (P<0.05). In the choledochal cyst group, the inside diameter of the hepatic artery was significantly longer than that of the common bile duct cyst (P<0.05), but there was no significant difference in the length of the gallbladder(P>0.05). Conclusion The application of ultrasound in the identification of congenital cystic biliary atresia and choledochal cyst has high value.
Key words: ultrasound     congenital cyst type biliary atresia     choledochal cyst    

8%~11%的胆道闭锁伴肝门部囊肿为囊肿型胆道闭锁[1]。胆总管囊肿属于一种小儿外科疾病,和囊肿型胆道闭锁具有相似的临床表现[2]。这两种疾病具有完全不同的手术方式及预后,因此临床很有必要有效鉴别诊断以黄疸为表现的肝门部囊性病变——囊肿型胆道闭锁和胆总管囊肿[3]。但是,现阶段,临床还没有相关医学研究显示确切有效的鉴别和诊断囊肿型胆道闭锁和胆总管囊肿的方法[4]。为了将有效诊断依据提供给临床,提高对先天性囊肿型胆道闭锁与胆总管囊肿的鉴别,本研究采用多方面比较,探讨了超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值,现报道如下。

1 资料与方法 1.1 一般资料

随机选取2016年6月~2017年6月广州市妇女儿童医疗中心收治的肝门区囊肿患儿31例。纳入标准:所有患儿均经超声检查发现肝门区囊肿,均接受超声检查及手术治疗。排除标准:将有手术禁忌症等患儿排除在外。依据手术结果将这些患儿分为囊肿型胆道闭锁组(n=15)和胆总管囊肿组(n=16)两组。囊肿型胆道闭锁组患儿中男性10例,女性5例,年龄23~67 d(35.2±5.4 d);胆红素150~214 μmol/L(182.2±32.5 μmol/L);直接胆红素112~158 μmol/L(135.2±23.9 μmol/L)。在手术类型方面,肝门空肠吻合术14例,肝移植术1例。胆总管囊肿组患儿中男12例,女4例,年龄33~72 d(44.5±10.2 d);胆红素151~214 μmol/L(192.8±32.4 μmol/L);直接胆红素113~158 μmol/L(145.6±23.2 μmol/L)。在手术类型方面,胆总管囊肿、胆囊切除+肝总管-空肠Roux-en-Y吻合术16例,其他0例。两组患儿的一般资料比较差异均无统计学意义(P>0.05,表1),具有可比性。

表1 两组患儿的一般资料比较[n(%)]
1.2 方法

采用SIEMENS ACUSON 2000型彩色多普勒超声诊断仪,将探头频率设定为3.5~12 MHz,对患儿肝门区囊肿形态、胆囊形态、餐前后胆囊变化等进行观察,对囊肿大小进行测量,将囊肿体积计算出来,计算方法为长与宽平方的一半或长、宽、高之积与π/6的乘积[5],将囊肿内胆泥沉积情况进行记录,对门静脉右支前方存在其厚度在4 mm及以上的高回声条索进行观察。将囊肿壁厚度分界点设定为1 mm。如果胆囊长径在19 mm以下或呈痕迹样,缺乏规则的形态,胆囊粘膜层缺乏光整的回声,胆囊壁具有较低的清晰度,则评定为胆囊形态异常。依据餐前后胆囊前后径变化将胆囊收缩率计算出来,计算方法为餐后与餐前胆囊前后径之比的百分率,胆囊收缩功能不良的评定标准为胆囊收缩率在50%以下[6]

1.3 统计学分析

采用SPSS21.0统计学软件,两组患儿的肝内胆管扩张、肝门部纤维块、胆囊内胆泥沉积、胆囊形态异常、胆囊收缩不良发生情况等计数资料用率表示,用 $\,\,{\chi ^2}$ 检验;两组患儿的肝动脉内径、胆囊大小、囊肿体积等计量资料用均数±标准差表示,组间比较使用t检验,P<0.05为差异有统计学意义。

2 结果 2.1 两组患儿的肝内胆管扩张、肝门部纤维块、胆囊内胆泥沉积、胆囊形态异常、胆囊收缩不良发生情况比较

囊肿型胆道闭锁(图1A)组患儿的肝内胆管扩张、胆囊内胆泥沉积(图2)发生率0%、6.7%(1/15)均低于胆总管囊肿(图1B)组75.0%(12/16)、50.0%(8/16)(P<0.05),肝门部纤维块(图3)、胆囊形态异常(图4)、胆囊收缩不良发生率80.0%(12/15)、86.7%(13/15)、73.3%(11/15)均高于胆总管囊肿组0、6.3%(1/16)、12.5%(2/16)(P<0.05,表2)。

表2 两组患儿的肝内胆管扩张、肝门部纤维块、胆囊内胆泥沉积、胆囊形态异常、胆囊收缩不良发生情况比较[n(%)]
图 1 囊肿型胆道闭锁(A)及胆总管囊肿(B)超声声像图
图 2 胆囊内胆泥沉积
图 3 肝门部纤维块
图 4 胆囊形态异常
2.2 两组患儿的肝动脉内径、胆囊大小、囊肿体积比较

囊肿型胆道闭锁组患儿的肝动脉内径长于胆总管囊肿组(P<0.05),囊肿体积小于胆总管囊肿组(P<0.05),胆囊宽径短于胆总管囊肿组(P<0.05),但两组患儿的胆囊长径之间的差异无统计学意义(P>0.05,表3)。

表3 两组患儿的肝动脉内径、胆囊大小、囊肿体积比较(Mean±SD)
3 讨论

胆道闭锁属于一种先天肝内外胆管闭锁性疾病,目前,临床还没有明确其病因,肝门空肠吻合术是临床的首选治疗方法,但是一些患儿发现时已经有胆汁性肝硬化发生或术后有肝衰竭、门脉高压发生,需要给予其肝移植手术。而胆总管囊肿是一种胆道远端梗阻,诱发因素为先天发育畸形,会继发近端胆道囊状扩张,临床采用的有效治疗方法为胆总管囊肿、胆囊切除+肝总管-空肠Roux-en-Y吻合术,患儿具有良好的预后[7]。通常情况下,肝内外胆管闭锁是胆道闭锁的主要临床表现,超声下无法将肝门区胆总管显示出来,有肝门区纤维块等表现,临床较易鉴别其和胆总管囊肿,但是有一特殊类型胆道闭锁有囊肿远端闭锁、胆总管囊状扩张,超声图像中该类胆道闭锁有肝门区囊性肿物,特别是在病程早期,临床缺乏充足的实验室检查证据,患儿缺乏典型的临床表现,超声医师发现囊性肿物后首先考虑是胆总管囊肿,可能会造成临床医师对患儿病情进行错误判断,采取不合适的手术方法[8]

相关研究表明,囊肿型胆道闭锁和胆总管囊肿的体积分别为2.54±0.30 cm3、56.05±10.78 cm3,前者显著小于后者[9]。囊肿型胆道闭锁患儿具有较厚的囊壁,胆总管囊肿具有较薄的囊壁。发生这一现象的原因为胆汁在肝内胆管闭锁的情况下无法从胆管系统通过向胆总管进入,同时远端胆总管闭锁,局部呈囊状扩张的胆总管只在门静脉前方分布,手术过程中通常发现有少量乳白色液体存在于囊状扩张胆总管内,称“胆汁湖”,因此,囊肿具有较小的体积。会有纤维化改变出现在闭锁的胆总管壁组织上,因此囊壁较厚。而管壁的支撑组织有先天性缺损存在,或有异位胰腺组织存在于管壁的支撑组织,使管壁支撑力不足,提供给了先天性胆总管囊肿发生的良好基础条件,胆汁从肝内胆管系统排入后在薄弱的胆总管内聚集,促进薄壁囊肿的形成,因此具有较大的体积。研究表明,在胆道闭锁的诊断中,胆总管闭锁的超声特征“三角索带征”具有96%~100%的特异度[10]。囊肿型胆道闭锁具有异常的胆囊形态学,缺乏良好的胆囊收缩功能,和胆总管囊肿相比,其具有显著较高的肝门部纤维块发生率[11]。在胆道闭锁的诊断中,胆囊“三联征”是超声最有用的征象,即胆囊长径在19 mm以下,缺乏清晰的胆囊壁,同时缺乏光滑的粘膜层、规则的胆囊或胆囊较小[12]。相关医学研究表明[13],在胆道闭锁的诊断中,餐后胆囊收缩功能不良达到了87.8%的灵敏度和89.4%的特异度,以此认为在胆道闭锁的诊断中,胆囊收缩不良、胆囊形态学异常、肝门区纤维块一方面灵敏度及特异度均较高,另一方面还能够对囊肿型胆道闭锁与胆总管囊肿进行有效的鉴别。

相关医学学者对囊肿型胆道闭锁和胆总管囊肿患儿的超声图像进行了回顾性分析[14-18],结果表明,和胆总管囊肿患儿相比,囊肿型胆道闭锁患儿具有显著较低的胆囊内胆泥沉积及肝内胆管扩张发生率。由于有胆汁存在于胆总管囊肿患儿的胆总管囊肿中,具有较长的存留时间,没有将胆汁及时排除,极易有胆泥沉积的现象发生,而囊肿型胆道闭锁在没有合并胆管炎时极少出现。因此,在囊肿型胆道闭锁和胆总管囊肿的鉴别,上述指标能够将有效依据提供给临床。基于此,超声扫查发现肝门区具有较小的体积,特别是如果囊肿体积在2.5 cm×2.5 cm×2.5 cm以下,具有较厚的囊壁,则应该考虑可能为胆道闭锁,应该将肝门区纤维块存在情况、肝内胆管内径、餐前后胆囊变化、胆囊大小及形态等超声表现有机结合起来,同时将其和临床资料有机结合起来,从而将最后的诊断做出来。囊肿型胆道闭锁具有较小的肝门区囊肿体积、较厚的囊壁、异常的胆囊形态,和胆总管囊肿相比具有较高的胆囊收缩不良发生率,而胆总管囊肿具有较大的肝门区体积、较薄的囊壁,和囊肿型胆道闭锁相比具有较高的肝内胆管扩张、囊肿内胆泥沉积发生率[19-25]。本研究结果表明,囊肿型胆道闭锁组患儿的肝内胆管扩张、胆囊内胆泥沉积发生率均低于胆总管囊肿组(P<0.05),肝门部纤维块、胆囊形态异常、胆囊收缩不良发生率均高于胆总管囊肿组(P<0.05),肝动脉内径长于胆总管囊肿组(P<0.05),囊肿体积小于胆总管囊肿组(P<0.05),胆囊宽径短于胆总管囊肿组(P<0.05),但两组患儿的胆囊长径之间的差异无统计学意义(P>0.05),和上述相关医学研究结果一致。总之,超声用于鉴别先天性囊肿型胆道闭锁和胆总管囊肿的应用价值高,值得推广。

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