Foley W Dennis, Quiroz Francisco A
Professor of Radiology (Foley and Quiros), Medical College of Wisconsin, Milwaukee, WI 53226, USA.
Ultrasound Q. 2007 Jun;23(2):123-35. doi: 10.1097/01.ruq.0000263851.53549.a5.
Sonography is the recommended initial imaging test in the evaluation of patients presenting with right upper quadrant pain or jaundice. Dependent upon clinical circumstances, the differential diagnosis includes choledocholithiasis, biliary stricture, or tumor. Sonography is very sensitive in detection of mechanical biliary obstruction and stone disease, although less sensitive for detection of obstructing tumors, including pancreatic carcinoma and cholangiocarcinoma. In patients with sonographically documented cholelithiasis and choledocholithiasis, laparoscopic cholecystectomy with operative clearance of the biliary stone disease is usually performed. In patients with clinically suspected biliary stone disease, without initial sonographic documentation of choledocholithiasis, endoscopic ultrasound or magnetic resonance cholangiopancreatography is the next logical imaging step. Endoscopic ultrasound documentation of choledocholithiasis in a postcholecystectomy patient should lead to retrograde cholangiography, sphincterotomy, and clearance of the ductal calculi by endoscopic catheter techniques. In patients with clinical and sonographic findings suggestive of malignant biliary obstruction, a multipass contrast-enhanced computed tomography (CT) examination to detect and stage possible pancreatic carcinoma, cholangiocarcinoma, or periductal neoplasm is usually recommended. Assessment of tumor resectability and staging can be performed by CT or a combination of CT and endoscopic ultrasound, the latter often combined with fine needle aspiration biopsy of suspected periductal tumor. In patients whose CT scan suggests hepatic hilar or central intrahepatic biliary tumor, percutaneous cholangiography and transhepatic biliary stent placement is usually followed by brushing or fluoroscopically directed fine needle aspiration biopsy for tissue diagnosis. Sonography is the imaging procedure of choice for biliary tract intervention, including cholecystostomy, guidance for percutaneous transhepatic cholangiography, and drainage of peribiliary abscesses.
超声检查是评估出现右上腹疼痛或黄疸患者的推荐初始影像学检查。根据临床情况，鉴别诊断包括胆总管结石、胆管狭窄或肿瘤。超声检查在检测机械性胆道梗阻和结石病方面非常敏感，尽管对检测包括胰腺癌和胆管癌在内的梗阻性肿瘤不太敏感。对于超声检查证实有胆囊结石和胆总管结石的患者，通常进行腹腔镜胆囊切除术并手术清除胆道结石病。对于临床怀疑有胆道结石病但最初超声检查未证实有胆总管结石的患者，内镜超声或磁共振胰胆管造影是接下来合理的影像学检查步骤。胆囊切除术后患者经内镜超声证实有胆总管结石应进行逆行胆管造影、括约肌切开术，并通过内镜导管技术清除导管结石。对于临床和超声检查结果提示恶性胆道梗阻的患者，通常建议进行多期对比增强计算机断层扫描（CT）检查以检测并分期可能的胰腺癌、胆管癌或胆管周围肿瘤。肿瘤可切除性评估和分期可通过CT或CT与内镜超声联合进行，后者常与疑似胆管周围肿瘤的细针穿刺活检相结合。对于CT扫描提示肝门部或肝中央部肝内胆管肿瘤的患者，通常先进行经皮胆管造影和经肝胆汁支架置入，然后进行刷检或透视引导下细针穿刺活检以进行组织诊断。超声检查是胆道介入的首选影像学检查方法，包括胆囊造瘘术、经皮经肝胆管造影的引导以及胆管周围脓肿引流。
