非肿瘤性疾病致梗阻性黄疸的影像学特征及鉴别诊断

Imaging features and differential diagnosis of obstructive jaundice caused from non-neoplastic diseases

目的探讨非肿瘤性疾病导致梗阻性黄疸的影像学特征及鉴别诊断。方法采用回顾性描述性研究方法。收集2014年8月至2016年8月北京大学人民医院收治的62例非肿瘤性疾病导致梗阻性黄疸患者的临床资料，其中13例IgG4相关性胆管炎（IAC）、2例原发性硬化性胆管炎（PSC）、21例反复发作性化脓性胆管炎（RPC）、2例Mirizzi综合征、4例沟槽状胰腺炎（GP）、20例Lemmel综合征。患者行CT平扫及增强扫描、MR／平扫及增强扫描、MRCP检查。由2位影像学诊断医师分别阅片，意见不统一时由第3位高年资医师再次阅片得出最终结果。观察指标：（1）影像学检查情况及影像学特征。（2）治疗及随访情况。完善患者实验室及其他相关检查，确诊后行相应治疗。患者治疗后采用门诊或电话方式进行随访。随访内容为患者预后情况。随访时间为6个月1次。随访时间截至2016年11月。结果（1）影像学检查情况及影像学特征：62例患者中，2l例行CT平扫联合增强扫描检查，7例行MRI平扫联合增强扫描检查，4例行MRCP检查，15例行CT平扫联合增强扫描及MRCP检查，1例行CT平扫联合增强扫描及MR／平扫联合增强扫描检查，3例行MRI平扫联合增强扫描及MRCP检查，11例行cT平扫联合增强扫描及MRI平扫联合增强扫描及MRCP检查。13例IAC患者影像学表现：MRI检查示胆管壁弥漫对称性增厚并延迟强化，胆管管腔狭窄而多无闭塞，胆总管远端多见。13例IAC患者中9例合并IgG4相关胰腺炎，7例合并双肾病变。2例PSC患者影像学表现：MRI检查示胆管壁多发局限性增厚并持续性强化，肝硬化表现。MRCP检查示肝内外胆管多灶性狭窄及扩张呈串珠样和（或）枯树枝样改变．肝内胆管边缘分支减少。21例RPC患者影像学表现：MR／、MRCP及CT检查示胆管壁增厚并延迟强化：肝内一二级胆管节段性扩张，远端胆管突然变窄，肝内胆管分支减少，而肝外胆管多为扩张，少数呈狭窄样改变；肝内胆管结石：肝内胆管积气；肝脏实质萎缩并胆管扩张，多见于肝左叶或右后叶；继发肝脓肿、胆管癌。2例Mirizzi综合征患者影像学表现：MRI检查示胆囊颈与肝总管连接处结石致肝总管狭窄，结石近端肝内外胆管扩张而远端胆管内径正常，胆囊胆管瘘形成，不规则胆囊壁增厚及周围炎症。4例GP患者影像学表现：MRI检查示十二指肠环及胰头区内无明确形态肿物，呈不均匀、渐进性强化。十二指肠壁内及胰头区囊肿形成。增强检查示胆总管壁增厚，呈渐进性狭窄，胰管正常或轻度扩张，十二指肠壁增厚并不同程度管腔狭窄。20例Lemmel综合征患者影像学表现：MRI检查示十二指肠降段内侧囊袋样结构，囊壁较薄，内含液体。MRCP检查示胆总管及其以上肝内外胆管扩张。（2）治疗及随访情况：62例患者中，2例IAC、1例PSC、7例RPC、2例Mirizzi综合征、3例GP、15例Lemmel综合征患者行相应外科手术治疗；其余32例未行手术治疗的患者接受相应内科治疗。62例患者中60例获得随访，随访时间为3～17个月。随访期间，28例行外科手术治疗患者明确诊断且术后恢复尚可，2例患者术后明确诊断后失访，32例内科治疗患者病情稳定。结论非肿瘤性疾病可导致梗阻性黄疸，其误诊率较高，特定的影像学表现有助于明确诊断．为临床提供帮助。

Objective To investigate the imaging features and differential diagnosis of obstructive jaundice caused from non-neoplastic diseases. Methods The retrospective descriptive study was conducted. The clinical data of 62 patients with obstructive jaundice caused from non-neoplastic diseases who were admitted to the Peking University People＇s Hospital between August 2014 and August 2016 were collected, including 13 with immunoglobulin G4 associated cholangitis （IAC）, 2 with primary sclerosing cholangitis （PSC）, 21 with recurrent purulent cholangitis （RPC）, 2 with Mirizzi syndrome, 4 with groove panereatitis （GP） and 20 with Lemmel syndrome. All the patients underwent plain and enhanced scans of computed tomography （CT） and magnetic resonance imaging （MRI） and magnetic resonanced cholangio-pancreatography （MRCP）. Film reading were respectively done by 2 imaging doctors, and then was analyzed again by senior doctors when there is disagreement. Observation indicators ： （ 1 ） situations of imaging examination and imaging features ; （2） treatment and follow-up. Patients received laboratory and related examinations and then underwent corresponding treatment after diagnosis. Follow-up using outpatient examination and telephone interview was performed once every 6 months to detect patients＇ prognosis up to November 2016. Results （ 1 ） Situations of imaging examination and imaging features ： of 62 patients, 21 underwent plain and enhanced CT scans, 7 underwent plain and enhanced MRI scans, 4 underwent MRCP, 15 underwent plain and enhanced CT scans and MRCP, 1 underwent plain and enhanced CT scans and plain and enhanced MRI scans, 3 underwent plain and enhanced MRI scans and MRCP and 11 underwent plain and enhanced CT scans, plain and enhanced MRI scans and MRCP. Imaging features of 13 patients with IAC： MRI scans showed that diffuse and symmetrical bile duct walls were thickened, with delayed enhancement. The narrowed lumen of bile duct was mainly occurred in common bile duct, without occlusion. Of 13 patients with IAC, 9 were combined with IgG4 associated pancreatitis and 7 with bilateral nephropathy. Imaging features of 2 patients with PSC： MRI scans showed that bile duct wall was multiple localized thickening and persistent enhancement, that was imaging feature of liver cirrhosis. MRCP examination showed that intra- and extra-hepatic bile ducts had multifocality stricture and beading-like and/or dry twig-like dilatation, and branches of intrahepatic peripheral bile duct were reduced. Imaging features of 21 patients with RPC ： MRI and CT scans and MRCP examination showed that there was thickening bile duct wall and delayed enhancement. The first and second level of intrahepatic bile duct were segmental dilatation, distal bile duct dramatically narrowed and branches of intrahepatic bile duct were reduced. Most of extrahepafic bile duct was dilatation and a few were narrow-like changes. There were stones of intrahepatic bile duct and pneumobilia. Liver parenchymal atrophy with cholangiectasis occurred most frequently in left lobe or right posterior lobe of liver. There were secondary liver abscess and cholangiocarcinoma. Imaging features of 2 patients with Mirizzi syndrome： MR1 scans showed that there was common hepatic duct stricture caused by stones in the junction between neck of gallbladder and common hepatic duct, and intra- and extra-hepatic bile ducts dilatation in proximal end of stones and normal bile duct in distal end of stones. There were gallbladder and biliary fistulas, irregular gallbladder wall thickening and inflammation around the gallbladder. Imaging features of 4 patients with GP ： MRI scans showed that no clear mass was detected in duodenal loop and head of pancreas, with heterogeneous and slightly irregular enhancement. Cyst formation occurred in intramural wall of duodenum and head of pancreas. Enhanced MRI scans showed that common bile duct wall was thickened and slightly irregular stricture, pancreatic duct was normal or mild expansion, and thickened duodenal wall had varying degrees of stenosis of lumen. Imaging features of 20 patients with Lemmel syndrome： MRI scans showed that pouch-like structure was detected inside of the descending duodenum, with thin cyst wall and liquid in cyst wall. MRCP examination showed dilatations of common bile duct and intra- and extra-hepatic bile ducts. （2） Treatment and follow-up： of all the 62 patients, 30 underwent corresponding surgeries, including 2 with 1AC, 1 with PSC, 7 with RPC, 2 with Mirizzi syndrome, 3 with GP and 15 with Lemmel syndrome, and the other 32 without surgery received corresponding medical treatment. Sixty of 62 patients were followed up for 3-17 months. During follow-up, 28 patients undergoing surgery received definitive diagnosis and good recovery, 2 were lost after definitive diagnosis and 32 undergoing medical treatment were in stable condition. Conclusion Non-neoplastic diseases can cause obstructive jaundice, with a higher misdiagnosis rate, imaging findings of which can be conducive to diagnose diseases and provide clinical treatment.