Emergency Ultrasound (EUS)教學(5)

重點式急診肝膽超音波之應用

新光醫院急診醫學科

陳國智醫師

中華民國醫用超音波學會指導醫師

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?

腦力激盪

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

19

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

Hartman’s pouch

Mucosal folds

41

Phyrigian cap

Biliary sludge

Tumefactive 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