1001117_eus_hepatobiliary & gu system
TRANSCRIPT
EUS教學
Hepatobiliary & GU System
陳國智醫師
新光醫院急診醫學科
輔仁大學醫學系
中華民國醫用超音波學會指導醫師
1
臨床情境
• 65歲男性，突發性左側腰痛30分鐘，Severity 9/10，從左腰痛到左側睪丸處
• 請問你該怎麼辦 ?
• 急診超音波在此能提供什麼幫忙?
臨床情境
• 49歲女性，糖尿病患者，發燒及左側腰痛二週，診所診斷為泌尿道感染，但患者對於口服抗生素反應不佳
• 請問你該怎麼辦 ?
• 超音波在泌尿道感染能提供什麼幫忙?
正常的腎臟解剖及
超音波影像認識
[重要]
泌尿道系統包含雙側腎臟 + 膀胱
任何重點掃描都應包含兩個互補介面
Compartments of the retroperitoneum
Anatomic relationship of the kidneys
Overview of kidney anatomy
正常的腎臟解剖位置
• 腎臟位在後腹腔，T12 - L4
• 右腎低於左腎
• 右腎在肝和膽的後/下方
• 左腎在脾的內/下方
• 腎上腺在腎臟的上/前/內側
Overview of kidney anatomy
• 長: 9-13 cm; 寬: 4-6 cm; 厚: 2.5-3.5 cm
• Gerota’s fascia: – 包覆kidney, capsule, perinephric fat
• Sinus – Hilum: vessels, nerves, lymphatics, ureter
– Pelvis: major and minor calyces
• Parenchyma surrounds the sinus – Cortex: site of urine formation, contains nephrons
– Medulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids
Longitudinal ultrasound view of the
normal right kidney
Transverse ultrasound view of the
normal right kidney
Normal left kidney
Normal filled urinary bladder
Male Pelvis
Prostate Enlargement
Longitudinal images of normal right kidney
Transverse image of normal right kidney
腎臟之超音波影像
• 正常情況下看不到輸尿管 (Ureters)
• Pelvis: 看的到的時候呈現黑色影像
• Sinus: 因為脂肪所以呈現白色 (echogenic)
• Medullary pyramids: hypoechoic
• Cortex:
– mid-gray, less echogenic than liver or spleen.
• Capsule: smooth and echogenic
重點式急診泌尿系統超音波
掃描注意事項
• 病患準備:
– 無
• 探頭: 3.0 ~ 3.5 MHz
– 瘦的人: 5.0 MHz
• 病患姿勢
– 平躺 (Supine)
– Posterior oblique,
lateral decubitus,
prone
I
LIVER STOMACH
IVC AORTA
K K
S
重點式急診泌尿系統超音波之應用
?
Clinical indications for EUS
• Acute flank pain/suspected renal colic
• Acute urinary retension
• Bladder size estimation
• Acute renal failure
• Complicated UTI (APN & renal abscess)
• Trauma
Acute flank pain/
suspected renal colic
EUS重點:
懷疑有obstruction時
排除AAA時
Acute flank pain/suspected renal colic
• 急性腹/腰痛和血尿的評估 – 懷疑腎絞痛 (renal colic)
– s/s: 腰陣痛合併鼠蹊部轉移
– 診斷工具: IVP v.s. US v.s Helical CT
• EUS的重點: – 有無阻塞，如hydronephrosis (2K1B都要掃)
– 要會辨識stone在超音波下的影像
– > 50y/o, 需同時排除AAA
• 進階掃描: – 阻塞物之定位及合併症
Overview of degrees of hydronephrosis
Mild Hydronephrosis
Moderate Hydronephrosis
Severe Hydronephrosis
Hydronephrosis with
acute calyceal rupture
Dilated ureter below bladder
(transverse view)
Algorithm
for renal colic
Renal stone
EUS重點:
Hyperdense lesion with acoustic shadow
Renal stone
Renal stone
Renal stone
Renal stone
Renal pelvis stone &
Hydronephrosis
Ureteropelvic junction stone
Ureterovescicular junction stone
Renal cyst
EUS重點
1. smooth, round, or oval
2. no internal echo
3. well-defined margin
4. posterior enhancement
Renal cyst
Renal cyst
Renal cyst
Polycystic kidney
Polycystic kidney
Renal abscess
為什麼這不是simple renal cyst ?
Bladder
• 解尿解不出來，要不要立刻導尿呢?
– Acute urine retension
• 小朋友要導尿留U/C，會不會failure ?
– Bladder size evaluation
膀胱容積 (ml) =
長 * 寛 * 高 * 0.75 (error: 15-35%)
Bladder index volume (AP * Transverse) 2.4cm2 = 2ml
Fungating bladder mass (拜託, 有obstructive uropathy一定要看UB)
Acute renal failure
重點:
找有無post-renal obstruction
Acute renal failure
• Pre-renal
– Kidney & IVC evaluation
• Intrinsic
– Difficult
• Post-renal
– Search obstruction
Complicated UTI
(APN & renal abscess)
EUS應用重點時機
1. Risk factors
2. Treatment failure
3. Severe sepsis/septic shock
Risk factors for complicated APN
• Elderly
• Male
• History of preexisting renal diseases
• Current use of catheters
• Previous renal calculi
• Diabetes mellitus
Chen KC, et al. AJEM (in press), doi:10.1016/j.ajem.2010.01.047
50F, Septic shock
50F, Peri-renal abscess
50F, Peri-renal abscess
Emphysematous Pyelonephritis
Trauma
EUS重點
Highly operator dependent
若gross hematuria, 血行動力不穩or 危險機轉，仍應考慮CECT
Renal trauma
Subcapsular renal hematoma
(Trauma)
57M, Post-ESWL
Catheters
Pitfalls
1. Bedside US is limited in scope
2. Hydronephrosis may be mimicked
3. Presence of hydronephrosis may be masked by dehydration
4. The absence of hydronephrosis does not rule out a ureteral stone
5. Patients with an acute AAA often present with flank pain
6. A bladder mass may be a hematoma
臨床情境
• 30歲男性，半夜2點，上腹及右上腹悶痛至急診就診，理學檢查有Murphy’s sign
• 請問你該怎麼辦 ?
• 急診超音波在此能提供什麼幫忙?
腻力激盪
急診超音波能應用在那些肝膽道疾病 ??
對急診臨床工作有何助益 ??
重點式膽道超音波的臨床應用
• 對診斷膽結石為快速且正速的工具
• Ultrasonic Murphy’s sign和理學檢查有著相同的意義
• 快速且非侵入性
• 無放射或顯影劑暴露的影響
• 床邊執行
• Cost-effective procedure
肝膽道圖示
Triangle of Calot
患者準備
• 常規掃描: 空腹6-8小時
• 急重症患者不適用空腹原則
• 如果患者剛進食不久
– 膽囊會收縮變小
– 膽囊壁會變厚
• 注意: 急性病變時，膽囊通常因下列原因脹大
– Poor oral intake
– Abdominal pathology
– Biliary tract obstruction
患者姿勢
• 起始姿勢: 平躺
• 利用兩種以上的姿勢的好處 – 對病灶有更好或更多面向的觀察
– 可以偵測stone or sludge的移動
• 其他姿勢 – Left or right lateral decubitus,
– Left posterior oblique
– Partially upright
探頭的擺放
• 參考: – 個人偏好 & 經驗; 患者的體態
• 善用肝臟: acoustic window
• 擺放位置: – Anterior subcostal
– Coronal
– Right posterior oblique
• 觀察重點: the portal triad
Longitudinal views of the gallbladder
Transverse views of the gallbladder
Intercostal views of the gallbladder
Portal vein and normal common bile duct
PV & CBD
Micky Mouse sign
Hepatic venous system
急診膽道系統超音波ACEP
• Primary: 辨識膽結石
• Extended:
–膽囊炎
– CBD異常: 擴張或結石
–肝異常: 腫瘤、膿瘍、pneumobilia
– Portal vein異常
–其他膽囊異常: 包含腫瘤
–黃胆
–腹水
Clinical indications
• Gallstones and biliary colic
• Acute cholecystitis
• Jaundice and biliary duct dilatation
• Abdominal sepsis
• Ascites
• Hepatic abnormalities
常見急診超音波應用
• 右上腹或上腹痛
–看有無結石
–看有無膽囊炎
• 黃胆
–看有無膽道阻塞
• 腹水
–看腹水，協助paracentesis
掃描時回答的問題
• 有無膽結石
• 膽囊有無發炎 – Sonographic Murphy’s sign
– Impacted stone
– GB wall thickening
– Pericholecystic fluid
– Increased transverse GB diameter
• 有無CBD dilatation
Biliary colic algorithm
80
Gallstones 注意Acoustic shadow
Polyp
Polyps & Tiny stones 比較一下兩者的不同處
膽囊炎臨床表現
• Fever
• Chills
• RUQ pain
• Leukocytosis
• Jaundice
• Positive Murphy’s sign
• Acalculous cholecystititis 1- 5 % –在急診壓這個診斷不是不可能，對的機率太小
膽囊炎的超音波影像
• 膽結石 – 大多數患者有結石存在
– 如果沒有結石，要考慮acalculous cholecystitis.
• 膽囊橫徑 > 4-5 cm
• GB wall thickness (正常 < 3mm) > 4-5 mm (anterior wall)
– Averages 5 mm in acute cholecystitis
– Averages 9 mm in chronic cholecystitis
膽囊炎: 其他超音波發現
• Decreased echogeneity of the entire wall
• Sonographic Murphy’s sign
• Pericholecystic fluid
• Diffuse, homogeneous echogeneity with GB
lumen (pus in lumen or GB empyema)
Sonographic Murphy’s Sign
• 將探頭直接放在膽囊上並施壓
• 若這技巧重覆患者的症狀，高度指向有症狀的膽結石或急性膽囊炎
• 尋找其他指向阻塞或發炎的發現:
– Gallbladder wall thickening
– Increased transverse diameter of GB
– Pericholecystic fluid
Acute Cholecystitis
Chronic cholecystitis
造成膽囊壁增厚的原因
• Present in many non-inflammatory conditions
– Post-prandial most common
– Congestive heart failure
– Starvation/hypoproteinemic states
– Ascites
– HIV
WES sign
(wall echo shadow)
CBD 掃描技巧Scanning Tips
• 請患者左側躺45度
• 掃描時，探頭和肋緣垂直
• 尋找portal vein最長的部份
• CBD應該就在portal vein的前方(螢幕上方)
• CBD和portal vein先交叉後平行
Parallel channel sign
Choledocholithiasis
Antler signs
Mirizzi syndrome
Cirrhosis of the liver
• Decreased liver size
• Increased
parenchymal
echogenicity
• Increased surface
irregularity
• Distorted intrahepatic
anatomy
Bacterial peritonitis
Hepatomegaly
Splenomegaly
Biliary sludge
Contracted gallbladder
Liver cyst
Liver abscess
Hemangioma
Metastatic tumors
GB stone
(變換掃描角度的重要意義)
Longitudinal view Intercostal oblique view
Packed gallbladder
(容易被忽略的acoustic shadow)
Cholecystitis ? Ascites
Pitfalls
• Misidentifying the gallbladder
• Inadequate visualization of the gallbladder and biliary system
• Confusion with shadowing
• Misdiagnosing cholelithiasis and cholecystitis
• Misdiagnosing dilated intrahepatic ducts
• Misdiagnosing ascites
• Cystic Duct stone
• Common bile duct stones
• Misdiagnosis of Biliary Colic
