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ai biliareAnatomia imagistica acailor biliare intra siextrahepatice
Aspecte normale si
patologice
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patologice Anatomia cilor biliare
intrahepatice(CBIH)- CBIH au originea n canalicule intralobulare cu
vrsare n canalele perilobulare i n spaiile porte;
- Cile biliare sunt grupatempreun cu ramurile
arteriale i portaleincepand cu spatiile porte;- Distribuia cilor biliare intrahepatice se suprapune
distribuiei venei porte;
- Fiecrui pedicul venos segmentar i sunt acolateunul sau dou canale biliare ce se dirijeaz ctrehilul hepatic pentru a forman final cele doucanale hepatice drept i stng.
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Anatomia cilor biliare
intra/ extrahepatice
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Anatomia cilor biliare
intrahepatice
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Anatomia cilor biliare
extrahepatice
-Anatomia cilor biliare extrahepatice: calea biliar principal(CBP) i vezicula biliar (VB);
-CB EXTRAHEPATICE ncep la unirea dintre cele dou canale(ductul hepatic drept i stng)ce formeaz canalul hepatic
comun
(anterior de VP) ce se ntinde pn la unirea cucanalul cistic (CC), dup care poart denumirea de canalcoledoc;
-CBP : un segment hilar;un segment intraepiploic;
un segment retroduodenopancreatic;un segment intraparietal-VB: rezervor membranos aplicat pe faa inferioar a ficatului;-VB i se descriu trei zone: fundul; corpul dispus oblic
ascendent catre posterior si spre stanga; colul ce se
continu cu canalul cistic.
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Anatomia cilor biliare
extrahepatice (CBEH)
Dimensiunile normale ale CBP, DHC i CC
Coledoc: la nivelul ligamentul gastrohepatic :
- adolesceni/ aduli- diametrul ax: 5-6mm;diametrul ax>8-10 mm= dilataie;- dup 60 de ani cretere cu 1 mm/10 ani;- dup colecistectomie diametrul 8 mm;- nou-nscut diametrul
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Anatomia cilor biliare
extrahepatice (CBEH)
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Anatomia normala a
veziculei biliare (VB)
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Dimensiunile normale ale
veziculei biliare (VB) Lungime:
sugari L: 1,5-3 cm,
copii L: 3-7cm,aduli L: 7-10 cm; Capacitate:30-50ml; Grosimea peretelui: 2-3 mm; Volumul biliar/ zi:250-1000ml secretat
de hepatocite.
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Anatomia cilor biliare extrahepatice
-anatomia jonctiunii pancreaticobiliare
(a) (c)(b) (d)
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Tehnici de explorare radio-
imagistic Ecografia: abdominal, endoscopic; Computer-tomografia (CT); Imagistica prin rezonan magnetic (IRM) i
colangiopancreatografia RM (CPRM); Colangiografia transhepatic; Colangiopancreatografia endoscopic retrograd
(ERCP); Studiile radioizotopice: 99mTc-HIDA; Radiografia abdominal simpl: calcificri, acumulri
aerice; Colecistografia oral; Colangiografia:
(- oral, - intravenoasa, - percutanata, - intraoperatorie i postoperatorie petub Kher).
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Ecografia
- Metoda de primintenie
- diagnostic pozitiv i diferenial;- orientare spre o altmetodde explorare;
- Avantaje:- accesibilitate,- cost sczut,- repetabilitatemonitorizare;
- Sensibilitate diagnosticlimitatpentru:
- leziunile mici, de CBP distal,- litiaza de ci biliare nedilatate;
Operator i pacient dependent!
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Ecografia
- Sonde de 3,5-5 MHz;- n decubit dorsal, decubit lateral stng, curealizarea de seciuni axiale, oblice i sagitale,extremitatea cefalic pancreatic reprezint
fereastra acustic pentru coledoc;- Pacienii cu distensie aeric500 ml de apa reducerea gazelorvizualizarea capuluipancreatic si a CBP (95%);
- Poziia de Trendelenburgdecelarea calculului,prin migrarea acestuia din coledocul distal.
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Ecografia- Ecografie + adm. unui prnz grasevidenierea
calculilor prin creterea calibrului cii biliare n amontede obstacol;- Non vizualizarea colecistului n ecografie:status postcolecistectomie; mascat de grilajul costal;anomalii de poziie ( poziie subcostal/ intrahepatic);carcinom VB; perforaie VB; absen congenital;VBcontractat postprandrial.
Ecoendoscopia:
- Sonda de inalta frecventa7,5-12 MHz;- Aplicare sistematic dificil;- Explorare transduodenala capului de pancreas;CBP segment distal; regiunii ampulare; a raporturilor
vasculare.
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Ecografia
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Computer tomografia Mod secvenial nativ i cu contrast nonionic injectat iv;
La nivelul zonelor de decalibrare se realizeaza seciunifine de 2-3mm, contiguen vederea evidenieriiobstacolului.
Mod spiral + contrast iv - colimare: 3-6 mm; pitch: 1-1,5;
increment: 1,5-3 mm; reconstrucii MPR, MIP, 3D.
Bilancomplet: CB, pancreas, vase, leziuni asociate.
Colangio-CT: achiziia spiral post colangiografietransparietal.
Contrastul biliar oral sau n perfuzie iv este contraindicat
la pacienii cu bilirubin peste 2 mg%.
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Computer tomografia
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IRM i CPRM
Evaluare neinvaziva arborelui biliar;parenchimului hepatic i pancreatic;structurilor vasculare intra/extrahepatice;
Permite o evaluare fiziologica a arboreluibiliar in opozitie cu ERCP in carecontrastul injectat poate modifica situatiaanatomofiziologica normala;
Antena body sau phased array;Intensitate magnet peste 0,5 T.
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IRM i CPRM
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Colecistografia oral Actualmente n majoritatea centrelor
abandonat; rol limitat n evaluarea anatomiei ifunciei VB; Doz: 6x0,5g Razebil la 2 ore dup mas de
sear. Ex se realizeaz la 14-16 ore
postadministrare de contrast, cu VB n repleie idup administrarea prnzului Boyden (prnzulcolecistochinetic). Selecia pacienilor: bilirubinsub 5 mg%;
Contraindicaie relativ: pacieni cu hepatopatiigrave. Contraindicaie absolut: peritonit, ileuspostoperator, pancreatit acut. Toxicitate:grea, vrsturi; reacie anafilactic imediat;
reacie hipotensiv tardiv; insuficien renal.
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Colecistografia oral
Non vizualizarea colecistului n colecistografia oral Vrful de opacifiere a VB: la 14- 19 ore;
1. Cauze extrabiliare: absena ingestiei contrastului;absorbie intestinal deficitar; vrsturi, obstrucie
esofagian, obstrucie gastric; hernie inghinal, hiatal,ombilical; diverticuli: Zencker, epifrenic, gastric,duodenal, jejunal; ulcer gastric; fistul gastro-colic;diaree, malabsorbie; ileus postoperator; traumatismsever; inflamaii: pancreatit acut; peritonit: patologiehepatic: colestaz intra/ extrahepatic; fistule bilio-enterice, anastomoze chirurgicale; pancreatita acut;
2. Cauze intrinseci VB: colecistectomie; anomalii depoziie; obstrucie duct cistic; colecistit cronic
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Colangiocolecistografia iv Inlocuit de CPRM i ERCP;
Indicaie izolat: bilan nainte de colecistectomiacelioscopicdiagnostic de litiaz CBP i evaluareavariantelor anatomice;
Contrast: Pobilan/Biligrafin/Endocistobil, injectat iv lent(6-10 min) n doz de 20-40 ml in funcie de greutateacorpului. Cantiti mai mari de contrast introduse iv nurealizeaz o opacifiere mai bun a CB, excesul deprodus fiind eliminat pe cale renal. Examenulcolangiocolecistografic iv cuprinde dou etape: timpulcoledocian i timpul vezicular; pentru apreciereafunciei VB se poate administra prnzul Boyden;
Rezoluie mic n comparaie cu ERCP;
Reacii de hipersensibilitate: mortalitate 1/ 7000.
C l i fi
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Colangiografia
percutanat (CPT) Injectarea de substan de contrast iodat direct n
arborele biliar intrahepatic; Tehnic: ac Chiba 22G; PCI minim 300 mgI/ml; bolnav n
decubit dorsal premedicat;Reperaj fluoroscopic/ecografic- arbore biliar drept peLMA n plan orizontal, ac cu direcie uor ascendent nplanul arcului costal XIXII;
CTH are indicaie n special n bilanul icterelorobstructive de CBP proximalsau n cazurile n careERCP nu se poate realiza;
n obstacolul hilar este uneori necesar opacifiereaseparata arborelui biliar drept i stng;
Incidene oblice, opacifieri multiple; CPT ofero alternativdiagnosticsi terapeutic.
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COLANGIOGRAFIETRANSHEPATICA PERCUTANA(CPT)
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ERCP Pe cale endoscopic prin cateterizare papilei i
opacifierea CBP, a CBIH i a Wirsungului;
Avantajele ERCP:- Posibilitatea efecturii i la bolnavii cu tulburri de
coagulabilitate, evaluarea papilei, a regiunii ampulare,a CBP i a CBIH,
- Evitarea producerii pneumotoraxului,hemoperitoneului sau a coleperitoneului prin injectareacontrastului iodat direct n CBP;
ERCP este o metod diagnostic i terapeuticpermind drenajul biliar endoscopic, extragereacalculilor coledocieni transendoscopic, dilatareastenozelor biliare benigne sau maligne saupapilosfincterotomia endoscopic.
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ERCP
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Algoritmul de explorarea a CBIH, VB
i CBP Ecografia-examen iniialsistematic,-uneori suficientdiagnostic pozitiv,-alegerea strategiei de explorare suplimentar; Colangio-IRM-Inlocuiete tehnicile de opaciefiere,-Confirm sindromul obstructiv,-Diagnostic etiologic - stenoz malign/ benign, litiaz, etc;
CT spiral-Explorare canalar i parenchimatoas leziuni tumorale; Ecoendoscopiecazuri complexe; ERCP i CPTaproape exclusiv n scop terapeutic.
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Patologia cailor biliare de tip benign
I. Anomalii de dezvoltare a CB
Apare probabil secundar unor procese de tip inflamator
tip hepatit neonatal la care se adaug fenomene decolangit sclerozant i tulburri vasculare locale; Incidena de 10 cazuri/ 100.000 nou nscui, M/F- 2:1;
Clasificare :
tipul I (A):rar, afectare multifocal a arborelui biliar(injurii vasculare n viaa intrauterin);tipul II (B):atrezie de CBIH;tipul III (C):atrezie de CBP extrahepatic cu respectareaCBIH.
I.A.Atrezia congenitala de cai biliare
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Atrezia congenitala de caibiliareEco: creterea dimensiunilor ficatului/ ecogenitate
crescut; absena vizualizrii structurilor portaleperiferice datorit fibrozei; absena vizualizriiVB/ VB mic; absena vizualizrii CBIH; dilataiechistic CBP;
Colescint igraf ia:absena excreiei biliare;CPRM:VB atrofic; absena vizualizrii CBP;
ngroarea spaiilor periportale;Colangiografia (endoscopic/ intraoperatorie);Biopsia hepatic:acuratee: 60-97%.
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Atrezia congenitala de caibiliare
I B Chi t l d l d
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I.B.Chistul de coledocDilataie chistic a cii biliare extrahepatice
reprezentnd 50-80% din totalitatea leziunilorchistice localizate la nivelul CB; Raport F/B de3/1.
- Asocieri lezionale: dilatri, stenoze sauatrezii parcelare de arbore biliar, anomalii aleveziculei biliare, boal polichistic hepatic,carcinom de vezicul biliar;
- Clinic triada: icter intermitent febril, durericolicative hepatobiliare, tumefaciela nivelulhipocondrului drept.
C
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Chistul de coledoc
Complicaii: litiaza coledocian (8-70% din
cazuri), colangitele (20% din cazuri),degenerescena malign(3-28% din cazuri),ciroza biliar(1-13% cazuri), ruptura chistului cuperitonit biliar.
Eco:dilataie fuziform de CBP cu decalibrarebrusc;Scint igraf ia cu HIDA ;CPRM :confirm diagnosticul: dilataie marcat
de CBP extrahepatic, de obicei de tip sacular;CBIH- de aspect normal sau pot fi discretdilatate; decalibrarea dilataiei chistice de CBPse produce brusc.
Chi t l d l d
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Chistul de coledocClasificarea chisturilor de ci biliare:
(Clasificarea Todani)
Tip Ia.Chist coledocian pur; b.Dilataiesegmentar a cii biliare principale; c.Dilataie
fusiform difuz a cii biliare principale;Tip IIDiverticul coledocian;Tip IIIColedococel;Tip IVa.Dilataie chistic a cilor biliare
intrahepatice i a cii biliare principale; b.Chisturimultiple de cale biliar principal;
Tip VBoal Caroli.
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Chistul coledocian -Tipul I
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Chistul coledocian-Tipul I
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Chistul de coledoc
-Tipul I
Aspect tomografic, la un copil de 3,4ani, evideniid dilataia chistic a cii
biliare principale
Aspect intraoperator.Se remarc vascularizarea bogat ifenomene inflamatorii perichisticeintense.Acestea au determinat realizarea unuiabord intern al chistului.
colangiografie intraoperatorie
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Chistul de coledocTipul I
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Chistul de coledocTipul I
colangiocarcinom asociat
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Diverticul -Tipul II
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Diverticul
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Chistul de coledoc
-Tipul IV
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Chistul de coledoc
-Tipul V (Boala Caroli)
Boala Caroli
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Boala Caroli
Afeciune autosomal recesiv; ectazii localizate lanivelul canaliculelor biliare ce comunic cu multipledilataii neobstructive de tip sacular;
Incidena: rar; mai frecvent ntlnit la copii i ndecada a 2-a /a-3-a de vrst;
Asocieri lezionale: fibroz hepatic, chisturi de coledoc,boal polichistic renal; IRM: multiple dilataii de tip sacular ale CBIH cu
dimensiuni variate i distribuie n general difuz nntreg parenchimul hepatic.
Central dot signpozitiv, corespunde unui ram portalnconjurat complet de canaliculul biliar dilatat; Colangiografia transhepatic-afirmarea diagnosticului; Complicaii: litiaz biliar n 34% cazuri, cu leziuni de
tip inflamator (colangite, abcese), grefarea unui
colangiocarcinom sau fenomene de HTP
Boala Caroli
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Boala Caroli
Boala Caroli
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Boala Caroli
Monolobara
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I D V i t t i
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I.D.Variante anatomice
ale CB
Inciden: 2-4% la autopsie; 13-18% ncolangiografia intraoperatorie;
Ducte aberante intrahepatice: nproximitatea VB, CHC, CBP, CC, DHD;
CC cu vrsare n DHD; duplicaia CC;
fistula congenital traheobiliar(comunicare ntre carin i DHS).
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DUCTE HEPATICE ACCESORII A.DUCT HEPATIC ACCESORIU CARE SE
VARSA IN DUCTUL HEPATIC DREPT IN
FISURA TRANSVERSALA (porta hepatis); B. DISTANTA INTRE DUCTUL CISTIC SI
DUCTUL ACCESOR ESTE MAI MICA. DUCTULACCESORIU SE DESPRINDE SUBCAREFOUR-UL BILIAR;
C.DUCTUL CISTIC SE VARSA INTR-UN DUCTACCESORIU LANGA JONCTIUNEA CU
DUCTUL HEPATIC COMUN. DUCTULHEPATIC ACCESORIU ARE APROXIMATIVACELASI DIAMETRU CU CEL AL DUCTULUIHEPATIC COMUN;
D.ACELEASI CARACTERISTICI CA LAPUNCTUL C. DAR CU O DISTANTA MAI MICADE LA JONCTIUNEA DUCTULUI ACCESORIU
PANA LA CAREFOUR-UL BILIAR; E, F, I, J, H.DUCTURI ACCESORII CARE SE
VARSA IN CANALUL HEPATIC COMUN LADIFERITE NIVELURI;
G.DUCTUL CISTIC SE VARSA IN DUCTULHEPATIC DREPT LA 1 CM DISTANTA DEHILUL HEPATIC SI ARE ACELASI DIAMETRU
CU DUCTUL HEPATIC COMUN.
DUCTE HEPATICE
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DUCTE HEPATICE
ACCESORII
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Duplicatie de duct hepaticcomun FICAT, DUODEN SI DUPLICATIE
DE DUCT HEPATIC COMUN:
-DUCT HEPATIC COMUN;-DUCT HEPATOENTERIC(SEVARSA IN PORTIUNEASUPERIOARA A DUODENULUI
LA 1,5 CM DE PILOR);-SEGMENT ANASTOMOTICINTREDUCTUL HEPATIC COMUN SIDUCTUL CISTIC ;-DUCTUL COLEDOC(SE VARSAMULT MAI JOS IN PARTEA
DESCENDENTA A DUODENULUIIMPREUNA CU DUCTULPANCREATIC LA 8 CM DE PILORLA NIVELUL PAPILEIDUODENALE).
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INSERTII ALE DUCTELORBILIARE ABERANTE Locurile de insertie ale
ductelor biliare seimpart in doua marigrupuri generale:
-(grupa A)cele care sedeschid deasuprapilorului in stomac si
-(grupa B)situate la
nivelul duodenului panala ampula Vater.
Anatomia cilor biliare
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Anatomia cilor biliare
extrahepatice-Duct cistic.
Variante ale inseriei
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Variante ale inserieicanalului cistic (CC)
Inciden:18-23%Direcie.1. Craniocaudal
Inserie: proximal n regiunea hilar;n 1/3 medie a CBP extrahepatice (75% cazuri);
n 1/3 distal a CBP extrahepatice (10%);
2. MediolateralInserie: lateral dreapt; anterioar n spiral;posterioar n spiral; proximal; lateral joas;medial joas (n proximitatea ampulei Vater);
3. Inserie ntr-un duct biliar intrahepatic;
4. Absena CC: VB dreneaz direct n DHC.
V i t d i i l
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Variante de inserieale
canalului cistic (CC)
Variante anatomice:-insertie laterala dreapta (A ),-insertie anterioara spirala (B),-insertie posterioara spirala (C),
-insertie inferioara joasa lateralacu traiect paralel cu ductulheptic comun (D),-insertie proximala(E),
-sau insertie joasa mediala (F).
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II A C l it l t
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II. A. Colangita sclerozant
primitiv (CSP)
II.A. Colangita sclerozant
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II.A. Colangita sclerozant
primitiv (CSP)
Clinic: icter intermitent i prurit;Complicaiile: ciroza biliar, litiaza intrahepatic i de CBP,colangitele bacteriene, grefarea unui colangiocarcinom;
Eco:creterea ecogenitii triadei portale, dilataiimoniliforme;
CT: alternarea dilataiilor cu zone de stenoz; aspectde arbore iarna; atrofie lobar n zonele afectate;
IRM, CPRM:infiltraie inflamatorie periportal(hipersemnal T2), aspect monilifom CB;
Scint igraf iacu Tc-99m.IDA; Colangiograf ia.
II A Colangita sclerozant
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II.A. Colangita sclerozant
primitiv (CSP)
II B C l it l t d
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II.B. Colangite sclerozante secundare Cauze: colangite bacteriene cronice secundare
stricturilor biliare / coledocolitiazei; modificri CBpostischemice; colangita infecioas n SIDA; anomaliicongenitale arbore biliar; neoplasme CB; modificripostoperatorii CB;
Colangita oriental Sinonime: colangita piogen recurent, boala Hong
Kong, litiaza intrahepatic pigmentar; Reprezint o infecie cronic sau recurent a CB, ce
asociaz procese de tip inflamator n parenchimulhepatic adiacent, leziuni fibrotice periportale, inflamaii ifibroz a complexului sfincterian vaterian, litiaz biliarpigmentar (calculi bilirubinici).
Colangita secundara-bacteriana
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Colangita secundara-bacteriana(secundara unui colangiocarcinom)
Colangita secundara
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g( -la 6 luni postcolecistectomie,
-colangita infectioasa in SIDA)
C
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Colangita secundara(posttransplant hepatic)
Colangita oriental
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Colangita oriental
Complicaiile: abcesele (18% cazuri), atrofiesegmentar sau lobar, splenomegalie, biliom,colangiocarcinom;CT:priz de contrast la nivelul pereilor CB;
calculi hiperdeni;IRM:dilataie important a CBIH mari; stenozela nivelul ductelor hepatice; amputarea itergerea vizibilitii cilor biliare periferice;
imagini lacunare n hiposemnal T2 n lumenulCB (calculi bilirubinici sau sludge); atrofiehepatic segmentar; abcese;ERCP.
Colangita oriental
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Colangita oriental
(+ colangiocarcinom)
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Imagini lacunare n CBP
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Imagini lacunare n CBP Pseudocalcul: contracia sfincterului Oddi; Aer: seciuni axiale/ sagital; Cheaguri sanguine; Calculi biliari; Sindrom Mirizzi; Tumori
- maligne: colangiocarcinom, hepatom, rabdomiosarcomembrionar, hamartom, carcinoid, tumori metastatice(tract GI, pancreas, sn, melanom, limfom);- benigne: adenom, papilom, fibrom, lipom, sarcom,
mieloblastom; Parazii: ascarizi, schistosoma japonicum, chist hidatic.Material ecogen n CB: calculi; aer; snge; tumori; parazii.
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Litiaza biliar
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Litiaza biliar
Compoziia calculilor:
-colesterol (70%): transpareni (93%),calcificai (7%); discret hipodeni fa de bil;calculi de colesterol pur (transpareni); calculimicti (colesterol+bilirubin+calciu) radioopaci n15-20% din cazuri- vizibili radiografic;
-pigmentari (30%): conin biulirubin, calciu imic cantitate de colesterol; faetai; radioopaci;CT- hiperdeni.
Litiaza biliar
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Litiaza biliar Calculi opaci/transpareni:
- transpareni: 84%- colesterol (85%); pigmentari (15%)- calcificai: pigmentari (67%); colesterol (33%)
. vizibili radiografic: 15-20%
. vizibili CT: 60%Calcificri centrale: fosfat de calciu/ n calculii micticolesterinici.Calcificri radiare sau periferice: calciu carbonat ncalculii micti pigmentari.
Sludge (noroi biliar)apare n staza biliar i
corespunde unor granule de bilirubinat de calciu icolesterol. Eco: material ecogen dispus decliv, structurat sub
forma unui nivel orizontal fluid-sludge.
III.A.Litiaza intrahepatic
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p
Litiaza intrahepatic este rar ntlnit ca entitate de sine
stttoare; Dintre factorii predispozaniamintim: colangitele primare
i secundare, boala Caroli i ascarizii biliari; Complicaii: colangite, abcese hepatice, fistule;
Clinic: dureri n hipocondrul drept; icter intermitent;Ecograf iapoate evidenia dilataie de CBIH cu miciimagini ecogene n lumen cu sau fr con de umbrposterioar;CPRMCalculii- imagini lacunare n hiposemnal accentuat
T2, hiposemnal T1, contur net delimitat; Diag. dif.: aerobilia. Cantiti mici de aer n CBIH duc la
neomogeniti de semnal fiind dificil de diagnosticat prinIRM, CT fiind metoda de elecie n aceste cazuri.
III A Litiaza intrahepatic
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III.A.Litiaza intrahepatic
III.B.Litiaza de cale
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biliar principal (CBP) Este cea mai frecvent cauz de obstrucie biliar;
Incidena este de 12-15% la pacieniicolecistectomizai; de 3-4% la pacieniipostcolecistectomie; de 75%n obstruciile biliare
cronice; Factorii predispozani: litiaz de colecist, stenoza
CBP, colangitele sau disfuncia complexuluivaterian;
Complicaii: pancreatite acute, de stricturi CBP,fistule biliare, colangite sau abcese hepatice;
Clinic: dureri n hipocondrul drept, icter de apariie
recent.
III.B.Litiaza de cale
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biliar principal (CBP)
Eco.Sb: 22-82%- calcul vizibil n 13-75% (ncondiii de dilataie CBP i bun vizualizare acapului pancreatic;
CT. Sensibilitate (Sb): 88%, specificitate:97%,acuratee: 94%; calcul vizibil n 75-88% dincazuri (calcul mixt, cu calcificare inelarperiferic, calcul n tras la int);
CPRM.Sb 81-100%; Sp 85-100% (calculii
trebuie s fie mai mari de 2mm); Colangiograf ia.Calculii sunt vizibili n 92%; Colang iograf ia int raoperator ie.Fali negativi:
4%. Fali pozitivi: 4-10%.
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III B Litiaza de cale
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III.B.Litiaza de cale
biliar principal (CBP)
Calcul i in coledocul d istal .
III B Litiaza de cale
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III.B.Litiaza de cale
biliar principal (CBP)
III B Litiaza de cale
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III.B.Litiaza de cale
biliar principal (CBP)
III.B.Litiaza de cale
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biliar principal (CBP)
ERCP. Calcul impactat in ductul biliarcomun distal.
Imaginea fluoroscopica-multipliicalculi in ductul hepatic comun vazuti
in timpul ERCP-ului.
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III.C.Litiaza veziculei biliare
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Clinic- colici biliare n 30-35% din cazuri; asimptomatic n 60-65% dincazuri;
Complicaii: colecistita acut (30%c), coledocolitiaza, colangite,pancreatite, duodenite, ileus biliar, sindrom Mirizzi, neoplasm VB;
Rg abdominal simpl-Sb: 10-16% (calculii calcificai);Colecistografia oral-Sb: 65-90%; imagine lacunar unic/
multipl; aspectul ductului cistic; contractilitatea VB dupprnzul gras;
Eco -Sb: 91-98%; fali negativi n 5% cazuri. Imaginehiperecogen, mobil, cu con de umbr posterioar i artefactde reverberaie; calcificrile sub 2 mm pot s nu aib con de
umbr posterioar.Nevizualizarea VB cu prezena uneiacumulri ecogene cu con de umbr posterioar;
CT-Sb: 80%; calculi hiperdeni/ calcari-60%c; hipodeni -colesterinici; izodeni cu bila, nedetectabili CT n 21-24% dincazuri.
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III.C.Litiaza
veziculeibiliare
Calculi de colesterol in VB
Colelitiaza pe o colangiograma.Multiplii calculi radiotransparenti in VB
-PTCACalculi in VB formati in 4 ani
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Litiaza veziculei biliare
III C Litiaza biliar
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III.C.Litiaza biliar
III.D.Sindromul Mirizzi
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- Determinat de compresia lateral dreapt a ductului
hepatic comun prin calcul voluminos inclavat n canalulcistic/n reginunea infundibular VB/n bontul cisticnsoit de o reacie inflamatorie cronic;- Frecvent asociat cu apariia unei fistule ntre veziculabiliar i ductul hepatic comun;
- Sindromul Mirizzi apare mai frecvent la pacienii cuinserie anormal joas a canalului cistic n ductulhepatic comun sau la pacienii cu un cistic paralel cutraiectul ductului hepatic comun;- Triad: calcul inclavat n infundibulul VB; dilataie de
CB n amonte de abuarea cisticului n CBP; amprent istenoz excentric DHC;Colangiografie i CPRM:obstrucie parial DHC prin
compresie extrinsec.- Diag. dif: adenopatii, neoplasm de DHC i VB.
III D Si d l Mi i i
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III.D.Sindromul Mirizzi
PATOLOGIA VB
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Bil hiperdens Colecistit hemoragic; hemobilie; bilcalcica;
Contrast: ageniurografici/colecistoopaci/ paramagnetici(Multihance).
Deplasarea VB-Impresiune normal dat de duoden/ colon-Mase hepatice: hepatom, hemangiom, noduli de regenerare,
chist biliar, chist hidatic, abcese, granuloame
-Mase extrahepatice: tumori retroperitoneale; boalpolichistic renal; limfom; adenopatii hilare hepatice;pseudochist pancreatic.
PATOLOGIA VB
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VB mareHidrops vezicular- colecistomegalie
Dimensiune-copii sub 1 an L>3 cm; - copii L>7 cm; - aduli L > 10 cm
Obstrucie- obstrucie duct cistic; - litiaz; - colecistit culitiaza; - semnul Courvoisier pozitiv (tum pancreatic,
duodenal, papilar, ampulara, duct hepatic comun); -pancreatit; - infecii: leptospiroz, ascaridoz, febrtifoid, febr mediteranean
Nonobstrucie (neuropatic)
- vagotomie- diabet/ alcoolism/ apendicit/ analgezie /hiperalimentaie/acromegalie/ sdr Kawasaki /anticolinergice/ SIDA/deshidratare/ nutriie parenteral/ sepsis
Normal (2%)
PATOLOGIA VB
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VB mic: colecistit cronic; fibroz chistic: n 25% dinpacieni; hipoplazie congenital/ colecist multiseptat;postprandrial; colestaz intrahepaticVB cu perete ngroat difuzgrosime >3 mmCauze intrinseci: colecistit acut; colecistit cronic;colecistit xantogranulomatoas; colecistozhiperplazic; perforaie VB; sepsis; carcinom VB(41%difuz); SIDA; colangit sclerozant; varice VB; ischemie
Cauze extrinseci: hepatit; hipoalbuminemie; insuficienrenal; insuficien cardiac dreapt; hipertensiunevenoas sistemic; obstrucie vv hepatice; ascit;mielom multiplu; ciroz; leucemie mielogenic acut;brucelozFiziologic- postprandrial
PATOLOGIA VB
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VB cu perete ngroat focalizat Metabolic Tumori benigne: adenom, papilom, fibroadenom,
chistadenom, neurinom, hemangiom, carcinoid Tumori maligne: carcinom, leiomiosarcom,
metastaze (melanom, neoplasm bronhopulmonar,
renal, esofag, sn, carcinoid, sarcom Kaposi, limfom,leucemie). Inflamaii: polip inflamator; granulom parazitar, chist
epitelial intramural, colecistitxantogranulomatoas).
Calculi adereni la perete Hipertrofie de mucoas: esut pancreatic ectopic;
glande gastrice ectopice, glande intestinale ectopice,esut hepatic ectopic, esut prostatic ectopic.
Ad d VB
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Adenoame de VB
PATOLOGIA VB
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Imagini lacunare n VB Fixe: polipi; adenomiomatoz; neurinom;
tumori primare/ secundare; calculi aderenila peretele VB;
Mobile: sludge; cheaguri de snge; calculi;
Pneumobilia; hamartoame multiple;
VB: sinus Rokitansky-Aschoff; calculiintramurali; colesteroloz VB.
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Polipi colesterolici
IV. Patologie benigna veziculara asociatasau nu cu litiaza biliara Colecistita acut
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Vrst: decada a 5-a- a 6-a; B/F- 1:3.
a. Litiazic- inciden 80-95% secundarunui calcul inclavat n canalul cistic
b. Alitiazic- inciden 10% cazuri.
Eco.Sb-81-100%; Sp-60-100%. PereteVB>3mm (Sb- 45-72%; Sp-76-88%); aspectstratificat al peretelui; hidrops VB (diam
ax>5 cm); semnul Murphy ecografic pozitiv(Sb:63-94%; Sp:85-93%); fluidpericolecistic; calculi intraveziculari, n
canalul cistic; sludge
IV.A.Colecistita acut
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CT cu contrast iv:VB destins; perete cu grosime peste3mm, hiperdens; coninut VB densificat; fluid
pericolecistic; modificri de perfuzie hepatic n fazprecoce cu iodofilie tranzitorie n parenchimulpericolecistic;CPRM(Sb mare). Hiposemnal T2 inelar nconjurandhipersemnalul lichidului biliar.
Complicaii: abcesul pericolecistic; sindromul Mirizzi;gangrena; colecistita emfizematoas; sindromBouveret (calcul ce a erodat peretele VB, migrat nlumenul duodenal pe care-l obstrueaz); ileusul biliar(migrarea calculului VB n tractul gastrointestinalsecundar fistulei bilio-digestive i inclavarea acestuia
n zonele de ngustare ale tractului digestiv-unghiulTreitz, valv ileocecal, colon sigmoid).
IV A C l i tit t
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IV.A.Colecistita acut
IV.A.Colecistita acutalitiazica(asociata cu adenomiomatoza)
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(asociata cu adenomiomatoza)
Colecistita acut
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C l i tit t liti i
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Colecistita acutlitiazica
Colecistita acutlitiazica (calcul
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(
inclavat in colul VB)
Colecistita acut-complicatii
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Colecistita acut complicatii(colecistita gangrenoasa, calcul inclavat)
Colecistita acut
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(gangrenoasa) si duodenita
Colecistita acut- (perforatie
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veziculara asociata cu colecistita
gangrenoasa)
Colecistita acut- perforatie cu
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Colecistita acut perforatie cuabces hepatic
Colecistita acut
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hemoragica
IV.B.Colecistita acut emfizematoas
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Asocierea ischemiei peretelui VB cu infecia
determinat de microorganisme productoare de gaz(Costridium perfringens, E coli, Staphylococus,Streptococus);
Factori predispozani: diabetul, obstrucie litiazic/alitiazic de canal cistic; boli debilitante;
Rg abdominal simpl: acumulrihipertransparente pe aria de proiecie a VB la 24-48 de ore de puseul acut; nivel hidroaeric n
lumenul VB, n peretele VB; pneumobilie;Eco:litiaz VB (50% c); imagini hiperecogene
arcuate ce contureaz peretele VB;
IV.B.Colecistita acutemfi ematoas
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emfizematoas
Complicaie: gangrena; perforaia; Diag.dif.: fistula enteric; incompeten sfincter
Oddi; abces periduodenal; abces periapendicularn ectopia apendicelui;
Colecistita gangrenoas-apare la imunodeprimai;evolueaz spre necroz parietal i perforaie;
Perforaia vezicular se poate face intraperitoneal,
n tubul digestiv (duoden,colon) cu apariia uneiaerobilii sau se poate colecta n patul VB subforma unui abces perivezicular.
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Colecistita acut
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emfizematoas
IV. C.Fistula colecistoenteric
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Etiologie: litiaz biliar (90%) acut/ cronic; colecistit; neoplasmCBP; diverticulit; boli inflamatorii de intestin subire; ulcer peptic;traumatisme; comunicare congenital; iatrogen;
Comunicare cu: duodenul (70%), colonul (26%), stomacul (4%),jejunul, artera hepatic, vena port, arborele bronic, pericardul,bazinetul, ureterul, vezica urinar, ovarul, vaginul;
Fistul: colecistoduodenal (50-80%); colecistocolic (13-21%);coledocoduodenal (13-19%); fistule multiple (7%);
Aspecte imagist ice: pneumobilie- imagini transparente tubulare cepredomin n poriunea central a ficatului; opacifierea CB de ctrebariu/ Gastrografin;VB mic mimnd un diverticul de bulb duodenal;imagini multiple hiperecogene cu umbr posterioar vag.
Triada diagnostic: sindrom ocluziv, aerobilie si opacitate litiazic.Rg abdominal simpl i mai ales CTevideniaz cu sensibilitatecrescut aceste modificri.
IV.D.Ileusul biliar
Fistula biliara
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Ileus biliar
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IV.E.Colecistita cronic
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Este o inflamaie cronic a pereilor veziculeibiliare;
Anatomopatologic procesul inflamator cronicintereseaz toate tunicile parietale, pereteledevenind gros i fibros;
Reprezint cea mai frecvent inflamaie acolecistului;
Cauzele ce duc la apariia colecistitei cronicesunt litiaza veziculei biliare i obstrucia de
canal cistic; Peretele VB este cu grosime crescut n medie
de 5 mm cu contur regulat sau neregulat.
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IV.F.Colecistitaxantogranulomatoas
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xantogranulomatoas
Este ncadrat n inflamaiile cronice aleveziculei biliare simulnd att clinic ct iimagistic un carcinom vezicular. Inciden: 1-2%.Vrst: decada 7-8.n 11% din cazuri este
asociat cu neoplasmul VB;Eco.VB cu perete ngroat neregulat; nodulihipoecogeni intraparietali;CT.Noduli hipodeni intraparietali (5-20 mm);
priz de contrast heterogen; Diag.dif: neoplasmul VB (59% focal, 41% difuz).
Colecistita
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xantogranulomatoas
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Vezicula de porelan
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Reprezint depunerea de carbonat de calciu nperetele VB. Inciden de 0,6-0,8% la pacienii
colecistectomizai; B/F- 1:5. Asociat cu litiaza VB n 90% din cazuri.
Eco:imagine hiperecogen cu umbrposterioar n patul colecistic.CT:imagini calcare n peretele VB; coninuthiperdens.Colecistografia oral:VB exclus.
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Colesteroloza Corespunde unor depozite anormale de colesterol n macrofagele
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Corespunde unor depozite anormale de colesterol n macrofageledin lamina propria. Exist dou forme: vezicula frag(ngroaredifuz a pereilor VB i litiaza colesterinic n 50-70%c); polipul
colesterolic: imagine lacunar unic/ multipl fixat la peretele VB.
Adenomiomatoza focal i difuz a VB. Inciden-5% din pacienii
colecistectomizai; vrsta peste 35 de ani; M/F-1:3. Exist 4 tipuri:difuz (adenomiomatoza)- ingrosare difuza si pseudodiverticuli;segmentar (infundibul);localizat n regiunea fundic(adenomioma)- ingrosare focalizata ce asociaza imaginidiverticulare; inelar septat; Se poate asocia cu calculiintraveziculari si in 33% din cazuri cu colesteroloza.
Eco.Aspect de coad de comet- artefact produs ntre cristalele decolesterol n sinusul Rokitansky- Aschoff.
Adenomiomatoza focaldifuz a VB
Adenomiomatoza focal
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difuz a VB
Adenomiomatoza focalf
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difuz a VB
Adenomiomatoza focaldif VB
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difuz a VB
Stenoz CBP
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Benign(44%): Sunt rezultatul complicatiilor
chirurgicala iatrogene in 90-95%. Restulcazurilor fiind reprezentate de stricturi aparuteposttraumatisme penetrante, in chistul decoledoc; colangit sclerozant; colangitrecurent cu piogeni; pancreatit acut/ cronic;pseudochist pancreatic; ulcer duodenal perforat;colecistit litiazic; abces; postradioterapie;stenoz papilar; SIDA; fibroza retroperitoneala;adenopatii compresive; pancreas ectopic; tumori
benigne (adenoame, hamartoame); varice inperetele CBP.
Adenoame de CBP
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Adenoame de CBP
Papilomatoza biliara
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Pancreatita cronica
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Stenoza papilara
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Adenopatie compresiva
Patologia cilor biliare de tip
li C l i i l
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malign- Colangiocarcinomul
Colangiocarcinomul intrahepatic cu originea nepiteliul CBIH mici; vrsta: 50-60 ani; B>F.Extensie de-a lungul CB, n parenchimul hepatic; meta ggl (15%). Masde 5-20 cm, cu noduli satelii, calcificri punctiforme (18%).
Eco.Mas omogen/ heterogen hiperecogen(75%), izo/hipo (14%);dilataie de CBIHn periferia tumorii. Uneori mas chistic. CT.Mas omogen rotund, hipodens cu margini neregulate;
hipocaptant; iodofilie mic, fugage, precoce, n periferie cu progresiancrcrii spre centrul tumorii, periferia splndu-se (semnul splriiperiferice).ncrcareomogen tardiv(74%).
IRM.Mas heterogen cu hiposemnal T2 central- fibroz, hipersemnalperiferic (tumor viabil), hiposemnal T1, hiperfixant postGadolinium.
Angio.Mas avascular/ hipo/ hipervascular.
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Colangiocarcinomul (CC) centrohilar(tumora Klatskin)
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( )
Clasificarea Bismuthcuprinde 4 tipuri de CC:-Tipu l I:tumor la nivelul ductului hepatic comun curespectarea bifurcaiei.-Tipu l II:tumora infiltreaz ductul hepatic comunextinzndu-se la nivelul bifurcaiei.-Tipu l IIIa:afectarea ductului hepatic comun, a bifurcaieicu extensie la nivelul hepaticului drept i ramificaiilor deordinul doi ale acestuia.-Tipu l IIIb :afectarea ductului hepatic comun, a bifurcaiei,tumora extinzndu-se la nivelul hepaticului stng iramificaiilor biliare stngi.-Tipu l IV:extensia tumorii de la nivelul ductului hepaticcomun, la nivelul hepaticului drept, stng i a ramificaiilorde ordinul doi.
Colangiocarcinomul extrahepaticCC de CBP (DHC i coledoc)
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CC de CBP (DHC i coledoc)
Exist forma:-obstructivcu amputaie n U sau V (70-85%)-stenozant(10-25%), margini neregulate,aspect rigid; dilataie CB n amonte.
-vegetant (polipoid)(5-6%).
Extensie limfatic (48%), infiltraie nparenchimul hepatic (23%);determinri
peritoneale (9%); nsmnri hematogene-rare (ficat, plmn, peritoneu).
Colangiocarcinomul
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Colangiocarcinomul
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Fig- 4 tipuri de colangiocarcinom:Tipul Exofitic;Tipul Infiltrativ;Tipul Polipoid;Tipul Mixt (intra si extracanalar).
Colangiocarcinomul
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Co a g oca c o u
Colangiocarcinomul (CC)
intrahepatic centrohilar
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(tumora Klatskin)
Colangiocarcinomul (CC)
intrahepatic centrohilar
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Colangiocarcinomul
extrahepatic
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extrahepatic
Colangiocarcinomul
extrahepatic
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extrahepatic
ChistadenocarcinomulTumor malign chistic multilocular cu originea n CB;
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Tumor malign chistic multilocular cu originea n CB;Se poate supraaduga hemoragia intratumoral; exist
multiple neregulariti de tip nodular la nivelul pereilor;calcificri grosieretumor rar, chistic, multilocular cupunct de plecare n CBIH. Inciden maxim: decada a 5a.
Eco:mas anecogen/ hipoecogen cu septuri ecogenen interior, delimitat de un perete gros ecogen (mimeazCHH).
CT:se prezint sub forma unei leziuni circumscrise cuperei groi,cu coninut fluid sau parafluid (mucinos/gelatinos) ce conine in interior septuri ce delimiteazmultiple caviti chistice. Iodofilie prezent la nivelulpereilor i septurilor.
IRM:aspectul componentelor chistice variaz funcie decantitatea de proteine coninut.
Ang io:mas avascular, deplasarea structurilorvasculare din vecintate.
Complicaii: ruptura tumorii intra sau retroperitoneal.
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Patologia cilor biliare de
tip malign
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tip malign Carcinomul hepatocelular (CHC)
Invazia de ci biliare este rar ntlnit n CHC.CPRM:stenoze neregulate n formele infiltrative saumase polipoide procidente intralumenal.
- cea mai frecvent tumor hepatic primar (80-90%) - 60-90% din CHC apar pe un ficat cirotic.
- factori de risc: ciroza (alcoolic); hepatita cronic;carcinogeni (hormoni, aflatoxin, thorotrast).
- mas solid unic/ multipl/ form difuz.
- 24% incapsulat; calcificri (10-20%c); invazie vascular(48%).- meta: pulmonare; suprarenale; osoase; ganglioni.- fetoproteina crescut la 90% din pacieni.
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Carcinomul hepatocelular(CHC)
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(CHC)
IRM:caracterizarea superioar a structurii intratumorale;hiposemnal/ hipersemnal T1 (Cu, snge, grsime),hipersemnal T2; capsula hiposemnal T1 i hipo/hipersemnal T2; comportare similar post contrast
paramagnetic cu ex CT. SPIO amelioreaz detecianodulilor de mici dimensiuni.Scint igraf iacu Tc-HIDA, Gallium.Angiograf ia:vase de neoformaie, unturi arterio-
venoase.Metastazelepot determina : zone de stenoz,obstrucie, deplasri, amputri, tergereaarborizaiei biliare normale
Carcinomul hepatocelular
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(diagnostic diferentialcolangiocarcinomulperiferic exofitic)
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Metastazele recurenta tumorala
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dupa adenocarcinom pancreatic)
CTiIRM-bilan preterapeutic.Inciden: 0 4-4 6 din pacienii supui interv chir pe CB;
Carcinomul veziculei biliare
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Inciden: 0,4-4,6 din pacienii supui interv. chir. pe CB;cel mai comun neo. biliar.
Vrsta medie : 73 ani. Asociat cu litiaza biliar, veziculade porelan, colecistita cronic, polipii VB;colangitasclerozant primitiv chistul de coledoc. Sediul deelecie- regiunea fundic (60%c).
Eco:mas ce nlocuiete VB, heterogen; tumor
inseparabil de ficat; mici imagini ecogene (calculi/calcificri). CT i IRM:stadializarea exact :ngroarea focal sau
difuz asimetric a peretelui vezicular; masa tumoralpericolecistic hipocaptant cu zone de necroz incluse;
n 90% din cazuri litiaza vezicular asociat. Contraindicaiile unei rezecii chirurgicale: atingerea
parenchimului hepatic (segmentele IV si V) n contact cupatul vezicular; infiltrarea CB este frecvent (60-90%dincazuri); prezena adenopatiilor celiace si pediculare;
nglobarea venei porte si a arterei hepatice
Adenocarcinomul
veziculei biliare
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veziculei biliare
Adenocarcinomul
veziculei biliare
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veziculei biliare
Carcinomul veziculei
biliare
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biliare
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Patologia cilor biliare de tipmalign
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Metastazele veziculare: apar n- cancerul de ovar,melanoame i rar n alte tipuri de tumori primare. Suntasociate cu metastaze hepatice. O forma particulareste hidrocolecistul secundar unei metastaze culocalizare la nivelul cisticului. Imagistica estenespecific
Neoplasme extrabiliare,extrahepatice cuinvazie de ci biliare
Tumorile periampulare(cefalice pancreatice, de regiuneampular, duodenale invazive) evaluate CT i mai alesIRM i CPMR pot prezenta, fie aspectul de stop total alCBP la contactul cu procesul tumoral, fie semnuldublului duct, adic dilataie de coledoc i ductpancreatic.
Metastazele veziculare
(melanom)
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(melanom)
Tumorile periampulare
(adenocarcinom pancreatic)
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(adenocarcinom pancreatic)
Carcinom pancreatic
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Carcinomul ampular
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Carcinom duodenal
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periampular
Patologia cilor biliare de cauztraumatic, iatrogen,
postoperatorie
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postoperatorie Incidena leziunilor de CB posttraumatisme
abdominale este rar (sub 0,1%).Mecanismul: dilacerare hepatic extins la
nivelul DH.
Complicaii: obstrucia biliar; biliom;extravazarea de bil; atrofia parial de ficat .
Eco, CT: colecie fluid (biliom).IRM: stenoze,amputaie de cale biliar; colecie cu semnal
lichidian dezvoltatn contiguitate cu un ram biliar(biliom).Colangiografie iv: extravazarea substanei de
contrast din CB.
Patologia cilor biliare de cauztraumatic, iatrogen,
postoperatorie
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postoperatorie Complicaii biliare dup proceduri percutanate
- Colangiografia transhepatic percutanatcu acChiba, incidena complicaiilor: de aproximativ 1,8%.Complicaii postCTH: bacteriemia, hematomulsubcapsular, fistula biliar, biliomul, peritonita, fistula
arteriovenoas, fistula vasculobiliar.CPRMpoate evidenia, n anumite cazuri, imaginiadiionale cilor biliare ce caracterizeaz fistulelebiliare iatrogene.Fistule arteriovenoase sau vasculobiliare: explorate
prin CTS cu contrast sau angio-RM.- Drenajul biliar externincidena complicaiilor: 10-15% din cazuri.- Biopsia hepaticrata complicaiilor: sub 1% .
Leziuni posttraumatice deCBIH (laceratie LD dupa
t ti )
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traumatism)
Leziuni posttraumatice deCBIH (bilioame hepatice
tt ti )
http://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12Fhttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12Ehttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12Dhttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12Chttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12Bhttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F12A8/13/2019 127597391-33-Cai-Biliare
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posttraumatice)
Leziuni de VB posttraumatice
(laceratia VB)
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( )
Complicaii biliare dupproceduri percutanate (biopsie
hepatica-hematom)
http://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F11Chttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F11Bhttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F11Ahttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F10Bhttp://radiographics.rsnajnls.org/cgi/content/full/24/5/1381/F10A8/13/2019 127597391-33-Cai-Biliare
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p )
Patologia cilor biliare de cauztraumatic, iatrogen,
postoperatorie
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postoperatorie Complicaii dup colecistectomie
- Stenoza ductului hepatic comun. Incidena dup colecistectomiaconvenional este de aproximativ 0,1%; 0,6% dup colecistectomialaparoscopic.- Extravazarea de bilpostcolecistectomie se produce fie de lanivelul bontului restant de canal cistic, fie prin leziunile parietale decanal hepatic comun sau canal hepatic drept. Extravazarea de bilpoate duce la apariia unei peritonite biliare, unui biliom sau unuiabces.- Sindromul postcolecistectomie, reprezint persistena/ recurenasimptomatologiei de tip biliar dup colecistectomie.Cauzele : -biliare : chirurgie incomplet (calculi restani n bontulcistic sau migrai la nivelul CBP), stenoze iatrogene de duct hepaticcomun, extravazare de bil, patologie de coledoc (fibrozacomplexului sfincterian vaterian, dischinezie biliar);- extrabiliare:pancreatite, hepatite cronice.- Calculii biliari migrai n CBP sau restani n bontul cistic
Complicaii dupcolecistectomie (calculi
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reziduali)
Complicaii dup colecistectomie(hematom in fosa VB;
duct hepatic drept aberant cu anastomoza
bili t i )
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bilioenterica)
Complicaii dup colecistectomieBiliom
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Patologia cilor biliare de cauztraumatic, iatrogen,
postoperatorie
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postoperatorie Stenoza postanastomoz hepaticojejunal
Stenozele cicatriciale postchirurgicale sunt scurte; aspect nespecific.20-23% din pacienii cu hepaticojejunostomie dezvolt stenoze cufenomene de colangit sau litiaz. Mecanismele ce duc la apariia
stenozelor anastomotice sunt reprezentate de procesele de fibroz ineoplasmele recurente.Semne imagistice (CPRM, CTH): dilataii de CBIH; stenoz de la nivelulgurii de anastomoz.Fibroza: stenoz scurt, limitat zonei de anastomoz, limite nete dedemarcaie.
Recidiv tumoral: mas tisular neregulat ce amputeaz i tergevizibilitatea anastomozei.n comparaie cu CTH, CPRM supraestimeaz zonele de stenoz, ERCPeste n majoritatea acestor cazuri imposibil de realizat.
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ColedocojejunostomieHepaticojejunostomie
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Patologia cilor biliare de cauztraumatic, iatrogen,
postoperatorie
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p p
Complicaii biliare posttransplant hepatic:stenoza gurii de anastomozanastomoza coledococoledocian incidenastenozei: 5%,
anastomoza coledocojejunal inciden: 27%dincazuri. Cauze: fibroz sau sutur anastomoticfoarte strns.IRM:evideniaz existena unei stenoze scurte, lanivelul anastomozei, cu limite net trasate.CTH:tratament percutanat.
Complicaii biliare
posttransplant hepatic
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p p p
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Hemobilie
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Pneumobilie dupasfincterotomie
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Lrgirea ductului hepatic comun decauze neobstructive
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Pasajul unui calcul (revenire la normal dup zile/sptmni) Postchirurgical (revenire la normal dup 30-60 de
zile)
Postcolecistectomie Hipomotilitate intestinal Variant de normal la vrstnici Ecografie + prnz gras cuplat permite
diferenierea de procesele obstructive prinmsurarea diam DHC nainte i la 45, 60 de mindup stimulare. Sb: 74%; Sp: 100%.
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Va multumesc.
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