肝胆疾病超声诊断 ppt课件.ppt

肝 胆 超 声,Mirror-image atifact,Because the sound travels more slowly in fluid than in the liver parenchyma, a large cyst can delay the passage of sound, causing the diaphragm to appear farther away than it is.,CT: a low-density lesion,drainage of Hepatic abscess,Transabdominal and transcervical chorionic villus sampling (CVS),The catheter is followed sonographically throughout its course from the cervix to an appropriate position within the placenta,RAI,RPI,RPS,RAS,2,2,3,4,RHV,The normal mean velocity in the main portal vein is about 15 to 18 cm per second, but the normal range is wide. The normal portal vein flow is antegrade( hepatopetal) throughout the entire cardiac cycle.,fissure for the ligamentum venosum (arrows),sagittal views: The fissure for the ligamentum venosumseparates the caudate lobe (C) from the lateral segment of the left lobe (LL).,.(1) a large antegrade systolic wave caused by the movement of the tricuspid annulus toward the cardiac apex; (2) a small retrograde V-wave caused by right atrial overfilling; the V-wave is usually below the baseline but may be above the baseline; (3) an antegrade diastolic wave caused by the opening of the tricuspid valve and flow of the blood from the right atrium to the right ventricle; (4) a retrograde A-wave caused by right atrial contraction; and (5) a retrograde C-wave caused by the closure of the tricuspid valve at the beginning of systole, which may be seen in a few patients,1. The normal hepatic vein waveform consists of waves in the following sequence: (1) a large antegrade systolic wave caused by the movement of the tricuspid annulus toward the cardiac apex; (2) a small retrogradeV-wave caused by right atrial overfilling; the V-wave is usually below the baseline but may be above the baseline; (3) an antegrade diastolic wave caused by the opening of the tricuspid valve and flow of the blood from the right atrium to the right ventricle; (4) a retrograde A-wave caused by right atrial contraction; and (5) a retrograde C-wave caused by the closure of the tricuspid valve at the beginning of systole, which may be seen in a few patients,A,B,DEBRIS CYST,1.The cysts become increasingly common with age, and the incidence is higher after 40 years of age, reaching 7% in persons over 80 years old. When larger than 4 cm, they are termed giant hemangiomas,Hemangiomas may increase in size during pregnancy or after estrogen administration. However, most hemangiomas in adults do not change in size or appearance.,Pathologically, hemangioma is composed of many vascular channels of different sizes supported by fibrous septa. The vascular spaces may contain thrombi.,Rarely, color flow or calcification is seen within the hemangioma.,1. a thick echogenic rind or a thin echogenic rim , was seen in 93% of atypical solid hemangiomas. This finding was considered suggestive of hemangioma. Atypical 2. Atypical hemangiomas with hypoechoic areas may contain a single echogenic septum or multiple septa . 3. target pattern is rarely seen in a hemangioma. 4. internal color flow is rarely seen within a hemangioma. When color flow is detected within a lesion that has the gray-scale appearance of a hemangioma, further evaluation is indicated.,Unlike hyperechoic metastasis or hyperechoic HCC, are compressed during examination , they may become less echogenic,1. Hemangiomas may increase in size during pregnancy or after estrogen administration. However, most hemangiomas in adults do not change in size or appearance. 2. When larger than 4 cm, they are termed giant hemangiomas.,hemangiomas with hypoechoic areas may contain echogenic septum,Adenomas 1. Hepatic adenoma is a rare benign liver tumor, most commonly related to oral contraceptive use and therefore most often seen in women of childbearing age and in young men. 2. Adenomas associated with type I glycogen storage disease are multiple in about 50% of patients,Because of the high incidence of hemorrhage or rupture, surgery is recommended whenever possible. Adenomas may undergo malignant transformation.,Evidence does suggest that this disorder may be hormone-dependent, because regressionof the lesion after discontinuance of oral contraceptive agents has been reported.,Adenoma with hemorrhage,Hepatic adenoma (liver cell adenoma or hepatocellular adenoma) is a rare benign liver tumor, most commonly related to oral contraceptive use and therefore most often seen in women of childbearing age. Anabolic steroid-induced hepatic adenoma is seen more commonly in young men. Adenomas associated with type I glycogen storage disease are multiple in about 50% of patients.,Adenoma,Focal nodular hyperplasia about 75% of patients are asymptomatic, and the mass is discovered incidentally. Hepatocytes appear normal, but they lack the normal cord arrangement. Kupffer cells are present, and the fibrous septa contain numerous bile ductules and vessels.,1. radiating peripherally from a central vessel in a stellate configuration, has been reported. In a series of 269 hepatic neoplasms, this pattern was seen only in focal nodular hyperplasia. Even though small number of reported cases, this color flow pattern may suggest the diagnosis of focal nodular hyperplasia. 2. Increased uptake of the radiocolloid, technetium-99m sulfur colloid, may be a specific feature of focal nodular hyperplasia.,focal nodular hyperplasia,focal nodular hyperplasia,Hepatic lipomas,lipoma Focal displacement and discontinuity of the diaphragm deep to the lipoma may occur because of the slower speed of sound in fat compared with the normal liver and refraction of the ultrasound beam at the edge of the mass,Computed tomography is helpful to confirm the diagnosis of lipoma, by demonstrating low density (-20 to -70 HU),Hepatic lipomas,lipomas may appear similar to hemangiomas and hyperechoic metastases, Hemangiomas may cause acoustic enhancement and rarely cause acoustic shadowing. Hyperechoic metastases are often inhomogeneous, are rarely solitary, and cause acoustic shadowing only when calcified. Moreover, hemangiomas and hyperechoic metastases do not cause artifactual displacement and discontinuity of the diaphragm deep to the mass,Adenoma with fat,21-64. Detour sign around a metastatic lesion. the hepatic vein (large arrow) displaced around the metastatic lesion,Infantile hemangioendothelioma,1. Infantile hemangioendothelioma, although rare, is the most common symptomatic vascular liver tumor of infancy. More than 85% of the tumors present before 6 months of age. The female-to-male ratio is 2:1. the most common clinical presentation is hepatomegaly with or without a palpable mass.,婴儿肝血管内皮瘤 良性罕见病 年龄小于6月； 体征: 肝肿大，右心衰 贫血，血小板减少,The incidence of congestive heart failure in hemangioendothelioma is high because of arteriovenous shunting within the mass, Complications include anemia, thrombocytopenia, and hemorrhage. It is considered a benign tumor; however, rarely distant metastases have been reported.,They may be hyperechoic, hypoechoic, or of mixed echogenicity, and they may contain cystic areas or calcifications.,错构瘤,Mesenchymal hamartoma Malignant transformation has not been reported.,Hepatocellular carcinoma,when the peripheral hypoechoic rim is thin (3 mm), it is the target or bull-eye pattern.,The halo or target pattern is not specific, but it is most often seen in malignant tumors, most commonly metastatic lesions in the liver, rather than benign tumors. In a study of 100 liver tumors, the target pattern was seen in 88% of malignant tumors and in only 14% of benign tumors. It is also occasionally seen in HCC.,th,乳腺癌肝转移有脂肪肝背景,21-57A. Peripheral cholangiocarcinoma.,21-57b. Peripheral cholangiocarcinoma.,The sonographic appearance of liver metastases is variable, and no definite association exists between the histologic type of the tumor and the sonographic appearance. Tumors of the same primary origin may have different sonographic appearances. Because of the nonspecific appearance of the metastases, ultrasound-guided biopsy of the mass is frequently necessary for the diagnosis.,Metastatic disease,metastases from colon carcinoma.,Metastases from breast carcinoma,Hyperechoic metastases (arrows) from colon carcinoma,The isoechoic metastatic lesion can be recognized only because of a thin, hypoechoic halo (white arrows) around the mass.,metastatic mass from colon carcinoma contains a calcification,Hyperechoic metastases (arrows) from a primary gastric carcinoma,Calcified metastasisfrom a primary colon carcinoma.,Cystic metastases. in the left lobe of the liver from mucinous carcinoma of the colon.,21-62B. a cystic metastasis (arrow) from ovarian carcinoma.,Generally, when the peripheral hypoechoic rim is thin (3 mm), it is the target or bull-eye pattern. The hypoechoic peripheral rim is caused by compressed normal liver parenchyma around the tumor or, more likely, by a zone of proliferating tumor in the periphery of the lesion. . In a study of 100 liver tumors, the target pattern was seen in 88% of malignant tumors and in only 14% of benign tumors. It is also occasionally seen in HCC.,the halo target or bull-eye pattern. 声晕 靶环 或 牛 眼 征,21-63. Diffuse metastases from carcinoma of the pancreas.,21-64. Detour sign around a metastatic lesion. : the hepatic vein (large arrow) displaced around the metastatic lesion,21-65A lymphoma of the liver,Primary lymphoma of the liver is extremely rare. Diffusely infiltrative involvement of the liver cannot be recognized sonographically. the most common pattern is secondary lymphoma ,secondary lymphoma ,Focal nodular lesions in the liver, is of multiple hypoechoic solid lesions, frequently with an irregular margin . Solitary lesions are less common . Hyperechoic lesion and the target pattern see are unusual,No cause is found for approximately 50% of abscesses. The abscesses may be solitary or multiple, when solitary, they are most frequently seen in the right lobe.,abscess,abscess Abscesses may appear cystic with an irregular, indistinct wall, a well-defined wall, or, less frequently, a thick wall,In the early stage, abscesses may appear hypoechoic and solid (Fig. 21-71), usually with distal acoustic enhancement;,21-72 gas-containing abscesses,21-72A,Ameba abscesses,21-73B Ameba abscesses,Hydatid cyst of the liver,Fatty liver results from accumulation of fat exceeding the normal 5% of liver weight. Fatty liver is caused by increased accumulation of triglycerides within the hepatocytes and is a reversible cellular response to various disease states and alterations in metabolism.,In grade 1 (mild), echogenicity is slightly increased, with normal visualization of the diaphragm and the intrahepatic vessel borders. In grade 2 (moderate), echogenicity is moderately increased, with slightly impaired visualization of the diaphragm or intrahepatic vessels. In grade 3 (severe), echogenicity is markedly increased, with poor or no visualization of the diaphragm, the intrahepatic vessels, and posterior portion of the right lobe.,脂肪肝,1度： 回声轻度增加，隔肌和肝内血管界限可见。 2度： 回声增加较多，,Fatty liver grade 2,Fatty liver grade 3,Fatty liever,Fatty liver,Coarse echo pattern Diffusely inhomogeneous echo pattern Increased echogenicity Surface nodularity Volume redistribution Enlarged caudate lobe and left lobe/small right lobe Caudate: right lobe ratio 0.65 Right lobe: left lobe ratio 1.3 Left portal vein diameter right portal vein diameter Signs of portal hypertension,TABLE 21-14. Sonographic Signs of Cirrhosis,cirrhoiss,The falciform ligament ( arrows) surrounded by ascites is seen between the anterior abdominal wall and the anterior surface of the liver. dividing the medial and lateral segments of the left lobe. Open arrow, dilated paraumbilical vein within the ligamentum,cirrhosis,To-and-fro flow in the main portal vein, another sign of portal hypertension, is best seen during active breathing,cirrhosis,The causes of portal hypertension can be divided into three major groups, according to the level of obstruction or increased resistance to the portal venous blood flow: (1) prehepatic; (2) intrahepatic; and (3) posthepatic.,21-17. Sonographic Signs of Portal Hypertension 门脉高压超声的表现 Ascites 腹水 Splenomegal y 脾大 Portosystemic venous collaterals 门脉侧枝循环 Hepatofugal (reversed) portal venous flow 门脉反向血流 Portal vein diameter 13 mm 门脉大于13mm Splenic and superior mesenteric vein diameter 10mm Lack of normal respiratory variations in diameters of splenic and superior mesenteric veins 静脉直径不随呼吸而变化 Coronary vein diameter 5 mm 冠状静脉大于 5 mm,In healthy persons, the diameter of the splenic and superior mesenteric veins increases (about 50%) in inspiration compared with the diameter in expiration.,A: Prehepatic portal hypertension can be caused by portal vein thrombosis, splenic vein thrombosis, splanchnic arteriovenous fistula, and splenomegaly. B: Intrahepatic portal hypertension be caused by alcoholic cirrhosis, schistosomiasis血吸虫病, hyperplasia, and idiopathic自发的 portal hypertension. C: Posthepatic portal hypertension can be caused by inferior vena cava obstruction and cardiac disease,1. In healthy persons, the diameter of the splenic and superior mesenteric veins increases (about 50%) in inspiration compared with the diameter in expiration. Patients with portal hypertension lack normal diameter variation (50% increase during deep inspiration). The lack of normal diameter variation has a sensitivity of 80% and a specificity of 95% to 100% for the diagnosis of portal hypertension.,1. Sonographically, the presence of a coronary vein diameter of 5 mm or larger has a sensitivity of 80% in the diagnosis of portal hypertension.,脐静脉,Normal 2mm,A dilated paraumbilical vein is seen on the transverse view as an anechoic, round structure within the ligamentum teres,herefore, a paraumbilical vein should be considered diagnostic of portal hypertension only if the diameter of the vein is larger than 3 mm or if the hepatofugal venous flow has a velocity greater than 5 cm per second. Reversal of flow direction (ie, away from the splenic vein)within the coronary vein may be a more sensitive sonographic indicator of portal hypertension than coronary vein dilatation,门脉高压 脐静脉3mm 或 反向血流5cm/s 冠状静脉（胃左静脉）反向血流较扩张更有意义,1. Tumor thrombus within the portal vein can be differentiated from bland thrombus by demonstrating arterial wave forms flow within the tumor thrombus,later, as severe portal hypertension develops, the portal vein diameter may decrease, probably because more blood is diverted to portosystemic collaterals,1. adjacent collateral veins enlarge to span the obstruction and permit continued hepatopetal flow of blood. These collateral channels represent the cavernous transformation of the portal vein.,3.5MHZ,5MHZ,1. The cysts become increasingly common with age, and the incidence is higher after 40 years of age, reaching 7% in persons over 80 years old.,