超声检查门静脉海绵样变特征表现

doi:10.3969/j.issn.1672-5069.2021.04.022

摘要/Abstract

摘要： 目的探讨门静脉海绵样变(CTPV)及其相关并发症的超声表现特征,并分析了超声漏诊的原因。方法 2017年6月～2020年6月首都医科大学附属北京地坛医院诊治的101例CTPV患者,经CT和MRI增强扫描诊断,接受腹部超声检查。总结CTPV及其相关并发症超声图像表现特征,并分析超声漏诊的原因,提出解决策略。结果在本组101例CTPV患者中,超声诊断82例(82.2%),漏诊19例(17.8%);在超声诊断病例中,82例(100.0%)患者门静脉主干及其分支周围出现广泛或局部蜂窝状粗细不等的血管结构,70例(85.4%)出现门静脉管壁增厚,76例(92.7%)在迂曲扩张的蜂窝状血管结构内部呈红蓝相间的丰富的血流信号,脉冲多普勒测得门静脉样低速血流频谱,10例(12.2%)门脉周围迂曲扩张蜂窝状血管压迫胆管,导致胆管扩张,8例(9.6%)出现胆囊增大,6例(7.4%)出现胆囊结石,5例(6.1%)出现胆管结石,5例(6.1%)出现门体分流。结论超声是诊断CTPV的首选影像学方法,超声漏诊的原因主要为海绵样变血管腔细、病变范围小,腹部胀气,假性胆管肿瘤征,肋间隙或胸骨下角窄。利用腹腔积液和胆囊等声窗扫查肝脏,采用超声造影技术或结合其他影像学技术检查可减少漏诊。

关键词: 门静脉海绵样变, 超声, 诊断

Abstract: Objective The aim of this study was to investigate summarize the ultrasonographic features of cavernous transformation of the portal vein (CTPV) in patients with chronic liver diseases (CLD). Methods Abdominal ultrasonography was conducted in 101 patients with CLD, who was diagnosed with CTPV by CT or MRI in Beijing Ditan Hospital affiliated to Capital Medical University between June 2017 and June 2020. The ultrasonic image features of CTPV and its related complications were summarized, and the causes of ultrasonic missed diagnosis were analyzed with the solutions proposed. Results Out of the 101 patients with CTPV proven by CT and/or MRI, the ultrasonic diagnosis was correct in 82 cases (82.2%), with 19 cases (17.8%) missed; among the cases correctly diagnosed by ultrasonography, 82 patients (100.0%) showed extensive or local cellular vascular structures around the portal vein trunk and its branches, the wall of portal vein was thickened in 70 cases (85.4%), the tortuously dilated cellular vascular structure showed red and blue interlaced rich blood flow signals in 76 patients (92.7%), the low-speed blood flow spectrum of portal vein was measured by pulse Doppler, the tortuously dilated honeycomb vessels around the portal vein compressed the bile duct, resulting in bile duct dilatation in ten cases (12.2%), the gallbladder enlargement occurred in 8 patients (9.6%), the cholecystolithiasis was present in 6 patients (7.4%), the bile duct stones were found in 5 cases (6.1%) and the portal shunt occurred in 5 cases (6.1%). Conclusion Ultrasonography is an important imaging method for the diagnosis of cavernous transformation of portal vein. The main reasons for ultrasonic missed diagnosis are small vascular lumen, small lesion scope, abdominal distension, pseudotumor of bile duct, narrow intercostal space and substernal angle. The enhanced CT or MRI examinations need to perform for correct diagnosis. The liver is scanned at acoustic windows of abdominal effusion or gallbladder and the contrast-enhanced ultrasonography might help reduce the missed diagnosis.

Key words: Cavernous transformation of portal vein, Utrasonography, Diagnosis

殷志勇, 王连双, 张瑶. 超声检查门静脉海绵样变特征表现[J]. 实用肝脏病杂志, 2021, 24(4): 540-543.

Yin Zhiyong, Wang Lianshuang, Zhang Yao. Ultrasonographic features of cavernous transformation of the portal vein in patients with chronic liver diseases[J]. Journal of Practical Hepatology, 2021, 24(4): 540-543.

参考文献

[1] Kessler A, Graif M, Konikoff F, et al. Vascular and biliary abnormalities mimicking cholangiocarcinoma in patients with cavernous transformation of the portal vein. Ultrasound Med, 2007, 26(8):1089-1095.
[2] 刘彦君. 肝硬化并发门静脉血栓防治研究进展. 实用肝脏病杂志, 2019, 22(4):605-608.
[3] Nasim M, Majid B, Tahir F, et al. Cavernous transformation of portal vein in the setting of protein C and anti-thrombin III deficiency. Cureus, 2019, 11(9):e5779.
[4] Han D, Tang R, Wang L, et al. Case report of a modified Meso-Rex bypass as a treatment technique for late-onset portal vein cavernous transformation with portal hypertension after adult deceased-donor liver transplantation. Medicine, 2017, 96(25):e7208.
[5] Lombardo S, Espejo JJ, Pérez-Montilla ME, et al. The keys to successful tips in patients with portal vein thrombosis and cavernous transformation. Radiologia, 2018, 60(2):94-104.
[6] 中华医学会肝病学分会. 肝硬化诊治指南. 实用肝脏病杂志, 2019, 22(6):770-786.
[7] 中华人民共和国国家卫生健康委员会医政医管局. 原发性肝癌诊疗规范(2019年版).中华肝脏病杂志, 2020, 28(2):112-128.
[8] Ma J, Yan Z, Luo J, et al. Rational classification of portal vein thrombosis and its clinical significance. PloS One, 2014, 9(11):e112501.
[9] Rodrigues SG, Maurer MH, Baumgartner I, et al. Imaging and minimally invasive endovascular therapy in the management of portal vein thrombosis. Abdom Radiol, 2018, 43(8):1931-1946.
[10] Specchi S, Pey P, Ledda G, et al. Computed tomographic and ultrasonographic characteristics of cavernous transformation of the obstructed portal vein in small animals. Vet Radiol Ultrasound, 2015, 56(5):511-519.
[11] Kuy S, Dua A, Rieland J, et al.Cavernous transformation of the portal vein. J Vasc Surg, 2016, 63(2):529.
[12] 宋丽俊, 袁雁, 王伟. 定量磁共振成像诊断原发性胆汁性肝硬化患者门静脉高压症价值分析. 实用肝脏病杂志, 2020, 23(4):568-571.
[13] Ramos R, Park Y, Shazad G, et al. Cavernous transformation of portal vein secondary to portal vein thrombosis: a case report. J Clin Med Res, 2012, 4(1):81-84.
[14] Song B, Min P, Oudkerk M, et al. Cavernous transformation of the portal vein secondary to tumor thrombosis of hepatocellular carcinoma: spiral CT visualization of the collateral vessels. Abdom Imaging, 2000, 25(4):385-393.
[15] Abdullah A, Binita M, Rose C, et al.Solitary hepatic nodule adjacentto the right portal vein:a common finding of alagille syndrome. J Pedia Gastro Nut, 2016, 62(2):226-232.
[16] Riaz A, Lewandowski R, Salem R.Radioembolization in advanced hepatocellular carcinoma. J Clin Oncol, 2018, 36(19):1898-1901.
[17] Krishnan P, Fiel MI, Rosenkrantz AB, et al.Hepatoportal sclerosis: CT and MRI appearance with histopathologic correlation. Am J Roentgenol, 2012,198(2):370-376.
[18] Bucsics T, Krones E. Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome. Gastroenterol Rep (Oxf), 2017, 5(2):127-137.
[19] Angelis CD, Pellicano R, Carucci P, et al. Endoscopic ultrasonography in hepatology: focus on portal hypertension. Minerva Gastroenterol Dietol, 2008, 54(2):131-139.
[20] Bauer J, Johnson S, Durham J, et al.The role of tips for portal vein patency in liver transplant patients with portal vein thrombosis. Liver Transpl, 2006, 12(10):1544-1551.
[21] Li YY, Duan YY, Yan GZ, et al. Application of ultrasonography in the diagnosis and treatment tracing of hepatocellular carcinoma-associated arteriovenous fistulas. Liver Int, 2007, 27(6):869-875.
[22] Fan Mei, Su C, Lu L, et al. Ultrasonic diagnosis and vasoactive substances examination in patients with cirrhosis. Asian Pac J Trop Med, 2014, 7(4):329-332
[23] Hwang M, Thimm MA, Guerrerio AL. Detection of cavernous transformation of the portal vein by contrast-enhanced ultrasound. J Ultrasound, 2018, 21(2):153-157.
[24] Danila M, Sporea I, Popescu A, et al. Portal vein thrombosis in liver cirrhosis - the added value of contrast enhanced ultrasonography. Med Ultrason, 2016, 18(2):218-233.