【作者】 张冬梅；

【导师】 田伟；

【作者基本信息】 昆明医学院 ， 影像医学与核医学， 2007， 硕士

【摘要】 【目的】探讨MR低张扫描在胆总管壶腹部梗阻诊断中的临床应用价值。分析低张对MR图像质量改善情况；分析低张前后MRCP及MRI对胆总管壶腹部梗阻病变诊断准确性；比较654-2、解痉灵两种低张药物在MR低张扫描中应用价值。【材料与方法】前瞻性分析我院经手术、病例、临床随访证实的98例怀疑胆总管壶腹部梗阻病变者临床和影像资料，其中73例三角肌内注射（简称肌注）654-2，25例肌注解痉灵。所有病例均行肌注654-2、解痉灵前、后MRCP及MRI扫描。其中男51例，女47例，年龄为28～82岁，平均年龄为54.42岁。MR成像设备采用GE公司1.5T SIGNA超导磁共振成像仪，对病人行FSE-T₂WI、SSFSE-T₂WI、SPGR-T₁WI扫描，拟诊为胆总管壶腹部梗阻且梗阻原因不明或病因显示不确切者肌注654-2（20mg）或解痉灵（20mg）同时饮水100-200ml，8 min后再启动低张扫描，必要时行三期动态增强扫描。胆总管壶腹部梗阻判断标准：肝外胆管依胆总管扩张最明显处直径＞8 mm为扩张，8～12 mm为轻度扩张，12～16 mm为中度扩张，＞16 mm为重度扩张。肌注654-2、解痉灵前后对MR图像质量改善情况行统计学分析；MRCP及MRJ对胆总管壶腹部病变的定位、定性诊断准确率低张前后进行自身对照研究。【结果】图像分析：由两位高年资MRI诊断医师对低张前后图像进行盲法评价。肌注654-2、解痉灵前后MRCP胃肠蠕动伪影抑制情况，两种药物低张后均抑制胃肠蠕动伪影（P＜0.05）；肌注654-2、解痉灵后两者对胃肠蠕动伪影抑制无统计学差异（P＞0.05）。分别比较肌注654-2或解痉灵前后MRI及MRCP对壶腹部解剖结构显示情况，其评价结果分四个等级；两种低张药物低张后明显提高了胆总管壶腹部解剖结构显示（P＜0.05）；肌注654-2、解痉灵后两者对胆总管壶腹部解剖结构显示无统计学差异（P＞0.05）。分别比较654-2、解痉灵低张前后壶腹周围器官影像清晰度，分三个等级，主要对胆总管下端、胰头、十二指肠降段的结构显示，两种药物低张后提高了壶腹周围器官的影像清晰度（P＜0.05）；肌注654-2、解痉灵后两者对壶腹周围器官影像清晰度提高无统计学差异（P＞0.05）。胆总管壶腹部梗阻MR征象：胆总管轻度扩张25例，中度扩张42例，重度扩张24例；胰、胆管软藤状扩张20例，残根状扩张40例，不典型肝内胆管扩张31例。壶腹周围癌中13例可见“双管征”，8例可见“半月征”，12例可见乳头状软组织结节影。壶腹周围癌17例见不同程度强化，剩余1例胰头癌无强化。35例结石在梗阻部位均可见点状低信号影。20例胆总管末端炎症性狭窄、5例胆道术后良性狭窄及3例十二指肠憩室显示梗阻端胆管逐渐变细。十二指肠乳头炎10例显示十二指肠乳头肿大，并乳头炎性水肿较重时呈“半透明”节结影。654-2、解痉灵低张后对病变定位、定性准确率提高有统计学意义（P＜0.05）；两种低张药物对胆总管壶腹部病变定位、定性准确率无统计学意义（P＞0.05）。【结论】1、MR低张扫描能抑制胃肠蠕动伪影，提高壶腹部解剖结构显示，提高与壶腹周围脏器影像清晰度，MRCP及MRI图像质量提高。2、低张后提高病变定位、定性准确率，是诊断胆总管壶腹部梗阻的一个重要方法。3、654-2、解痉灵都可以作为MR低张扫描较理想的低张药物，因654-2经济效益更好，推荐为MR低张扫描首选药物。4、低张MR清楚显示胆总管壶腹部梗阻征象，对诊断及其鉴别诊断胆总管壶腹部梗阻具有重要临床应用价值。更多还原

【Abstract】 Objective To explore the clinic value of hypotonic MR scan in patient with obstruction in ampullary portion of choledoch. To analyze the infection of hypotonic and enhanced MR scan in the quality of the MR image. To analyze the accuracy of location of focus and reliability of determining focus of the obstruction in ampullary portion of choledoch in MR scan with hypotonic medicine or MR scan without hypotonic medicine. To compare the clinic possibility of hypotonic druggery of 654-2 and scopolamine butylbromide injection in MR scan.Methods and materials The data of hypotonic and enhanced MR scan were prospective and evaluated in 98 patients with obstruction in ampullary portion of choledoch. All lesions of digestive tract were proved in surgery,pathology, clinical following up. Including654-2(73) , scopolamine butylbromide injection(25) . The data of hypotonic MR scan were evaluated in 98 patients with obstruction in ampullary portion of choledoch. Male group(38 cases) and Female group (22 cases). The mean age of all 98 cases was 54．42(range,28～82) years. MR imaging equipment is GE 1．5T SIGNA. scaning FSE-T2WI、SSFSE-T2WI、SPGR-T1WI sequence. Hypotonic MR scan is startuped after 8 minute injecting hypotonic medicine with water(100-200 ml) ,That isn’t sure of the pathogeny of the obstruction in ampullary portion of choledoch. The diagnosis standard of the obstruction in ampullary portion of choledoch: The degree of dilated common duct could be divided into three categories ( low, middle, and marked grade ). To analyze the infection of hypotonic and enhanced MR scan with water in the quality of the MR image of MR scan with hypotonic medicine or MR scan without hypotonic medicine. The hypotonic MR scan decides the accuracy of location of focus and reliability of determining focus of the obstruction in ampullary portion of choledoch by self control.Results Images analysis:the image quality of MRCP and MRI were analyzed and compared by two radiologists respectively in double-blind method. The motion artifact by intestines is disappear in the images of hypotonic MR scan, that was significant difference(P <0．05) between hypotonic MR scan and MR scan without hypotonic medicine. There was significant difference(P>0．05) between hypotonic MR scan with 654-2 and MR scan with scopolamine butylbromide injection. The manifestation of the ampullae demonstrating anatomy in hypotonic MR scan are classified into four grades. In hypotonic group , the ability of demonstrating anatomy had been greatly improved (p < 0．05) ;There was significant difference(P>0．05) of demonstrating anatomy between MR scan with 654-2 and MR scan with scopolamine butylbromide injection. The demonstration of adjacent organs and structure to the digestive tract in hypotonic MR scan are classified into three grades,mosty including distal common bile duct, head of pancreas, descending part of duodenum,behind of peritoneum. It also improved in demonstration of adjacent organs and structure to the digestive tract (P<0．05) . Significant difference(P>0．05) between MR scan with 654-2 and MR scan with scopolamine butylbromide injection. The direct manifestation of the obstruction in ampullary portion of choledoch in hypotonic MR scaned: low-grade dilatation of choledoch (25 cases), middle-grade dilatation (42 cases), and marked-grade dilatation (23 cases). In duct, ’soft bine’dilatation (20 cases), ’nub’dilatation (40 cases), and atypical dilatation(31 cases). In the ampullary carcinoma, there were’double pipe’sign in 13, and’half-moon’sign in 8．The soft tissue nodus of parenchyma with pap-illa could be seen in the dilated sections of dropp ing of duodenum in 12 cases. Manifestations on dynamic enhancement scan(17 cases), no marked enhancement(1 cases). Low signal Choledocholithiasis(n = 35) , MRCP manifestations on obstructed end of common bile duct of stenosis of cholangitic of the distal common bile (n=20)、postcholecystectomy of terminal common bile duct(n =5) and duodenal diverticulum(n = 3) : funnel shape or ring-like narrowness. Manifestations of the duodenal papillitis (n= 5) and duodenal ampullary inflammatory edema (n= 5) : duodenalpapilla swell and no marked enhancement. The accuracy of location of focus and reliability of determining focus of the obstruction in ampullary portion of choledoch hypotonic MR scan are increase(P<0．05) . There was significant difference(P>0．05) of the accuracy of location of focus and reliability of determining focus of the obstruction in ampullary portion of choledoch between MR scan with 654-2 and MR scan with scopolamine butylbromide injection.Conclusion 1．Hypotonic MR scan can improve the quality of MRCP and MRI images.2．Hypotonic MR scan can increase the accuracy of location of focus and reliability of determining focus of the obstruction in ampullary portion of choledoch, that is a important method in the obstruction.3．654-2 and scopolamine butylbromide injection are taked as ideal hypotonic medication.Because 654-2 is more benefit than scopolamine butylbromide injection,654-2 is recommended as the first medicine.4．The direct manifestation of the obstruction is display distinctly in hypotonic MR scan, That is clinic applied value of the diagnosis and differential diagnosis of the obstruction in ampullary portion of choledoch.更多还原