IT 의료융합 1 차임상세미나 2013-4-3 복부질환초음파 이재영
나는오늘누구를위하여 종을울리나?
전통적의료 의사 공학설계자 의사 최첨단진단장비들 USG, CT, MRI 환자 환자 현대의료
사용자중심의사고
US in the Abdomen Detection DDx Look Behavior Response by external stimuli Guiding Tool
Abdominal Organs Liver Bile ducts Gallbladder Pancreas
I. Liver Disease Diffuse liver disease Focal liver lesions
Diffuse Liver Disease
Chronic Hepatitis Chronic inflammatory reaction Continues without recovery for > 6 months US findings Normal Coarse echogenicity Sensitivity: < 60% Specificity: < 60% Subjective No signs of cirrhosis
Chronic hepatitis: US Progression to cirrhosis Early detection of nodule formation
Liver Cirrhosis Irreversible fibrosis & regenerating nodule Diffuse throughout the liver Localized fibrosis or nodule: not cirrhosis Nodule formation (-): congenital hepatic fibrosis Causes Chronic viral hepatitis, Alcoholic liver disease Macronodular vs micronodular (3mm)
Liver cirrhosis Micronodular LC Macronodular LC
Surface Nodularity Coarse and increased parenchymal echo
Regenerating or Dysplastic nodules
Ascites and splenomegaly
Enlarged PV and Collaterals
PV thrombosis
Fatty Liver Most common diffuse liver disease Silent fatty liver Clinical importance Liver transplantation donor Focal fat sparing or deposit NASH Accumulation of TG within Hepatocyte Acquired, Reversible Disorder
Fatty Liver: US findings Increased parenchymal echogenicity Obliteration of PV wall echo Increased sonic attenuation Hardly visible diaphragm
Increased Parenchymal Echo Severe + Obliteration of PV Wall + Nonvisualized Dø Mild Moderate
Fatty Liver: Distribution Diffuse Uneven Lobar, segmental, subsegmental Focal fat sparing vs focal fat deposit
Focal Fat Sparing
Summary Diffuse liver disease Hard to diagnosis Subjective Overlaps of US findings between diseases Focal liver disease Characteristic gray scale US findings Use More Options Harmonics Color & Power Dopplers Transducer with multifrequency
A hepatic focal lesion
1. Hyperechoic rim Strongly suggesting hemangioma
2. Hypoechoic rim Highly suggesting malignant disease HCC Metastasis Abscess
HCC
Colon cancer Carcinoid GB cancer Lymphoma EHE
3. Anechoic lesion
Cyst with artifacts
II. Bile Duct Disease
Value of US in Bile Duct 1. Primary screening tool for biliary disease > 90%: Obst. Jaundice vs. Nonobst. Jaundice 2. Supportive tool for biliary disease 60-92%: Can evaluate the location of Obst. 39-71%: Can evaluate the reason of Obst. Due in part to difficulty in identifying distal CBD in as many as 8% of patients. CT: location (97%) and cause (94%)
1 2 3 4
Clinical Application of BD USG To exclude biliary disease To evaluate IHD stones To analyze involved ducts To evaluate the site and cause of obstructive jaundice
Intrahepatic biliary calculi
Clonorchis sinensis infestation
Suprapancreatic CBD lesion
III. Gallbladder Disease
How to measure wall thickness
Gallbladder Stones
Strong points of US in GB stones Sen, Spe, Accuracy > 95 ~ 99% Caution in scanning Position change Completely filled GB Stones Tumefactive sludge Very slow movement Waiting > 5 min after position change
54/F A 1.2 cm diameter gallbladder polyp A. Conventional USG B. CI C. CI + SRI D. CI + THI
Tubular adenom
Fundal Adenomyoma
Pitfalls of GB USG Miss a fundal lesion Reverberation artifact Folding of the GB Two chambered GB Miss GB neck or cystic duct lesion Masking lesion in the GB Misinterpret Beam thickness artifact When contracted Adjacent bowel or stomach
IV. Pancreatic Disease
Pancreatic US Echogenicity Same as or higher than liver Aging: Echogenecity Size Pancreatic duct < 2 mm on USG Clinically very limited d/t surrounded by bowel Clinical applicaton For F/U of cystic lesions in head and body For aspiration and biopsy For intervention
Summary Bile duct Primary screening tool for biliary disease > 90%: Obst. Jaundice vs. Nonobst. Jaundice Supportive tool for biliary disease GB Very strong in GB stones, polyps and adenomyomatosis High resolution USG is useful Pancreas Very limited in use F/U for cystic lesions of H and B
Update of Ultrasound 1. Elastography 2. Fusion Imaging 3. Contrast-enhanced US
1. Liver Elastography
Liver Biopsy in HF Long represented the gold standard Drawbacks Invasiveness A morbidity of 1/1000 A mortality of 1/10000 Potential sampling errors Need for less-invasive diagnostic tests for hepatic fibrosis
A 46-year-old male with chronic viral hepatitis B AP EP
Courtesy of Scott Friedman, ISDA annual meeting, 2007
2. Fusion Imaging Definition: To create cross-sectional images of CT or MR volume data that correspond to the angle of the transducer in the magnetic field in real time Available in several vendors US machine (GE, Philips, Esaote, and Hitachi)
3. Contrast-enhanced US To characterize liver nodule To guide inconspicuous tumor on US To detect post-tx residual tumor To evaluate local recurrence
Enhancement pattern summary 3-5
When I was in USA
Spoke Wheel pattern of FNH FNH in a 14-year-old girl. Chung E M et al. Radiographics 2010;30:801-826
Final Summary Detection Image quality DDx Look Behavior Response by external stimuli Guiding Tool
감사합니다!