MRCP在梗阻性黄疸中医辨证分型的应用研究
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摘要
目的：
通过对磁共振胰胆管成像(MRCP)、磁共振成像(MRI)影像分析，探讨磁共振胰胆管水成像(MRCP)在梗阻性黄疸中医辨证分型中，阳黄、阴黄影像改变，确定MRCP在中医黄疸中的应用价值。
方法：
对72例梗阻性黄疸患者，同时进行MRI及MRCP检查。其中男性49例，女性23例，年龄9岁～85岁，平均57.82岁。肝内肿瘤性病变17例、肝外肿瘤性病变25例、胆总管结石12例、先天性胆管囊肿8例、炎性病变10例。全部研究对象均常规进行MRI扫描和MRCP扫描，有详尽、完整的临床和(或)手术及病理资料。怀疑为占位性病变患者还进行动态增强MRI扫描。
MRI检查前准备：禁食4-12小时以上，有利于显示胆囊和胆管。扫描即刻口服静脉用钆喷酸葡胺(Gd DTPA)可减少胃肠道伪影。并在检查开始前对病人进行呼吸训练，为检查期间屏气做充分准备。
全部病例均使用美国GE Signa Contour 0.5T中场超导磁共振机。使用柔软表面体部线圈(QD Body FlexⅡ)常规T1WI、T2WI及脂肪抑制序列扫描。MRCP采用单次激发、单次屏气(SSFSE Long TE Cholangio Slab TE：1273.8，Band Width：10.42，Fov 35，Scan Time：3s，Slice Thickness：80～90，spacing：0.0，Freq：256，Phase 160，NEX：1.00 and SSFSE Short TE Cholangio-Slab，TE：288.0，Band Width：10.42，Fov 35，Scan Time：2s，Slice Thickness：80～90，spacing：0.0，Freq：256，Phase：160，NEX：1.00)扫描和屏气多层2DFSE(SSFSE Cholangio Thin Slice TE：1273.8，Band Width：10.42，Fov 35，Scan Time：24～26s，Slice Thickness：10.0，spacing：0.0，Freq：256，Phase：160，NEX：1.00)扫描方法。对屏气困难，难以长时间屏气的患者，采用呼吸门控下RTr FSE MRCP(TE：260，Band Width：10.42，Echo Train Length Fov 40，Scan Time：360s，Slice Thickness：3.0，spacing：0.0，Freq：256，Phase：160，NEX：4.00)多层2D MRCP扫描。
根据祖国医学理论，同时结合现代医学影像学，研究中医黄疸辨证分型。将全部观察对象分为阳黄和阴黄两大证型。对全部梗阻性黄疸病例进行常规T1WI、T2WI及脂肪抑制序列和MRCP扫描。通过影像表现与阳黄和阴黄证型对比分析，建立梗阻性黄疸的中医辨证分型的医学影像客观指标。
肝外胆管扩张程度与阳黄和阴黄的相关性。根据Guibaud等的关于胆管扩张程度的分法，将胆管扩张分为三度即轻度、中度、重度。
轻度：胆总管直径大于7mm，仅有肝外胆管扩张者为轻度；
中度：胆总管直径大于10mm，肝内胆管扩张程度2／3者为中度；
重度：胆总管直径大于13mm，肝内胆管扩张程度大于2／3者为重度。
肝内胆管扩张形态软藤状、枯枝状与阳黄和阴黄的相关性。
结果：
72例梗阻性黄疸病例，清晰显示扩张的肝内胆管、总胆管，和(或)扩张的胰管。从统计数据分析，阳黄构成比41.66％，阴黄55.34％；阳黄主要以结石、炎症、先天囊肿为主；阴黄主要以肝内、肝外肿瘤为主。阳黄平均年龄46.7，阴黄平均年龄61.31。经统计学分析，肝外胆管扩张程度与阳黄和阴黄呈有差别高度显著性相关(u=5.1998，P＜0.005)，阴性黄疸患者的肝外胆管扩张程度以重度和中度为主，占38／42；阳性黄疸患者的肝外胆管扩张程度以轻度和中度为主，占28／30。从统计表中可以看出，阳黄和阴黄两者之间，肝外胆管扩张程度同时也存在有部分交叉。经统计学分析，肝内胆管扩张形态与阳黄和阴黄呈有差别高度显著性相关(X~2=26.462，P＜0.005)，阴性黄疸患者的肝内胆管扩张形态以软藤状为主，占38／42；阳性黄疸患者的肝内胆管扩张形态以枯枝状为主，占17／24。从统计表中可以看出，阳黄和阴黄两者之间，肝内胆管扩张形态同时也存在有部分交叉。
结论：
MRCP图像清晰，MRCP能清楚显示扩张肝内胆管、胆总管、胆囊的形态、扩张部位以及与周围组织结构的关系。可以立体、多角度、全面地观察梗阻程度、梗阻部位的形态、范围，为中医临床提供直观的、有价值的影像资料，是梗阻性黄疸的理想诊断手段。对梗阻性黄疸中医辨证分型的诊断具有客观影像诊断指标，是一种直接、有效、安全、可靠的方法。
Purpose: To evaluate the value of the magnetic resonance cholangiography (MRCP) in diagnosing Syndrome types of TCM jaundice of Yin-Huang and TCM jaundice of Yang-Huang to obstructive jaundice by analyzed image of MRCP and MRI.
Materials and Methods: 72patients with obstructive jaundice were performed both MRCP and MRI, whom contents 49male and 23female from 9 to 85 years old, the average age is 57.82. Including 17 cases of intrahepatic tumor formation, 25 cases of per hepatic tumor formation, 12 cases of common bile duct stones, 8 cases of congenital cyst and 10 cases of inflammation. All of them has specificated clinical or surgical and histopathologic data. The one who been suspected has tumor formation should perform intensive MRI scan.
Absolute diet for 4 to 12 hours before the MRI examination can display bile duct and gallbladder clearly. The 3%compound solution of Gd-DTPA was taken to restrain the high signals from remaining liquid in stomach .Tell the patients take breath treatment to prepared for hold-breath during the examination.
Use GE Signa Contour 0.57 ( USA) Magnetic Resonance Imaging machine, performed in QD Body Flex II normal T1WI, T2WI and STIR (shot tall inversion recovery) . SSFSE Long TE Cholangio Slab TE: 1273.8, Band Width: 10.42, For 35, Scan Time: 3s, Slice Thickness: 80-90, spacing: 0.0, Freq: 256, Phase: 160, NEX: 1.00.And in SSFSE Cholangio Thin Slice TE: 1273.8, Band Width: 10.42, Fov35, Scan Time: 24-26s, Slice Thickness: 10.0, spacing: 0.0, Freq: 256, Phase: 160. NEX: 1.00. The one who can not hold breath for long time performed with RTr FSE MRCP TE: 260, Band Width: 10.42, Echo Train Length Fov40, Scan Time: 360s, Slice Thickness: 3.0, spacing: 0.0, Freq: 256, Phase: 160, NEX: 4.00.
Using the theory of the TCM and modern medical image, make detachment of all the data in to Syndrome types of TCM jaundice of Yin-Huang with TCM jaundice of Yang-Huang. Establish the objective assess styles of it. The correlation in extent of dilatation of perihepatic bile duct and the Syndrome types of TCM jaundice of Yin-Huang and Yang-Huang, in the Guibaud grades of dilatation of common bile duct there have three styles:
I. the diameter of common bile duct more than 7mm, only have dilatation in perihepatic bile duct;
II. the diameter of common bile duct more than 10mm, the dilatation of intrahepatic less than two-thirds;
III. the diameter of common bile duct more than 13mm, the dilatation of intrahepatic more than two-thirds.
The correlation with dilatation shape and Syndrome types of TCM jaundice of Yin-Huang and Syndrome types of TCM jaundice of Yang-Huang.
Results:
The images of all the bile ducts and pancreatic duct were showed clearly, of all cases included 41.66% of Yang-Huang, which contents stones, inflammations and congenital cyst, consist of style I and II, the majority shape style is soft canes-like, the average age is 46.7; 55.34%of Yin-Huang, which contents both intrahepatic and perihepatic tumor formation, consist in style II and III, the majority shape style is soft bines-like, the average age is 61.31. In statistics, there shown highly relationships between grades of dilatation and Syndrome styles, also shown distinct relationships between shapes and Syndrome styles, obviously distinction between the Yin-Huang and Yang-Huang.
Conclusion:
MRCP can reveal the conformation, location of the common bile duct, gallbladder and the relationship of the texture around them clearly, give a solid objective opinion to diagnoses Syndrome types of TCM in obstructive jaundice.
通过对磁共振胰胆管成像(MRCP)、磁共振成像(MRI)影像分析，探讨磁共振胰胆管水成像(MRCP)在梗阻性黄疸中医辨证分型中，阳黄、阴黄影像改变，确定MRCP在中医黄疸中的应用价值。
方法：
对72例梗阻性黄疸患者，同时进行MRI及MRCP检查。其中男性49例，女性23例，年龄9岁～85岁，平均57.82岁。肝内肿瘤性病变17例、肝外肿瘤性病变25例、胆总管结石12例、先天性胆管囊肿8例、炎性病变10例。全部研究对象均常规进行MRI扫描和MRCP扫描，有详尽、完整的临床和(或)手术及病理资料。怀疑为占位性病变患者还进行动态增强MRI扫描。
MRI检查前准备：禁食4-12小时以上，有利于显示胆囊和胆管。扫描即刻口服静脉用钆喷酸葡胺(Gd DTPA)可减少胃肠道伪影。并在检查开始前对病人进行呼吸训练，为检查期间屏气做充分准备。
全部病例均使用美国GE Signa Contour 0.5T中场超导磁共振机。使用柔软表面体部线圈(QD Body FlexⅡ)常规T1WI、T2WI及脂肪抑制序列扫描。MRCP采用单次激发、单次屏气(SSFSE Long TE Cholangio Slab TE：1273.8，Band Width：10.42，Fov 35，Scan Time：3s，Slice Thickness：80～90，spacing：0.0，Freq：256，Phase 160，NEX：1.00 and SSFSE Short TE Cholangio-Slab，TE：288.0，Band Width：10.42，Fov 35，Scan Time：2s，Slice Thickness：80～90，spacing：0.0，Freq：256，Phase：160，NEX：1.00)扫描和屏气多层2DFSE(SSFSE Cholangio Thin Slice TE：1273.8，Band Width：10.42，Fov 35，Scan Time：24～26s，Slice Thickness：10.0，spacing：0.0，Freq：256，Phase：160，NEX：1.00)扫描方法。对屏气困难，难以长时间屏气的患者，采用呼吸门控下RTr FSE MRCP(TE：260，Band Width：10.42，Echo Train Length Fov 40，Scan Time：360s，Slice Thickness：3.0，spacing：0.0，Freq：256，Phase：160，NEX：4.00)多层2D MRCP扫描。
根据祖国医学理论，同时结合现代医学影像学，研究中医黄疸辨证分型。将全部观察对象分为阳黄和阴黄两大证型。对全部梗阻性黄疸病例进行常规T1WI、T2WI及脂肪抑制序列和MRCP扫描。通过影像表现与阳黄和阴黄证型对比分析，建立梗阻性黄疸的中医辨证分型的医学影像客观指标。
肝外胆管扩张程度与阳黄和阴黄的相关性。根据Guibaud等的关于胆管扩张程度的分法，将胆管扩张分为三度即轻度、中度、重度。
轻度：胆总管直径大于7mm，仅有肝外胆管扩张者为轻度；
中度：胆总管直径大于10mm，肝内胆管扩张程度2／3者为中度；
重度：胆总管直径大于13mm，肝内胆管扩张程度大于2／3者为重度。
肝内胆管扩张形态软藤状、枯枝状与阳黄和阴黄的相关性。
结果：
72例梗阻性黄疸病例，清晰显示扩张的肝内胆管、总胆管，和(或)扩张的胰管。从统计数据分析，阳黄构成比41.66％，阴黄55.34％；阳黄主要以结石、炎症、先天囊肿为主；阴黄主要以肝内、肝外肿瘤为主。阳黄平均年龄46.7，阴黄平均年龄61.31。经统计学分析，肝外胆管扩张程度与阳黄和阴黄呈有差别高度显著性相关(u=5.1998，P＜0.005)，阴性黄疸患者的肝外胆管扩张程度以重度和中度为主，占38／42；阳性黄疸患者的肝外胆管扩张程度以轻度和中度为主，占28／30。从统计表中可以看出，阳黄和阴黄两者之间，肝外胆管扩张程度同时也存在有部分交叉。经统计学分析，肝内胆管扩张形态与阳黄和阴黄呈有差别高度显著性相关(X~2=26.462，P＜0.005)，阴性黄疸患者的肝内胆管扩张形态以软藤状为主，占38／42；阳性黄疸患者的肝内胆管扩张形态以枯枝状为主，占17／24。从统计表中可以看出，阳黄和阴黄两者之间，肝内胆管扩张形态同时也存在有部分交叉。
结论：
MRCP图像清晰，MRCP能清楚显示扩张肝内胆管、胆总管、胆囊的形态、扩张部位以及与周围组织结构的关系。可以立体、多角度、全面地观察梗阻程度、梗阻部位的形态、范围，为中医临床提供直观的、有价值的影像资料，是梗阻性黄疸的理想诊断手段。对梗阻性黄疸中医辨证分型的诊断具有客观影像诊断指标，是一种直接、有效、安全、可靠的方法。
Purpose: To evaluate the value of the magnetic resonance cholangiography (MRCP) in diagnosing Syndrome types of TCM jaundice of Yin-Huang and TCM jaundice of Yang-Huang to obstructive jaundice by analyzed image of MRCP and MRI.
Materials and Methods: 72patients with obstructive jaundice were performed both MRCP and MRI, whom contents 49male and 23female from 9 to 85 years old, the average age is 57.82. Including 17 cases of intrahepatic tumor formation, 25 cases of per hepatic tumor formation, 12 cases of common bile duct stones, 8 cases of congenital cyst and 10 cases of inflammation. All of them has specificated clinical or surgical and histopathologic data. The one who been suspected has tumor formation should perform intensive MRI scan.
Absolute diet for 4 to 12 hours before the MRI examination can display bile duct and gallbladder clearly. The 3%compound solution of Gd-DTPA was taken to restrain the high signals from remaining liquid in stomach .Tell the patients take breath treatment to prepared for hold-breath during the examination.
Use GE Signa Contour 0.57 ( USA) Magnetic Resonance Imaging machine, performed in QD Body Flex II normal T1WI, T2WI and STIR (shot tall inversion recovery) . SSFSE Long TE Cholangio Slab TE: 1273.8, Band Width: 10.42, For 35, Scan Time: 3s, Slice Thickness: 80-90, spacing: 0.0, Freq: 256, Phase: 160, NEX: 1.00.And in SSFSE Cholangio Thin Slice TE: 1273.8, Band Width: 10.42, Fov35, Scan Time: 24-26s, Slice Thickness: 10.0, spacing: 0.0, Freq: 256, Phase: 160. NEX: 1.00. The one who can not hold breath for long time performed with RTr FSE MRCP TE: 260, Band Width: 10.42, Echo Train Length Fov40, Scan Time: 360s, Slice Thickness: 3.0, spacing: 0.0, Freq: 256, Phase: 160, NEX: 4.00.
Using the theory of the TCM and modern medical image, make detachment of all the data in to Syndrome types of TCM jaundice of Yin-Huang with TCM jaundice of Yang-Huang. Establish the objective assess styles of it. The correlation in extent of dilatation of perihepatic bile duct and the Syndrome types of TCM jaundice of Yin-Huang and Yang-Huang, in the Guibaud grades of dilatation of common bile duct there have three styles:
I. the diameter of common bile duct more than 7mm, only have dilatation in perihepatic bile duct;
II. the diameter of common bile duct more than 10mm, the dilatation of intrahepatic less than two-thirds;
III. the diameter of common bile duct more than 13mm, the dilatation of intrahepatic more than two-thirds.
The correlation with dilatation shape and Syndrome types of TCM jaundice of Yin-Huang and Syndrome types of TCM jaundice of Yang-Huang.
Results:
The images of all the bile ducts and pancreatic duct were showed clearly, of all cases included 41.66% of Yang-Huang, which contents stones, inflammations and congenital cyst, consist of style I and II, the majority shape style is soft canes-like, the average age is 46.7; 55.34%of Yin-Huang, which contents both intrahepatic and perihepatic tumor formation, consist in style II and III, the majority shape style is soft bines-like, the average age is 61.31. In statistics, there shown highly relationships between grades of dilatation and Syndrome styles, also shown distinct relationships between shapes and Syndrome styles, obviously distinction between the Yin-Huang and Yang-Huang.
Conclusion:
MRCP can reveal the conformation, location of the common bile duct, gallbladder and the relationship of the texture around them clearly, give a solid objective opinion to diagnoses Syndrome types of TCM in obstructive jaundice.
引文
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31．熊肇明，汤光宇，钱明平．MRCP与ERCP对胆胰系疾病诊断价值比较．中国微创外科杂志，2005，5(7)：549-550
32．周健，贾乾斌，彭其芳．MRCP评估医源性胆管狭窄的临床价值．腹部外科2004，17(3)：185-186
33．刘杰，宋彬，徐隽，等．MRCP在肝外胆管梗阻中的诊断价值[J]．中国普外基础与临床杂志，2005，12(2)：188-189
34．江东新，蔡立华，袁术文．MRCP在梗阻性黄疸诊断中的应用价值 中国医师杂志2005年12月第7卷第12期1617
35．张琴，刘平 肝硬化黄疸中医证型研究．中西医结合肝病杂志，2001，11(3)：139-141
36．孙均，安江，徐彦斌1肝性黄疸的中医证型标准及其化验指标的相关性研究报告．中医研究，2000，13(5)：20
37．张菁，成伟忠，陆敏，等1肝复康治疗肝炎肝硬化顽固性黄疸的临床观察．上海中医药杂志，2003，37(1)：12-14
38．唐仪强 118例黄疸的B超声像图与中医分型的关系 江苏中医1999年第20卷第1期·15·
39. Guibaud L, Bret PM, Reinhddc, et al. Bile Duct Obstruction and Choledoc holithiasis: Diaggnosiswith MR Cholangiography. Radiology 1995. 192(1): 109-115
40．John T．Hansen，Bruce M．Koeppen et all奈特人体生理学彩色图谱 人民卫生出版社 2005年4月 主译 朱大年
41. Vaghese JC et al. Diagnostic Accuracy of MR Cholangiopancreatography and Ultrasound Compared with Direct Gholangiopancreatography of Choledocholithiasis Clinical radiology, 2000, 55 (3): 25-35.
42. Gregory TS et al. Comparison of Edoscopic Retrograde Cholangiopancreatography with Cholangiopancreatographyin Patients with Pancreatitis[J]. Radiology, 1999, 210 (2): 605-610.
43. Kim TK, Kim BS, kim JH et al. Diagnosis of intrahepatic stones: Superiority of MR Cholangiopancreatography over Endoscopic Retrograde Cholangiopancreatography[J]. AJR, 2002, 179 (2): 429-434.
44. Wall BK, Schumacher KA, Weidermaier W, et al. Dilated biliary tract: evalution with MR Scholangiography with a T2-weighted contrast-enhanced fast sequence Radiology, 1991, 181 (3): 805-808
45．田秀菊，姚家琪，动态增强CT扫描及MRCP在诊断胰头癌的应用 中华临床医学月刊 2006年1月
46．游淼，姚家琪，螺旋CT扫描及MRCP在诊断梗阻性黄疸的对比性研究 中国实用医学杂志 2006年2月
47．朱应礼，柏根基，徐益MRI和MRCP在胰胆管恶性梗阻性病变中的定性研究 医学影像学杂志2006年第16卷第5期
48. Kim MJ, Mitchell DG, Ito D, et al. Biliary dilating: differentiation of benign from malignant causes value of adding conventional MR imaging to MR cholangiopancreatography. Radiology, 2000, 214: 173-181.
49．高玉颖，郭启勇，陈丽英，等．MRCP对恶性胆道狭窄的诊断 中国临床医学影像杂志，2000，11(3)：259-262．
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9. Kim TK, Kim BS, kim JH et al. Diagnosis of intrahepatic stones: Superiority of MR Cholangiopancreatography over Endoscopic Retrograde Cholangiopancreatography [J]. AJR, 2002, 179 (2): 429-434.
10. All BK, Schumacher KA, Weidermaier W, et al. Dilated biliary tract: evalution with MR Scholangiography with a T2-weighted contrast-enhanced fast sequence Radiology, 1991, 181 (3): 805-808
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23．孙贞超(综述)，唐光才(审校)磁共振胰胆管成像的临床应用及进展医学综述2007年2月第13卷第4期
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26. Adamek HE, Albert J, Breer H, et al. Pancreatic cancer detection with MRCP and ERCP: a prospective controlled Study. Lancer, 2000, 356 (3): 190-193.
27．宋烨 高原等 恶性梗阻性黄疸的影像诊断价值的ROC分析 上海医学影像2005年第14卷第一期 55-59
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29. Reinho ld C, Bret PM. MR cholangiopancreatography. A bdom Imaging, 1996, 21: 105.
30. M acaulay SE, Schulte SJ, Sek ijima JH, et al. Evaluation of a non-breath-ho ld MR cholangiography technique. Radiology, 1995, 196: 227.
31．熊肇明，汤光宇，钱明平．MRCP与ERCP对胆胰系疾病诊断价值比较．中国微创外科杂志，2005，5(7)：549-550
32．周健，贾乾斌，彭其芳．MRCP评估医源性胆管狭窄的临床价值．腹部外科2004，17(3)：185-186
33．刘杰，宋彬，徐隽，等．MRCP在肝外胆管梗阻中的诊断价值[J]．中国普外基础与临床杂志，2005，12(2)：188-189
34．江东新，蔡立华，袁术文．MRCP在梗阻性黄疸诊断中的应用价值 中国医师杂志2005年12月第7卷第12期1617
35．张琴，刘平 肝硬化黄疸中医证型研究．中西医结合肝病杂志，2001，11(3)：139-141
36．孙均，安江，徐彦斌1肝性黄疸的中医证型标准及其化验指标的相关性研究报告．中医研究，2000，13(5)：20
37．张菁，成伟忠，陆敏，等1肝复康治疗肝炎肝硬化顽固性黄疸的临床观察．上海中医药杂志，2003，37(1)：12-14
38．唐仪强 118例黄疸的B超声像图与中医分型的关系 江苏中医1999年第20卷第1期·15·
39. Guibaud L, Bret PM, Reinhddc, et al. Bile Duct Obstruction and Choledoc holithiasis: Diaggnosiswith MR Cholangiography. Radiology 1995. 192(1): 109-115
40．John T．Hansen，Bruce M．Koeppen et all奈特人体生理学彩色图谱 人民卫生出版社 2005年4月 主译 朱大年
41. Vaghese JC et al. Diagnostic Accuracy of MR Cholangiopancreatography and Ultrasound Compared with Direct Gholangiopancreatography of Choledocholithiasis Clinical radiology, 2000, 55 (3): 25-35.
42. Gregory TS et al. Comparison of Edoscopic Retrograde Cholangiopancreatography with Cholangiopancreatographyin Patients with Pancreatitis[J]. Radiology, 1999, 210 (2): 605-610.
43. Kim TK, Kim BS, kim JH et al. Diagnosis of intrahepatic stones: Superiority of MR Cholangiopancreatography over Endoscopic Retrograde Cholangiopancreatography[J]. AJR, 2002, 179 (2): 429-434.
44. Wall BK, Schumacher KA, Weidermaier W, et al. Dilated biliary tract: evalution with MR Scholangiography with a T2-weighted contrast-enhanced fast sequence Radiology, 1991, 181 (3): 805-808
45．田秀菊，姚家琪，动态增强CT扫描及MRCP在诊断胰头癌的应用 中华临床医学月刊 2006年1月
46．游淼，姚家琪，螺旋CT扫描及MRCP在诊断梗阻性黄疸的对比性研究 中国实用医学杂志 2006年2月
47．朱应礼，柏根基，徐益MRI和MRCP在胰胆管恶性梗阻性病变中的定性研究 医学影像学杂志2006年第16卷第5期
48. Kim MJ, Mitchell DG, Ito D, et al. Biliary dilating: differentiation of benign from malignant causes value of adding conventional MR imaging to MR cholangiopancreatography. Radiology, 2000, 214: 173-181.
49．高玉颖，郭启勇，陈丽英，等．MRCP对恶性胆道狭窄的诊断 中国临床医学影像杂志，2000，11(3)：259-262．