弥漫性肝病的超声与病理对比分析

发布时间：2018-09-14 19:14

【摘要】：目的：探讨多普勒超声判断弥漫性肝病病变程度的应用价值。方法：回顾性分析2010年~2013年于山西医科大学第一附属医院感染科就诊，经超声引导下肝穿刺活检确诊的112例弥漫性肝病患者的多普勒超声检查资料，按临床及病理穿刺结果所得疾病种类分别针对每一种弥漫性肝病的超声特点进行总结性分析，其中慢性乙型肝炎按肝实质回声分为弥漫性改变组、弥漫性不均匀性改变组、弥漫性网格状改变组、弥漫性网格状伴结节形成组，与10例健康志愿者作为对照组进行组间比较，比较的指标有肝右叶最大斜径、门静脉内径及其流速、肝动脉峰值流速、阻力指数、脾脏大小（脾脏厚径、脾脏长径、脾脏解剖长径）；药物性肝病的分析方法同上；非酒精性脂肪性肝炎分为轻度弥漫性改变组、中度弥漫性改变组、重度弥漫性改变组，与10例健康志愿者作为对照组进行组间比较，比较指标同上；而自身免疫性肝炎、原发性硬化性胆管炎、原发性胆汁性肝硬化、Gilbert综合症这4种疾病均不进行分组，分别将其与10例健康志愿者作为对照组进行比较，比较指标同上，同时还重点观察肝内、肝外胆管走行；管壁回声；胆囊壁回声等。结果： 1.慢性乙型肝炎（41例） ①弥漫性改变组11例，弥漫性不均匀性改变组14例，弥漫性网格状改变组9例，弥漫性网格状伴结节形成组7例。 ②弥漫性网格状伴结节形成组的肝动脉峰值流速（71.47±4.87cm/s）、阻力指数（0.73±0.04）、脾脏解剖长径（14.64±2.17cm）均与其它四组存在统计学差异；而其门静脉内径（1.25±0.16cm）、门静脉流速（16.20±2.65cm/s）、脾脏厚径(4.49±0.52cm)同对照组、弥漫性改变组、弥漫性不均匀性改变组间存在统计学差异；弥漫性网格状改变组的门静脉内径（1.20±0.08cm）同对照组、弥漫性改变组存在差异，门静脉流速（17.16±2.78cm/s）和肝动脉峰值流速（65.42±4.21cm/s）同对照组存在差异，脾脏解剖长径（13.84±1.06cm）同对照组、弥漫性改变组、弥漫性不均匀性改变组间存在统计学差异；弥漫性网格状伴结节形成组和弥漫网格状组的肝右叶最大斜径均同对照组有差异。 ③弥漫网格状伴结节形成组中有2例可见脾脏肋下及边。 2.药物性肝病（37例） ①弥漫性改变组6例，弥漫性不均匀性改变组7例，弥漫性网格状改变组13例，弥漫性网格状伴结节形成组11例 ②弥漫性网格伴结节形成组门静脉内径（1.29±0.11cm）、门静脉流速（16.36±2.31cm/s）、肝动脉峰值流速（72.87±5.17cm/s）、阻力指数（0.73±0.06）、脾脏的长径（12.64±1.03cm）、解剖长径（14.20±2.56cm）均同其它四组存在统计学差异；弥漫网格状改变组门静脉内径（1.21±0.09cm）、阻力指数（0.67±0.02）、脾脏的长径（12.01±0.91cm）、解剖长径（13.56±1.89cm）均同对照组和弥漫性改变组存在差异，而肝动脉峰值流指数（66.11±5.31cm/s）仅同对照组有差异。 ③弥漫网格状组中有2例可见脾脏肋下及边；弥漫网格状伴结节形成组中为3例。 ④3例病理结果为肉芽肿性病变的在超声上的表现均为弥漫不均匀性改变，另有2例病理结果显示为重度肝细胞及毛细胆管性淤胆，其声像图上可见肝实质回声呈弥漫性改变，肝内管壁回声增强，胆囊呈重度炎性改变。3.非酒精性脂肪性肝炎（14例） ①轻度弥漫性改变组7例，中度弥漫性改变组5例，重度弥漫性改变组2例。②重度弥漫性改变组其门静脉内径（1.23±0.12cm）与正常对照组、轻度弥漫性改变组比较均有显著的差异；而门脉血流速度（16.87±2.14cm/s）与其它三组无统计学差异；肝动脉峰值流速（70.47±2.65cm/s）和阻力指数（0.74±0.03）均与其它三组存在统计学差异，而脾脏解剖长径（12.37±0.61cm）同对照组有统计差异。中度弥漫性改变组的门静脉内径（1.18±0.11cm）同对照组存在差异，肝动脉峰值流速（65.32±3.43cm/s）同对照组和轻度弥漫性改变组存在差异。 4.自身免疫性肝炎（11例）9例肝实质回声较低，增粗，欠均匀，2例为弥漫性改变；3例肝内管壁回声增强；7例胆囊壁增厚，2例胆囊腔缩小，2例为胆囊实体样改变；肝门淋巴结肿大3例；9例脾脏增大（3个径线均同对照组有差异），7例肝大（肝右叶最大斜径14.39±1.56与对照组有差异）；CDFI示肝内血流无特殊变化。 5.原发性硬化性胆管炎（5例）3例肝内散在的片状强回声；3例胆总管壁呈不均匀性增厚（厚约0.34—0.45cm）致管腔不规则狭窄，呈僵硬的高回声带，狭窄上段胆管扩张不明显；1例肝外胆管壁回声增强伴管壁增厚，3例肝内胆管壁回声增强；2例可见肝内三级胆管局限性扩张；5例均出现胆囊壁毛糙并不均匀性增厚，约0.28—0.38cm，伴胆结石1例；2例肝大，3例脾大（厚径和解剖长径同对照有统计学差异）；未见肝门淋巴结增大；肝动脉峰值流速（72.57±3.21cm/s）、阻力指数（0.71±0.06）均增高，相比较对照组有差异，门脉流速（18.07±1.26cm/s）与对照组比较有差异，门静脉内径（1.06±0.22cm）与对照组无差异。 6.原发性胆汁性肝硬化（1例）肝右叶最大斜径14.21cm，，提示肝脏增大；肝实质回声呈略增粗或细密样稍强回声改变；肝内血管走形相对正常；胆囊壁毛糙；脾脏3个径线为10.4cmX4.1cm X13.8cm提示脾大；门静脉内径1.28cm；CDFI示门静脉血流速度为16.21cm/s，肝动脉峰值流速78.23cm/s、阻力指数0.78。 7.Gilbert综合症（3例）1例肝实质回声略增强呈弥漫性改变，2例为肝内回声增粗欠均匀；肝右叶最大斜径无统计学差异，3例脾脏均大（长径及解剖长径同对照组有差异），CDFI示肝内血流无特殊变化。结论： 1.通过对弥漫性肝病患者的超声检查发现：肝实质回声，胆道系统，门静脉内径及其流速，肝动脉峰值流速及阻力指数，脾脏的大小，均可很大程度上反映肝脏病变的严重程度及发展趋势。 2.在非肝炎病毒所致肝损伤中药物性肝病所占的比例较大（本文占52.11%），超声提示肝脏有损伤时，在除外病毒性肝炎后多应想到有药物性肝病的可能。 3.自身免异性肝病早期的临床诊断有一定困难,本文通过对11例自身免疫性肝炎、5例原发性硬化性胆管炎、1例原发性胆汁性肝硬化的病例分析得出，在超声检查中应注意以下几点： ①对于有肝脏增大同时病毒学检查指标阴性者，应考虑自身免疫性肝炎的可能； ②对于胆汁郁积者,多观察胆管壁是否增厚以及管腔狭窄的严重程度，不要将管壁增厚变窄的胆管、狭窄上段的胆管轻度扩张视为正常的胆管，提高原发性硬化性胆管炎的诊断率； ③对于肝硬化门脉高压的患者，通过观查肝脏的形态和回声及血流情况，以注意有无原发性胆汁性肝硬化的存在。
[Abstract]:Objective: To explore the diagnostic value of Doppler ultrasound in diffuse liver disease.
Methods: The data of Doppler ultrasonography in 112 patients with diffuse liver disease diagnosed by ultrasound-guided liver biopsy in the Department of Infection, the First Affiliated Hospital of Shanxi Medical University from 2010 to 2013 were retrospectively analyzed. Summary analysis showed that chronic hepatitis B patients were divided into diffuse change group, diffuse inhomogeneous change group, diffuse reticular change group, diffuse reticular change group, diffuse reticular with nodule formation group, and 10 healthy volunteers as control group. The index of comparison was the maximum oblique diameter of right lobe of liver, the diameter of portal vein and its diameter. Flow velocity, peak hepatic artery flow velocity, resistance index, spleen size (spleen thickness, spleen length, spleen anatomical length); analysis methods for drug-induced liver disease were the same; non-alcoholic steatohepatitis was divided into mild diffuse change group, moderate diffuse change group, severe diffuse change group, and 10 healthy volunteers as control group. Compared with 10 healthy volunteers as control group, autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and Gilbert syndrome were not divided into four groups. Echo; gallbladder wall echo.
Result:
1. chronic hepatitis B (41 cases)
(1) There were 11 cases in diffuse change group, 14 cases in diffuse inhomogeneous change group, 9 cases in diffuse grid change group and 7 cases in diffuse grid with nodule formation group.
(2) The peak hepatic artery velocity (71.47 There was significant difference between the two groups in diffuse inhomogeneous changes, and in the diffuse reticular changes, the internal diameter of portal vein (1.20 + 0.08cm) was different from that of the control group, the portal vein velocity (17.16 + 2.78 cm / s) and the peak hepatic artery velocity (65.42 + 4.21 cm / s) were different from those of the control group, and the anatomical length of spleen (13.84 + 1.06c). M) There was significant difference between diffuse change group and control group, diffuse change group, diffuse inhomogeneous change group, diffuse reticular nodule formation group and diffuse reticular group, and the maximum oblique diameter of right lobe of liver was different from control group.
3. In the diffuse grid with nodule formation, 2 cases showed the spleen under the ribs and edges.
2. drug-induced liver disease (37 cases)
(1) There were 6 cases in diffuse change group, 7 cases in diffuse inhomogeneous change group, 13 cases in diffuse grid change group, and 11 cases in diffuse grid with nodule formation group.
(2) The internal diameter of portal vein, portal vein velocity, hepatic artery peak velocity, resistance index, spleen length and anatomical diameter of diffuse reticular nodule formation group were significantly different from those of the other four groups. Diameter (1.21 [0.09cm], resistance index (0.67 [0.02]), spleen length (12.01 [0.91 cm], anatomical length (13.56 [1.89cm]) were significantly different from the control group and diffuse change group, but the peak flow index (66.11 [5.31 cm / s] of hepatic artery was only different from the control group.
(3) Subcostal and marginal spleens were seen in 2 cases of diffuse reticulation group and 3 cases of diffuse reticulation with nodule formation group.
(4) The ultrasonographic manifestations of 3 cases with granulomatous lesions were diffuse and heterogeneous, and 2 cases with severe hepatocytic and capillary cholestasis showed diffuse changes in the echo of liver parenchyma, enhanced echo of intrahepatic duct wall and severe inflammation of gallbladder. Hepatitis (14 cases)
There were 7 cases in mild diffuse change group, 5 cases in moderate diffuse change group and 2 cases in severe diffuse change group. Peak arterial flow velocity (70.47 (+2.65 cm/s) and resistance index (0.74 (+0.03)) were significantly different from those of the other three groups, while splenic anatomical length (12.37 (+0.61 cm) was statistically different from that of the control group. There were differences between mild diffuse group and mild diffuse group.
4. 9 cases of autoimmune hepatitis (11 cases) had low echo of hepatic parenchyma, thickening and inhomogeneous, 2 cases had diffuse changes; 3 cases had enhanced echo of intrahepatic duct wall; 7 cases had thickened gallbladder wall, 2 cases had narrowed gallbladder cavity, 2 cases had solid changes of gallbladder; 3 cases had enlarged hilar lymph nodes; 9 cases had enlarged spleen (3 diameters were different from the control group); 7 cases had enlarged liver (right hepatic duct). The maximum oblique diameter of the lobe was 14.39 + 1.56, which was different from that of the control group. CDFI showed no special changes in blood flow in the liver.
5. Three cases of primary sclerosing cholangitis (5 cases) had scattered sheet echoes in the liver; three cases had irregular stenosis of the common bile duct wall (about 0.34-0.45 cm thick), stiff hyperechoic cords, and no obvious dilatation of the upper bile duct; one case had enhanced echoes of the extrahepatic bile duct wall with thickening of the duct wall; three cases had enhanced echoes of the intrahepatic bile duct wall; Limited dilatation of the third-grade intrahepatic bile duct was seen in 1 case, roughness and uneven thickening of the gallbladder wall in 5 cases, about 0.28-0.38 cm, with gallstones in 1 case, hepatomegaly in 2 cases, splenomegaly in 3 cases (thickness and anatomical diameter were the same as the control group), no enlargement of hilar lymph nodes, peak velocity of hepatic artery (72.57 + 3.21 cm/s) and resistance index (0.71 + 0.06). Compared with the control group, the portal vein velocity (18.07 + 1.26 cm/s) was different, and the internal diameter of portal vein (1.06 + 0.22 cm) was not different.
6. Primary biliary cirrhosis (1 case), the largest oblique diameter of the right lobe of the liver was 14.21 cm, suggesting enlargement of the liver; slightly enlarged or dense echoes of the liver parenchyma; relatively normal blood vessels in the liver; rough gallbladder wall; splenomegaly with 3 diameter lines of 10.4 cm X 4.1 cm X 13.8 cm; portal vein internal diameter of 1.28 cm; portal vein blood flow velocity with CDFI The degree was 16.21cm/s, the peak velocity of hepatic artery was 78.23cm/s, and the resistance index 0.78..
7. In Gilbert syndrome (3 cases), 1 case showed diffuse enhancement of hepatic parenchyma echo, 2 cases showed inhomogeneous enhancement of intrahepatic echo, the largest oblique diameter of the right lobe of the liver had no statistical difference, 3 cases had large spleen (the length and anatomical diameter were different from those of the control group), and CDFI showed no special changes of intrahepatic blood flow.
Conclusion:
1. Ultrasound examination of diffuse hepatopathy showed that echo of liver parenchyma, biliary system, diameter and velocity of portal vein, peak velocity and resistance index of hepatic artery, and size of spleen could reflect the severity and development trend of hepatopathy to a great extent.
2. Drug-induced liver disease accounts for a large proportion of non-hepatitis virus-induced liver injury (52.11%). When ultrasound indicates liver injury, the possibility of drug-induced liver disease should be considered after excluding viral hepatitis.
3. The early clinical diagnosis of autoimmune heterosexual liver disease is difficult. Through the analysis of 11 cases of autoimmune hepatitis, 5 cases of primary sclerosing cholangitis and 1 case of primary biliary cirrhosis, the following points should be paid attention to in ultrasonic examination:
(1) The possibility of autoimmune hepatitis should be considered in patients with liver enlargement and negative viral markers.
(2) For patients with cholestasis, more attention should be paid to the thickening of bile duct wall and the severity of lumen stenosis, not to the thickening and narrowing of bile duct wall, slight dilatation of the upper bile duct as normal bile duct, so as to improve the diagnosis rate of primary sclerosing cholangitis.
(3) For patients with cirrhosis and portal hypertension, the morphology, echo and blood flow of the liver were observed to observe the presence or absence of primary biliary cirrhosis.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R445.1;R575

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