肝窦阻塞综合征的超声影像学特征分析

Ultrasonographic features of hepatic sinusoidal obstruction syndrome

目的描述肝窦阻塞综合征(HSOS)的多模态超声表现,并探讨超声在HSOS诊断中的应用价值。方法回顾性分析2014年9月至2018年6月在复旦大学附属中山医院就诊的33例HSOS患者的临床特征和超声影像学特征,其中5例行超声造影和剪切波弹性成像检查,观察肝脏大小、肝区回声、肝静脉、门静脉、下腔静脉、胆囊、脾、体腔积液、肝弹性模量等情况;并用Cochran-Armitage趋势检验分析不同严重程度患者的超声征象阳性率。结果患者中25例(75.8%)有土三七服药史,临床症状主要以腹胀、肝区痛、腹水和肝功能明显异常就诊。灰阶超声特征为16例(48.5%)肝肿大,10例(30.3%)肝区回声增强增粗,11例(33.3%)胆囊壁增厚,14例(42.4%)脾大,31例(93.9%)腹水,9例(27.3%)胸水,7例(21.2%)盆腔积液;彩色多普勒表现为20例(60.6%)肝静脉细窄,18例(54.5%)肝静脉频谱异常,5例(15.2%)门静脉细窄,门静脉平均流速(0.14±0.03)m/s,6例(18.2%)出现门静脉反流;超声造影表现为5例(100.0%)动脉期呈“花斑样”不均匀增强,肝动脉-肝静脉渡越时间和门静脉-肝静脉渡越时间分别为(22.3±3.3)s和(13.0±2.2)s;三维超声造影显示:肝动、静脉、门静脉充盈缓慢及节段性充盈缺损;肝弹性模量(54.0±10.1)kPa。肝肿大、肝静脉细窄和肝静脉频谱异常的阳性率与病情严重程度存在相关性(Z=2.830、2.171、2.840,P均<0.05)。结论HSOS与服用中药土三七密切相关,超声造影及剪切波弹性成像对HSOS的诊断具有潜在的应用价值。

Objective To describe the multi-mode ultrasonographic features of hepatic sinusoidal obstruction syndrome(HSOS)and explore the value of ultrasound in the diagnosis of HSOS.Methods The clinical and ultrasonographic features of 33 patients with HSOS diagnosed from September 2014 to June 2018 at Zhongshan Hospital,Fudan University were retrospectively analyzed.Among them,five patients underwent contrast-enhanced ultrasonography and shear wave elastography.The size of the liver,hepatic echo,hepatic veins,portal veins,inferior cava vein,gallbladder,spleen,body cavity effusion,and hepatic elastic modulus were observed,and the Cochran-Armitage trend test was used to analyze the positive rate of ultrasonographic signs in patients of different severity.Results Twenty-five(75.8%)cases had a history of taking Tusanqi,and most of the cases presented for abdominal distension,liver area pain,ascites,and liver function abnormalities.Gray-scale ultrasound detected 16(48.5%)cases of hepatomegaly,10(30.3%)cases of hepatic echo enhancement and thickening,11(33.3%)cases of gallbladder wall thickening,14(42.4%)cases of splenomegaly,31(93.9%)cases of ascites,9(27.3%)cases of pleural effusion,and 7(21.2%)cases of pelvic effusion.Color Doppler ultrasound revealed 20(60.6%)cases of hepatic vein narrowing,18(54.5%)cases of abnormal hepatic venous waveforms,and 5(15.2%)cases of portal vein narrowing.The mean portal veins flow velocity was(0.14±0.03)m/s,and 6(18.2%)cases had portal vein regurgitation.Contrast-enhanced ultrasonography showed 5(100.0%)cases of'flower spotted'uneven enhancement in the arterial phase,hepatic artery to hepatic vein transit time was(22.3±3.3)s,portal vein to hepatic vein transit time was(13.0±2.2)s,and elastic modulus was 50.9±18.2 kPa.There was a correlation between the severity of the disease and the detection rate of hepatomegaly(Z=2.830,P=0.005),hepatic vein narrowing(Z=2.171,P=0.030),and abnormal hepatic venous waveforms(Z=2.840,P=0.005).Conclusion HSOS is closely related to the use of herbal medicine Tusanqi.The ultrasonographic features of HSOS include hepatomegaly with liver echo enhancement and thickening,gallbladder wall thickening,splenomegaly,body cavity effusion;portal vein narrowing,reduced flow velocity,bidirectional blood flow,hepatic vein narrowing and abnormal hepatic vein waveforms;'flower spotted'uneven enhancement in the arterial phase,prolonged hepatic artery to hepatic vein transit time and portal vein to hepatic vein transit time,and increased liver elastic modulus.Hepatomegaly,hepatic vein narrowing,and abnormal hepatic venous waveforms detected by ultrasound are positively related to clinical severity.Contrast-enhanced ultrasound and shear wave elastography have potential application value.