patologie biliare
DESCRIPTION
IMAGISTICA IN PATOLOGIA BILIARATRANSCRIPT
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DIAGNOSTICUL DIAGNOSTICUL RADIO-IMAGISTIC AL RADIO-IMAGISTIC AL
AFECTIUNILOR VEZICULEI AFECTIUNILOR VEZICULEI SI CAILOR BILIARESI CAILOR BILIARE
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METODE DE EXPLORAREMETODE DE EXPLORARE
• Rg. abdominala simpla• Ecografia• CT• IRM• ERCP• Colangiografia percutana transhepatica• Colangiografia pe tub Kehr
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EcografiaEcografia
• Screening• Colecist si cai biliare• Repaus alimentar 6 ore• Calibrul cailor biliare, continut• Dimensiunile colecistului, continut, pereti• Parenchim hepatic• Pancreas
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CTCT
• Indicata ca metoda de linia a 2-a• Obstructia biliara maligna (confirmare,
stadializare, aprecierea rezecabilitatii)• Reconstructii multiplanare, MIP, minIP
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CALCULI IN COLECIST Tumora ampulara:dilatatie a cailor biliare si c.Wirsung
T
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Wirsung
coledoc
TUM
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IRM - MRCPIRM - MRCP
• T1, T2 FSE• T1 SE sau GRE cu supresia grasimii• Secvente puternic ponderate T2 – fluidele
stationare hiperintense, tesuturile din jur cu semnal foarte slab
• Informatii anatomice
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WIRSUNG
COLEDOC
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ERCPERCP
• Injectarea contrastului retrograd dupa cateterizarea papilei pe cale endoscopica
• Litiaza• Stenoze coledociene• Sfincterotomia• Biopsia• Extragerea calculilor
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COLANGIOGRAFIE PE TUB T
• Postoperator• Calculi restanti in caile biliare
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LITIAZA BILIARALITIAZA BILIARA
• Calculi veziculari si/sau canalari (CBIH/CBEH)• US: imagine reflectogena, cu con de umbra,
mobila;• CT• MRCP: imagine hipointensa/bila hiperintensa;• ERCP – dgn+terapeutica
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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 posterior
calcul
FICAT
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US; LITIAZA VEZICULARA;
COLECISTITA CRONICA LITIAZICA SEMNUL RAPTOPOULOS
SEMIOLOGIE: -colecist “ocupat”-fara lichid; -semiluna reflectogena si - vid sonic posterior masiv
Vid sonic
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Colecistita acutaColecistita acuta
• litiazica/ alitiazicalitiazica/ alitiazica• US: edem parietal + calculi + Murphy US: edem parietal + calculi + Murphy
pozitivpozitivComplicatii - CT:Complicatii - CT:- Colecistita gangrenoasa;Colecistita gangrenoasa;- Perforatia VB - abcese;Perforatia VB - abcese;- Colecistita emfizematoasa (DZ);Colecistita emfizematoasa (DZ);
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US:COLECISTITA ACUTA ALITIAZICA
SEMIOLOGIE: -perete gros,dedublat; -continut lichidian neomogen, sedimentat decliv, reflectogen
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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 contact cu capsula in patul vezicular
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Colecistita cronica litiazicaColecistita cronica litiazica
• US:- perete ingrosat;- litiaza;- continut lichidian redus/absent - semn Raptopoulos;
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Obstructie biliaraObstructie biliara
= ICTERImagistic:- evidentierea dilatarii cailor biliare (US, CT, IRM);- evidentierea sediului obstacolului (intrahepatic/
hil/ suprapancreatic/ pancreatic);- caracterizarea obstacolului (CT, IRM, MRCP);
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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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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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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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Anomalii congenitaleAnomalii congenitale
• Chist de coledoc = Chist de coledoc = dilatare focala congenitala;dilatare focala congenitala;I – dilatarea fuziforma a coledoculuiII – diverticul extrahepatic supraduodenalIII – diverticul intraduodenal (coledococel)
• Boala Caroli = Boala Caroli = dilatarea chistica a CBIHdilatarea chistica a CBIH+ fibroza;+ fibroza;Complicatii: litiaza, colangita, colangiocarcinoame;Complicatii: litiaza, colangita, colangiocarcinoame;
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Cl.rad.imag.-IasiCl.rad.imag.-Iasi
US:Boala Caroli: megacoledoc,-cai biliare cu ,-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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Adenocarcinomul de vezicula biliaraAdenocarcinomul de vezicula biliara
• formatiune intraluminala/ ingrosare focala a peretelui;
• US, CT;• ± calculi;• ± suprainfectie;• bilant de extensie: adenopatii, MTS
hepatice;
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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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CT, contrast i.v.:CARCINOM COLECISTIC+MTS.HEPATICE
Metastaze hepatice: noduli hipodensi hepatici cu dimensiuni variabile 5-20 mm
T
Tumora in lumenul v.biliare,captind neomogen contrastul
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ColangiocarcinomColangiocarcinom
• intrahepatic (periferic) – US, CT, IRM nespecific;
• hilar (Klatskin) – CT, IRM cu reconstructii – aprecierea rezecabilitatii;
• distal – simuleaza cancer pancreatic/ ampular;
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US:US: Colangiocarcinom de cai biliare: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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Radiologie interventionala biliaraRadiologie interventionala biliara
• CPTCPT• Drenaj biliar externDrenaj biliar extern• Drenaj biliar internDrenaj biliar intern• EndoprotezareaEndoprotezarea
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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
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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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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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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