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孕妇右上腹疼痛影像学表现

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孕妇右上腹疼痛影像学表现 RUQ Pain in Pregnancy:  A Case of a Choledochal Cyst Jennifer Torpey, Year III Gillian Lieberman, MD Harvard Medical School Beth Israel Deaconess Medical Center March 2010 Agenda • Our Patient A.B. • RUQ Anatomy and Differential Diagnosis of  Acute RU...
孕妇右上腹疼痛影像学表现
RUQ Pain in Pregnancy:  A Case of a Choledochal Cyst Jennifer Torpey, Year III Gillian Lieberman, MD Harvard Medical School Beth Israel Deaconess Medical Center March 2010 Agenda • Our Patient A.B. • RUQ Anatomy and Differential Diagnosis of  Acute RUQ pain • Choledochal Cysts • Menu of Tests and Images from Companion  Patients • Summary and Follow‐up of our Patient Our Patient: Initial Presentation • A.B. is a 38 year old G2P1 at 23 weeks who  presented with 2‐3 days of RUQ pain that continued  to worsen – Pain is dull, feels like pressure, is not worsened or  ameliorated with eating or activity  – No fever, chills, nausea, vomiting, abdominal trauma or  sick contacts, no change in bowel habits – No loss of fluid, no vaginal bleeding, minimal contractions  q2 min which subsided, + fetal movement Our Patient: Past Medical History • Obstetric  Hx: SVD x1, no complications – Benign pre‐natal course for current pregnancy • Medical Hx: Denies • Surgical Hx: ? Open removal of  gallbladder/cyst at age 13 in China • Medications: None • Allergies: None • Denies tobacco, alcohol and drug use • T 98.9, BP 103/68, HR 81, RR 20 • Gen: NAD, mildly uncomfortable • Abd: Gravid, moderately distended – marked tenderness to palpation in RUQ and R‐side,  fullness appreciated but unable to palpate borders  due to tenderness – No rebound or guarding – Fundus palpable 1 cm below the umbilicus • Labs: ALT 6, AST 21, alk phos 47, Tbili 0.2  – WBC 7.2, Hg 12, Hct 34.6, Plt 271 Our Patient: Physical Exam Before moving on with the case let’s  review: 1) The anatomy of important structures in  the right upper quadrant  2) The differential diagnosis of Acute RUQ  pain 3) Preferable Imaging Modalities in  Pregnancy Anatomy of the Biliary Tree http://gallstoneflush.com/images/biliary%20tract.JPG Differential Diagnosis of  Acute RUQ Pain • Gallbladder Disease: – Cholecystitis – Cholangitis – Choledocholithiasis • Hepatitis  • Hepatomegaly • Retroperitoneal  appendicitis  • Malignancy: – Hepatocellular carcinoma – Cholangiocarcinoma – Liver metastases – Gastric cancer – Metastatic cancer – Lymphoma Gillian Lieberman, MD. Primary Care Radiology: Radiologic Assessment of Abdominal Pain. Eradiology.bidmc.harvard.edu Imaging Modalities in Pregnancy • Preferable to Avoid Ionizing Radiation – Plain films, CT, ERCP, nuclear medicine • Common Tests: – Ultrasound: sound waves • Pros: Inexpensive, good for identifying fluid • Cons: Requires skilled technologist, limited view – MRI: electromagnetic radio waves • Pros: use up to 1.5 Tesla, good soft tissue differentiation • Cons: should not use gadolinium as it crosses the  placenta, expensive • Special Tests: – MRCP: special MRI for imaging the bile and pancreatic ducts Now it is time to review our patient’s  imaging.   The first step: RUQ ultrasound Let’s look at a normal ultrasound first. Normal RUQ Ultrasound Right hepatic duct Left hepatic duct www.medison.ru/uzi/img/p401.jpg RUQ ultrasound Our Patient: RUQ Ultrasound PACS, BIDMC There is a very large anechoic structure found inferior to the liver. Our Patient: RUQ Ultrasound • 13.3 x 10.8 x 12.7 cm cystic structure with layering echogenic material,  which most likely represents a markedly distended gallbladder • Gallbladder neck and presumed dilated cystic duct are markedly  tortuous, containing multiple echogenic foci, compatible with gallstones • Common bile duct cannot be imaged due to tenderness limiting  examination • There is no peripheral intrahepatic biliary dilation but evaluation of  the central biliary tree is limited • No gallbladder wall thickening or definite pericholecystic fluid • Normal hepatopetal flow is seen in the main portal vein.  To better define this abnormal fluid  collection we should look at our  patient’s MRI … Our Patient: MRI of Abdomen/Pelvis What Do You See? PACS, BIDMC CORONAL SSFSE (HASTE) MRI SAGITTAL SSFSE (HASTE) MRI Our Patient: MRI of Abdomen/Pelvis PACS, BIDMC * * * * * * * Liver, * Cystic structure, * Fetus CORONAL SSFSE (HASTE) MRI SAGITTAL SSFSE (HASTE) MRI Our Patient: MRI Findings • Massively dilated common bile duct which measures up to 11 x  13 cm in transaxial diameter • Massive dilation of the central intrahepatic bile ducts with  numerous filling defects within the ducts consistent with stones• Pancreatic head is seen to be splayed about the distended CBD • Duodenum is displaced laterally and posteriorly to the dilated  duct• No definite obstructing stone or mass is identified, but the  distortion of the duodenum and pancreatic anatomy limits  definitive evaluation• Gallbladder is collapsed and displaced anterior to the dilated  CBD• ‐ Intrauterine pregnancy identified, no gross abnormalities  visualized DIAGNOSIS: Type I or IVb Choledochal Cyst Choledochal Cysts: The Basics • Rare, congenital dilatations of the biliary tract – Intrahepatic and extrahepatic • Risk Factors: – Female predominance – more common in Asia • Complications: – Recurrent cholangitis, Choledocholithiasis – Biliary stricture, Recurrent acute pancreatitis – Malignant transformation: 15% risk of developing  cholangiocarcinoma Todani Classification for Choledochal Cysts Type I Fusiform or cystic dilations of the extrahepatic biliary tree Type II Saccular diverticulum of the extrahepatic biliary tree Type III Bile duct dilatation within the duodenal wall (choledochocele) >50% of choledochal cysts 5% of choledochal cysts 5% of choledochal cysts Brunicardi, FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE: Schwartz’s Prinicples of Surgery, 9th Edition: http://www.accessmedicine.com Todani Classification ‐ Continued Type IVa Multiple cysts present, intra and extrahepatic (Caroli’s disease) Type IVb Multiple cysts present, extrahepatic only Type V Intrahepatic biliary cysts only 5-10% of choledochal cysts 1% of choledochal cysts5-10% of choledochal cysts Brunicardi, FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE: Schwartz’s Prinicples of Surgery, 9th Edition: http://www.accessmedicine.com Imaging to Determine Management of  Choledochal Cysts • Type I, II and IV cysts will be visible on RUQ US – Types III (duodenal) and V (intrahepatic) will not • HIDA scan to determine continuity with biliary tract – Excellent for extrahepatic cysts, difficult for intrahepatic cysts • CT scans and MRI provide better intrahepatic visualization – Better for surrounding structures, evaluation of malignancy • TREATMENT: Surgery • Cyst excision, Roux‐en‐Y hepaticojejunostomy • Others: Cholecystectomy, Intrahepatic cyst resection Let’s look at some companion patients for  more examples of choledochal cysts. Companion Patient #1 – RUQ US Herman and Siegel - Neonate born to 19 yo G2P1 - Identified Type I Choledochal Cyst in utero - Thought to be ovarian cyst early on in pregnancy Cyst, * Dilated intrahepatic ducts Cyst Cyst * RUQ ultrasound Companion Patient #2 – RUQ US • Choledochal cyst  identified on RUQ US • Polypoid mass at  proximal region of  cyst • Pathology confirmed  cholangiocarcinoma Cyst Polypoid Mass Liver Lee HK, Park SJ et al RUQ ultrasound Companion Patient #3 ‐ MRCP Dilated intrahepatic ducts Choledochal cyst Haciyanli et al • 28 yo female • Recurrent episodes of RUQ pain • MRCP images best defined the type and extent of the choledochal cyst compared to US and CT images • Surgery performed •Patient doing well NB: MRCP images do not require contrast as bile serves as a natural contrast material. Companion Patient #4 ‐ MRI • 19 yo G1P0 at 22 wks • Presented with RUQ pain • Found Type I choledochal cyst filled with stones • Underwent CCY, Roux‐ en‐Y  hepaticojejunostomy,  and cyst excision • Healthy baby born at 40  weeks gestation • MRI used for diagnosis * Fetus* Choledochal Cyst Conway. Choledochal cyst during pregnancy. Am J Obstet Gynecol 2009. SAG T1-weighted MRI Companion Patient #5: HIDA scan http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/a_chol/image.html This NORMAL HIDA scan shows radiotracer in the liver after 5 minutes (left image) and radiotracer in the gallbladder and duodenum after 45 minutes (right image). HIDA Anterior view Companion Patient #6: ERCP PACS, BIDMC * * Choledochal Cyst• NB: ERCP is an invasive procedure, seldom used today for diagnosis of choledochal cysts. • 50 yo male with abnormal liver function tests and abnormal anechoic structure found on RUQ US •ERCP for CBD stent placement ERCPERCP Let’s get back to our patient … Our Patient: Intermittent History • Recovered from acute episode of RUQ pain • Decided to hold off on surgery until  postpartum, if possible • Healthy baby boy delivered at 37 weeks • Imaging for surgical planning: CT and MRCP – Identified Type I vs. IVb choledochal cyst – Planned surgery: cyst excision, roux‐en‐y  hepaticojejunostomy, intrahepatic stone removal,  liver biopsy Our Patient: Imaging for Surgical Planning CT MRCP * Choledochal Cyst Liver * Liver PACS, BIDMC * C+ COR CT Our Patient’s Surgery: Roux‐en‐Y Hepaticojejunostomy Jejunum Duodenum Jejunojejunostomy Hepaticojejunostomy Roux En “Y” Percutaneous transhepatic stents Our Patient ‐ Follow Up • Recovered slowly from  surgery • Baby boy is doing well • Followed closely by  hepatology and surgery • Two weeks post‐op CT – Dilated intrahepatic ducts * – Pneumobilia * PACS, BIDMC * * C+ COR CT Summary • Imaging is essential for diagnosis of RUQ pain  and surgical planning • Imaging modalities should be chosen carefully  in pregnancy to avoid harm to the fetus – Good choices include ultrasound, MRI and MRCP • Other RUQ imaging options include: CT, HIDA  scan, ERCP • Choledochal cysts are rare but have serious  complications and should be removed  surgically Acknowledgements • Dr Gillian Lieberman – BIDMC Core Radiology Clerkship Director • Dr Jean‐Marc Gauguet – BIDMC Radiology Resident and “Big Sib” • Maria Levantakis – BIDMC Core Radiology Clerkship Administrator References • Conway W., Campos G. and Gagandeep S.  “Choledochal Cyst During Pregnancy: The patient’s first pregnancy was  complicated by congenital anomaly.” Images in Obstetrics: AJOG. May 2009. 200 (5).  588e1‐e2 • Normal RUQ US www.medison.ru/uzi/img/p401.jpg • Herman T., Siegel MJ. “Neonatal Type I Choledochal Cyst.” Journal of Perinatology. 27, 453–454 (1 July 2007)  http://www.nature.com/jp/journal/v27/n7/fig_tab/7211759f1.html • Haciyanli M., Genc H., et al. “An Adult Choledochal Cyst – the MRCP Findings: Report of a Case.” Surg Today (2008)  38:1056–1059 • Wiseman K., Buczkowski A., et al. “Epidemiology, Presentation, Diagnosis and Outcomes of Choledochal Cysts in Adults in an  Urban Environment.” American Journal of Surgery 189 (2005) 527–531. • Lee HK, Park SJ et al. “Imaging Features of Adult Choledochal Cysts: a Pictorial Review.” Korean J Radiol 2009;10:71‐80 • Sokol Ronald J, Narkewicz Michael R, "Chapter 21. Liver & Pancreas" (Chapter). Hay WW, Jr., Levin MJ, Sondheimer JM,  Deterding RR: CURRENT Diagnosis & Treatment: Pediatrics, 19e: http://www.accessmedicine.com.ezp‐ prod1.hul.harvard.edu/content.aspx?aID=3404306. • Oddsdottir Margret, Pham Thai H, Hunter John G, "Chapter 32. Gallbladder and the Extrahepatic Biliary System" (Chapter).  Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE: Schwartz's Principles of Surgery, 9e:  http://www.accessmedicine.com.ezp‐prod1.hul.harvard.edu/content.aspx?aID=5026661. • Kruskal J, Levine D, Wilkins‐Haug L, Barss V.  “Diagnostic  Imaging Procedures During Pregnancy” UpToDate. Sept 2009.  http://utdol.com/online/content/topic.do?topicKey=maternal/2119 • Singham J, Yakada EM, Scudamore CH. “Choledochal Cysts. Part 2 of 3: Diagnosis.” Can J Surg, Vol. 52, No. 6, December  2009.  506‐511 • Lieberman, G. “Primary Care Radiology: Radiologic Assessment of Abdominal Pain.” Primary Care Radiology Module.  Eradiology.bidmc.harvard.edu • Diagnostic Imaging Pathways. Department of Health: Government of Western Australia.  http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/a_chol/image.html RUQ Pain in Pregnancy: A Case of a Choledochal Cyst Agenda Our Patient: Initial Presentation Our Patient: Past Medical History Our Patient: Physical Exam Slide Number 6 Anatomy of the Biliary Tree Differential Diagnosis of �Acute RUQ Pain Imaging Modalities in Pregnancy Slide Number 10 Normal RUQ Ultrasound Our Patient: RUQ Ultrasound Our Patient: RUQ Ultrasound Slide Number 14 Our Patient: MRI of Abdomen/Pelvis�What Do You See? Our Patient: MRI of Abdomen/Pelvis Our Patient: MRI Findings Choledochal Cysts: The Basics Todani Classification �for Choledochal Cysts Todani Classification - Continued Imaging to Determine Management of Choledochal Cysts Slide Number 22 Companion Patient #1 – RUQ US Companion Patient #2 – RUQ US Companion Patient #3 - MRCP Companion Patient #4 - MRI Companion Patient #5: HIDA scan Companion Patient #6: ERCP Slide Number 29 Our Patient: Intermittent History Our Patient: Imaging for Surgical Planning Our Patient’s Surgery:�Roux-en-Y Hepaticojejunostomy Our Patient - Follow Up Summary Acknowledgements References
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