右上腹痛的影像学评估

1 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Radiologic evaluation of RUQ pain: Hepatic and Biliary possibilities Mayra E. Lorenzo, Harvard Medical School Year III Gillian Lieberman, MD January 2003 2 Mayra E. Lorenzo 2003 Gillian Lieberman, MD RUQ pain DDx (what lives there) Gallbladder Biliary tract Liver Subprhenic spaces GI GU Mr. S is a 37y/o male with Type I DM, ESRD, hepatitis C who presents with fevers to 104 F, GNR bacteremia and RUQ tenderness Patient History 3 Mayra E. Lorenzo 2003 Gillian Lieberman, MD I. RUQ pain with positive clinical Murphy’s sign (arrested inspiration or gasping on palpation of RUQ) II. RUQ pain with fever with negative Murphy’s sign III. RUQ pain without fever and negative Murphy’s sign Simplifying RUQ pain 4 Mayra E. Lorenzo 2003 Gillian Lieberman, MD I. RUQ pain with positive clinical Murphy’s sign (arrested inspiration or gasping on palpation of RUQ) Biliary (acute cholecystitis, biliary colic) Sonography • Reliable for detection of gallstones • Image entire abdomen • Blood flow analysis without contrast (Doppler) • Determine if stone impacted by moving patient • Radiologic Murphy’s sign (patient’s site of max. tenderness by compression with transducer). High positive predictive value for acute cholecystitis in patient with RUQ pain, fever and leukocytosis. Can be absent in gangrenous cholecystitis Biliary Scintigraphy (use if ultrasound inconclusive, few false- negatives) 5 Mayra E. Lorenzo 2003 Gillian Lieberman, MD II. RUQ pain with fever with negative Murphy’s sign Cholangitis Hepatic abscess Subphrenic abscess Gangrenous cholecystitis Perforated duodenal ulcer Pancreatitis RLL pneumonia Sonography Contrast enhanced CT ERCP and MR for common bile duct stones 6 Mayra E. Lorenzo 2003 Gillian Lieberman, MD III. RUQ pain without fever and negative Murphy’s sign Hepatic tumor (internal hemorrage/rupture into peritoneal cavity) CT MR 7 Mayra E. Lorenzo 2003 Gillian Lieberman, MD II. RUQ pain with fever with negative Murphy’s sign Cholangitis Hepatic abscess Subphrenic abscess Gangrenous cholecystitis Perforated duodenal ulcer Pancreatitis RLL pneumonia Sonography Contrast enhanced CT ERCP and MR for common bile duct stones Our patient, Mr. S, falls into: 8 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Ultrasound BIDMC PACS round hyperechoic signal with acoustic shadowing anechoic area within gallbladder echogenic material within gallbladder DDx -gallstone -adenomyomatosis -polyp DDx Pus sludge hematoma Carcinoma Adenomyomatosis Polyp, cholesterol DDx Fluid bile Thickened gallbladder wall Mr. S’s Ultrasound: Transverse view 9 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Up-to-date •Thickened wall (greater than 4 or 5 mm, double wall sign) •Radiologic Murphy’s sign •Pericholecystic fluid •Gallstones Ultrasound findings in acute cholecystitis: 10 Mayra E. Lorenzo 2003 Gillian Lieberman, MD • Pathogenesis: • Mechanical inflammation (obstruction, distension) • Chemical inflammation (lysolechitinÆphospholipase A on lechitin in bile) • Bacterial inflammation (most common organisms found: Escherichia coli, Enterococcus, Klebsiella, and Enterobacter) • Complications of untreated acute cholecystitis:Edema and inflammation can progress to necrosis and gangrene • EmpyemaÆgangrenous cholecystitis (especially in diabetics, with sepsis) • Gallbladder perforation • Chloecystoenteric fistula • Gallstone illeus (gallstone through cholecystoenteric fistula) • Emphysematous cholecystitis (Clostridium welchii) Acute Cholecystitis 11 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Ultrasound BIDMC PACS heterogeneous echogenic mass no defined border round hyperechoic signal with acoustic shadowing anechoic signal echogenic material within gallbladder DDx -gallstone -adenomyomatosis -polyp DDx Pus sludge hematoma Carcinoma Adenomyomatosis Polyp, cholesterol DDx Fluid bile DDx of heterogeneous liver mass: Abscess Focal nodular hyperplasia Hepatocellular carcinoma Hyatid cyst Metastasis Neoplasm lymphoma Thickened gallbladder wall Mr. S’s Ultrasound: Transverse view 12 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Echogenic material within gallbladder Gallstone Continuation of heterogeneous echogenic mass and gallbladder BIDMC PACS anechoic signal Mr. S’s Ultrasound: Oblique sagital view 13 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Abscess (pyogenic, amebic, fungal) adenoma focal nodular hyperplasia hepatocellular carcinoma hyatid cyst lymphoma metastasis Hepatocellular carcinoma Æ Contrast enhanced MR or CT to further evaluate… DDx for a hypoechoic liver mass on ultrasound 14 Mayra E. Lorenzo 2003 Gillian Lieberman, MD With history of Type I DM and gram negative rod bacteremia… Most likely DDx: 1. Acute suppurative cholecystitis with comunicating intrahepatic liver abscess Ultrasound: •heterogeneous liver mass •thickened gallbladder wall with echogenic material and gallstones •apparent continuation between liver mass and gallbladder lumen RUQ pain with fever with negative Murphy’s sign Cholangitis Hepatic abscess Subphrenic abscess Gangrenous cholecystitis Perforated duodenal ulcer Pancreatitis RLL pneumonia Differential Diagnosis for our Patient after Ultrasound 15 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Three phases of hepatic contrast enhancement: 1. No contrast 2. Arterial phase: 20 second delay 3. Portal venous phase: 45-60 second delay Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., Liver lessions will have a different patterns of enhancement in the various phases Contrast-enhanced CT for further evaluation of heterogeneous liver mass 16 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Mr. S’s no-contrast CT Difficult to appreciate fine details of lession BIDMC PACS 17 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Enhancing border Non- enhancing septated lession BIDMC PACS Mr. S’s CT with contrast: arterial phase 18 Mayra E. Lorenzo 2003 Gillian Lieberman, MD BIDMC PACS gallbladder Mr. S’s CT with contrast: arterial phase 19 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Comunication BIDMC PACS Mr. S’s CT with contrast: arterial phase 20 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Fluid within gallbladder wall Pericholecystic fluid BIDMC PACS Mr. S’s CT with contrast: arterial phase 21 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Fluid within gallbladder wall BIDMC PACS Mr. S’s CT with contrast: arterial phase 22 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Fat stranding Pericholecystic fluid BIDMC PACS Mr. S’s CT with contrast: arterial phase 23 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Pyogenic Liver Abscess •Two major mechanisms: local spread from contiguous infections within the peritoneal cavity or hematogenous seeding of the liver •Usually polymicrobial •Microabscesses from enteric organisms coalesce •Hematogenously spread Staphylococcus results in diffuse microabscesses throughout the liver •Ultrasound: from hypoechoic to hyperechoic ill-defined lessions. Gas within abscess can causes high intensity linear echoes with acoustic shadows and reverberations •Contrast CT scan: •hypodense lessions •Range from unilocular with smooth borders to complex internal septations with irregular borders •Rim enhancement in 6% •Some are gas-containing. More common in diabetic population 24 Mayra E. Lorenzo 2003 Gillian Lieberman, MD •Interventional Radiology: Ultrasound guided percutaneous drainage of gallbladder Æ purulent fluid ÆCx: Klebsiella Diagnosis: Suppurative Cholecystitis with Intrahepatic Liver Abscess •Antibiotics Patient continued to spike fevers, abdominal pain and tenderness… •CT guided drainage of intrahepatic liver abscess-unsuccesfull •Surgery: open cholecystectomy and incission and drainage of liver abscess •Thickened gallbladder with stones (Path: chronic cholecystits with focal acute inflammation). •Edematous wall, no evidence of perforation •2x3cm liver abscess contiguous with gallbladder Patient did well post-operatively. Continued on antibiotics and was discharged to home. Diagnosis and Treatment 25 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Conclusions •Learned: •Most useful radiologic tests to evaluate different types of RUQ pain •Radiologic findings of acute cholecystitis •Radiologic findings of pyogenic liver abcess 26 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Also… Echogenicity on ultrasound does not translate to density on CT BIDMC PACSBIDMC PACS 27 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Cecil Textbook of Medicine 21st Edition Amebic liver abscess Entamoeba histolytica •10% of world population infected (Mexico, Central and South America, India, tropical Asia, Africa) •Liver abscess: up to 5 months after diarrheal illnessÆfever, RUQ pain Also interesting to note the appearance of amebic liver abscesses on CT and that their clinical presentation can be similar to that of Mr. S… 28 Mayra E. Lorenzo 2003 Gillian Lieberman, MD References Silverman, P.M. and Zeman, R. K., editors. CT and MRI of the Liver and Biliary System, Contemporary Issues in CT, Vol 12, 1990. Ros, P.R. (guest editor). Hepatic Imaging, The Radiologic Clinics of North America, March 1998, Vol. 36:2 Gamuts in Radiology Nino-Murcia, M. and Jeffrey, R.B. Imaging the Patient with Right Upper Quadrant Pain. Seminars in Roentgenology, Vol 36, No. 2 April 2001, pp 81-91 www.uptodate.com Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed. Cecil Textbook of Medicine 21st Edition Saini, S. Imaging of the Hepatobiliary Tract. NEJM (1997) Volume 336:1889-1894 29 Mayra E. Lorenzo 2003 Gillian Lieberman, MD Special thanks to… James Busch, MD Matt Spencer, MD Marissa Heller Gillian Lieberman, MD Pamela Lepkowski Our Webmasters: Larry Barbaras and Cara Lyn D’amour Radiologic evaluation of RUQ pain: Hepatic and Biliary possibilities Patient History Simplifying RUQ pain Slide Number 4 Slide Number 5 Slide Number 6 Slide Number 7 Mr. S’s Ultrasound: Transverse view Ultrasound findings in acute cholecystitis: Acute Cholecystitis Mr. S’s Ultrasound: Transverse view Mr. S’s Ultrasound: Oblique sagital view DDx for a hypoechoic liver mass on ultrasound� Differential Diagnosis for our Patient after Ultrasound Contrast-enhanced CT for further evaluation of heterogeneous liver mass Mr. S’s no-contrast CT Mr. S’s CT with contrast: arterial phase Mr. S’s CT with contrast: arterial phase Mr. S’s CT with contrast: arterial phase Mr. S’s CT with contrast: arterial phase Mr. S’s CT with contrast: arterial phase Mr. S’s CT with contrast: arterial phase Pyogenic Liver Abscess Diagnosis and Treatment Conclusions Also… Amebic liver abscess References Special thanks to…