双语病例Acutecholecys

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病例选自《MayoClinicBodyMRICaseReview》

History

49-year-oldmanwithahistoryofpriorintrahepaticbiliarystonediseaseandnewonsetofrightupperquadrantpain

49岁男性，既往有肝内胆管结石病史，新发右上腹痛。Fig3.1.1

Fig3.2.1：

Fig3.2.2：

Fig3.2.3：

ImagingFindings

CoronalSSFSE(Figure3.2.1)andaxialfat-suppressedSSFP

(Figure3.2.2)imagesshowmoderategallbladderwallthickeningwithmuraledemaandagallstoneinthegallbladderneck.Ofnote,asmallerstone,probablyimpactedinthecysticduct,andthebilefluid-fluidlevelcanbeseenonaxialSSFPimages.Axialpostgadolinium3DSPGRimages(Figure3.2.3)showirregularmucosalenhancementofthegallbladderwall,aswellaspatchyenhancementoftheliveradjacenttothegallbladderfossa.

冠状位SSFSE序列(Figure3.2.1)和横断位脂肪抑制SSFP序列(Figure3.2.2)示胆囊壁中度增厚，囊壁水肿，胆囊颈部可见结石。另外，胆囊管内可见更小的结石，阻塞胆囊管。横断位SSFP序列示胆汁淤积，胆囊内可见液-液平面。

3DSPGR横断位增强扫描(Figure3.2.3)示胆囊壁粘膜不规则强化，胆囊窝周围肝实质见斑片状强化。

Diagnosis

Acutecholecystitis

急性胆囊炎

Comment

MRIisnottheprimaryimagingtestforpatientswithrightupperquadrantpainandsuspectedcholecystitis.USismuchmorereadilyavailable,ischeaper,andisreasonablyaccurate,andwecertainlyagreewiththeAmericanCollegeofRadiologyAppropriatenessCriteriaforthisindication,althoughthecriterialumpMRI,CTwithorwithoutcontrastmedium,andscintigraphyassecondaryoptionswithequalvalidity(aquestionableconclusion).Nevertheless,incaseswhereUSisindeterminateorthereareotherpotentialdiagnoses,MRIcanbehelpful.Inthiscase,sincethepatienthadknownintrahepaticbiliarystones,itwasthoughtthatMRIwouldbethemoreusefultest.

对于右上腹痛、临床怀疑胆囊炎的患者，MRI并不是首选的影像学检查。美国放射学会适用标准认为超声检查经济、有效、准确，是影像学检查的首选，MRI、CT平扫或增强、闪烁扫描法有效性相同，可作为备选的检查（这一结论值得商榷）。

然而，当超声检查无法确诊，或存在其他可能性诊断时，MRI对诊断有一定的帮助。本例患者已知肝内胆管结石病史，MRI对诊断更有帮助。

Acutecholecystitisusuallyresultsfromobstructionofthecysticductorgallbladderneckbyanimpactedgallstone.Acalculouscholecystitisoccursin5%to10%ofcasesandmaybeincitedbyagallbladderpolyp,neoplasm,oradenomyomatosis.MRIfindingsinacutecholecystitisincludeimpactedgallstonesinthegallbladderneckorcysticduct,gallbladderwallthickening3mm,gallbladderwalledema,gallbladderdistention(diameter40mm),pericholecysticfluid,andfluidaroundtheliver.Thepresenceof1ormoreofthese6criteriawaspredictiveofcholecystitis,withasensitivityof88%andspecificityof89%in1study.Theseresultsaredubious,however,becausemostofthecriteriaarenonspecificandhavelongdifferentialdiagnosticlists(ie,notallcirrhoticpatientshaveacutecholecystitis),butintheappropriateclinicalsetting,theymaybeusefulfindings.Wewouldalsoaddtothelistthepresenceofmucosalormuralenhancement,anearuniversalindicationofinflammation.Hyperenhancementoftheadjacenthepaticparenchyma,seeninthiscase,isanonspecificfindingbutissuggestiveofadjacentinflammation.

急性胆囊炎多由结石阻塞胆囊颈或胆囊管引起。结石所致胆囊炎发病率约5%-10%，可由胆囊息肉、肿瘤、胆囊腺肌瘤病刺激发病。MRI表现包括胆囊颈或胆囊管内结石嵌顿、胆囊壁增厚＞3mm、胆囊壁水肿、胆囊增大（直径大于40mm）、胆囊周围积液、肝周积液。

一项研究表明:满足上述6条胆囊炎诊断标准中的一项或多项，诊断敏感性88%，特异性89%。然而这一结果并不准确，因为上述的各项标准都没有特异性，需要与很多疾病鉴别诊断（例如，并非所有的肝硬化病人都有胆囊炎），只是在特定的临床条件下，这些表现有助于临床诊断。此外，胆囊壁或粘膜层的强化是胆囊炎症的普遍表现。

本例患者胆囊附近的肝实质也可见异常强化，这是一个非特异性征象，提示临近的肝实质炎症。

Anotheroptioninassessingpatientswithsuspectedcholecystitisistousegadoxetatedisodium(Eovist)andessentiallyperformtheMRequivalentofnuclearscintigraphy.Onhepatobiliaryphaseimages,youshouldbeabletoseeexcretedcontrastinthecysticductandgallbladder.Ifyoudon’t,itsabsenceimpliesobstructionofthecysticductandcholecystitis.

对于怀疑胆囊炎的患者，钆塞酸二钠（Eovist）增强扫描也是影像学检查的选择之一，其检查的原理类似于核素的闪烁扫描。增强扫描的肝胆相位图像上，可以见到经胆囊和胆囊管排出的造影剂，如果没有看到造影剂排出，则提示胆囊管梗阻和胆囊炎。

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