本文選題：十二指腸乳頭旁憩室 + 磁共振胰膽管成像　； 參考：《鄭州大學(xué)》2014年碩士論文

【摘要】：研究背景與目的 磁共振胰膽管成像（MRCP）是一種無(wú)需使用對(duì)比劑即可呈現(xiàn)胰膽管結(jié)構(gòu)的成像技術(shù)，自從上個(gè)世紀(jì)90年代Wallner等[1]率先使用磁共振設(shè)備成功獲得胰膽管水成像以來(lái)，隨著技術(shù)的不斷發(fā)展更新已經(jīng)日趨成熟。由于MRCP的無(wú)創(chuàng)性，操作安全簡(jiǎn)便，無(wú)輻射等優(yōu)點(diǎn)，最主要的是與常規(guī)有創(chuàng)性的成像技術(shù)如ERCP、PTC等在診斷準(zhǔn)確性方面可相媲美，使其在膽胰系統(tǒng)疾病的診斷中得以廣泛開(kāi)展。MRCP使用重T2加權(quán)技術(shù)，使T2弛豫時(shí)間較長(zhǎng)呈高信號(hào)的膽胰管、胃及十二指腸等含液體的器官清晰顯示，并與周?chē)M織形成鮮明的對(duì)比。十二指腸乳頭旁憩室（PAD）是指位于十二指腸乳頭2~3cm范圍內(nèi)的憩室，由于其解剖位置與膽胰管關(guān)系的特殊性，有時(shí)也會(huì)造成膽胰系統(tǒng)疾病，臨床上稱(chēng)為乳頭旁綜合征(Lemmel’s syndrome)。由于PAD常合并膽胰系統(tǒng)疾病，并且許多研究證實(shí)PAD與膽總管結(jié)石、胰腺炎的發(fā)生相關(guān)[2-6]。但是由于十二指腸乳頭旁憩室表現(xiàn)缺乏特異性，未受到臨床重視，易造成誤診、漏診，它的診斷主要依靠胃腸道造影、ERCP等影像檢查技術(shù)，，隨著MRCP臨床應(yīng)用的不斷增多，發(fā)現(xiàn)乳頭旁憩室的病例也在增加。 本研究的目的是總結(jié)十二指腸乳頭旁憩室在MRCP、MRI圖像中的特征性表現(xiàn)；根據(jù)MRCP上顯示的十二指腸乳頭旁憩室與膽胰管的關(guān)系，探討MRCP對(duì)十二指腸乳頭旁憩室以及其與膽胰系統(tǒng)疾病關(guān)系的診斷價(jià)值。 材料方法 搜集2010年1月—2013年9月，在鄭州大學(xué)第二附屬醫(yī)院MRI室檢查，經(jīng)過(guò)EPCP證實(shí)的45例PAD患者的MRCP影像資料及臨床資料，其中男21例，女24例，平均年齡為71歲�；仡櫺苑治鲞@45例患者的影像資料。所有病例均采用3D-MRCP序列，軸位脂肪抑制T2WI序列，屏氣冠狀位脂肪抑制FIESTA序列，屏氣軸位以及冠狀位LAVA三期增強(qiáng)序列掃描。圖像經(jīng)過(guò)MIP后處理后由兩名高年資的診斷醫(yī)師獨(dú)立閱片，達(dá)成共識(shí)后，進(jìn)行診斷及鑒別診斷。通過(guò)PAD在MRCP、MRI上的影像表現(xiàn)，總結(jié)其信號(hào)特征、位置以及測(cè)量憩室的直徑等。對(duì)PAD合并的膽胰系統(tǒng)疾病的例數(shù)進(jìn)行分類(lèi)，分別統(tǒng)計(jì)PAD直徑、位置與有無(wú)合并膽總管結(jié)石的關(guān)系，應(yīng)用SPSS17.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。 結(jié)果 45例PAD，2例為多發(fā)憩室，共47個(gè)。MRCP表現(xiàn)為十二指腸降段內(nèi)側(cè)的囊袋狀影，29個(gè)（61.8%）可見(jiàn)PAD頸部與十二指腸粘膜相連續(xù)；軸位脂肪抑制T2WI序列中表現(xiàn)為十二指腸內(nèi)側(cè)胰頭右后方的囊狀影，邊界清楚，可見(jiàn)部分被胰頭鉤突包埋，與胰頭交界處邊緣銳利，清晰，26個(gè)PAD（55.3%）可見(jiàn)氣液平面。LAVA三期增強(qiáng)掃描憩室內(nèi)未見(jiàn)強(qiáng)化，憩室壁薄光滑，同腸粘膜信號(hào)。經(jīng)過(guò)MIP后處理的MRCP圖像上PAD的顯示率為65.9%(31/47)，MIP后處理MRCP圖像+原始薄層MRCP圖像+軸位T2WI序列對(duì)PAD的顯示率達(dá)95.6%(45/47),兩者相比差異有顯著統(tǒng)計(jì)學(xué)意義（P0.05）。 PAD合并膽胰系統(tǒng)疾病的發(fā)病率為80%（36/45），其中膽總管結(jié)石為44.4%（20/45）。合并膽總管結(jié)石的PAD有較大的直徑，與未合并膽總管結(jié)石的PAD直徑相比，差異有統(tǒng)計(jì)學(xué)意義（P0.05）。周?chē)秃退叫晚遗c有無(wú)伴發(fā)膽總管結(jié)石無(wú)顯著性差異（P0.05）。 結(jié)論 1、十二指腸乳頭旁憩室在MRCP圖像中有比較典型的特征性表現(xiàn)，MRCP對(duì)十二指腸乳頭旁憩室的定位和定性診斷都較準(zhǔn)確，3D-MRCP與軸位T2WI序列相結(jié)合可作為診斷十二指腸乳頭旁憩室的優(yōu)先選擇序列。MRCP結(jié)合MRI平掃及增強(qiáng)掃描對(duì)膽胰系統(tǒng)疾病做出及時(shí)診斷的同時(shí)，提示憩室與膽胰系統(tǒng)疾病的相關(guān)性，為臨床明確病因、診斷和治療提供幫助。 2、十二指腸乳頭旁憩室的大小與膽總管結(jié)石的形成可能存在一定的相關(guān)性。
[Abstract]:Research background and purpose
Magnetic resonance cholangiopancreatography (MRCP) is an imaging technique that can present the structure of the pancreatic bile duct without using a contrast agent. Since Wallner and other [1] took the lead in obtaining the cholangiopancreatography after the first use of MRI equipment in the last century in 90s, it has become more and more mature with the continuous development of technology. The operation is safe and simple because of the noninvasive of MRCP. With the advantages of no radiation, the most important thing is to compare with the conventional and invasive imaging techniques such as ERCP, PTC and so on, which can be used in the diagnosis of biliary and pancreatic diseases by.MRCP using heavy T2 weighted technique, the T2 relaxation time is high in the high signal bile duct, and the organs containing liquid in the stomach and duodenum are clear. It shows and contrasts with the surrounding tissue. The duodenal papillary diverticulum (PAD) refers to the diverticulum located in the 2~3cm of the duodenum papilla. Because of its anatomical location and the particularity of the relationship between the bile duct and the pancreatic duct, the duodenal nipple diverticulum sometimes causes the disease of the biliary and pancreatic system, which is called the Lemmel 's syndrome in clinical. Because PAD often combines the bile. Pancreatic diseases, and many studies have confirmed that PAD is associated with choledocholithiasis and the occurrence of [2-6]., but the lack of specificity of the papillary diverticulum of the duodenum is lacking, and it is not subject to clinical attention. It is easy to cause misdiagnosis and missed diagnosis. Its diagnosis mainly depends on gastrointestinal imaging, ERCP and other imaging techniques, with the increasing clinical application of MRCP. Many cases of papillary diverticulum have also been found to be increasing.
The purpose of this study was to summarize the characteristics of the duodenal para papillary diverticulum in MRCP and MRI images, and to explore the diagnostic value of MRCP on the para papillary diverticulum and its relationship with the biliary and pancreatic diseases according to the relationship between the para papillary diverticulum and the biliary pancreatic duct on MRCP.
Material method
From January 2010 to September 2013, the MRCP imaging data and clinical data of 45 patients with PAD confirmed by EPCP in the MRI room of the Second Affiliated Hospital of Zhengzhou University were examined, including 21 males and 24 females, with an average age of 71 years. The imaging data of these 45 patients were analyzed retrospectively. All the cases were 3D-MRCP sequence and axial fat suppression T2WI sequence. The FIESTA sequences, the breath holding axis and the coronal LAVA three phase enhanced sequence scan were held. After MIP post-processing, the images were read independently by two senior medical doctors, and the diagnosis and differential diagnosis were made after the consensus was reached. The signal characteristics, location and measurement diverticulum were summarized by the image of PAD on MRCP and MRI. The number of cases of biliary and pancreatic diseases combined with PAD were classified, and the relationship between PAD diameter, location and choledocholithiasis without combined choledocholithiasis was statistically analyzed, and SPSS17.0 software was used for statistical analysis.
Result
45 cases of PAD, 2 cases of multiple diverticulum, a total of 47.MRCP manifestations of the internal capsule of the duodenum descending segment, 29 (61.8%) visible PAD neck and duodenal mucosa continuous, the axial fat suppression T2WI sequence is manifested as the right posterior duodenal pancreatic head of the cystic shadow, the boundary is clear, visible part of the pancreatic head uncinate burial, and the junction of the head of the pancreas The edge was sharp and clear. 26 PAD (55.3%) visible air and liquid plane.LAVA three enhanced scanning diverticulum was not strengthened, the wall of the diverticulum was thin and smooth, with the signal of intestinal mucosa. The display rate of PAD on the MRCP image after MIP was 65.9% (31/47), and MRCP image + original thin layer MRCP image + axial T2WI sequence to PAD was 95.6% (45/47). There was a significant difference between the two groups (P0.05).
The incidence of PAD with choledochic and pancreatic diseases was 80% (36/45), of which choledocholithiasis was 44.4% (20/45). The PAD with choledocholithiasis had a larger diameter. The difference was statistically significant compared with the PAD diameter without common bile duct stones (P0.05). There was no significant difference between the peripheral and horizontal diverticulum and the common bile duct stones (P0.05).
conclusion
1, the papillary diverticulum of the duodenum has a typical characteristic in the MRCP image. MRCP is more accurate for the location and qualitative diagnosis of the duodenal paravillum diverticulum. The combination of 3D-MRCP and axial T2WI sequence can be used as a priority selection sequence for the diagnosis of duodenal papilla diverticulum by.MRCP combined with MRI scan and enhanced scan for the biliary and pancreatic systems. When the disease is diagnosed in time, it suggests the correlation between diverticulum and diseases of biliary and pancreatic system, so as to provide help for clinical diagnosis, diagnosis and treatment.
2, the size of the peripapillary diverticulum may be related to the formation of common bile duct stones.
【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R445.2;R574.51

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