1、慢性胰腺炎及其并发症的慢性胰腺炎及其并发症的MRI表现表现1ppt课件 Chronic pancreatitis is an inflammatory disease characterized by progressive and irreversible structural damage to the pancreas resulting in permanent impairment of both exocrine and endocrine functions. ERCP is the gold standard for early chronic pancreatitis, bu
2、t it is invasive. MRI may be an alternative for patients in whom CT or ERCP is contraindicated or not tolerated.MRI provides noninvasive biliary and pancreatic duct imaging and MRI provides noninvasive biliary and pancreatic duct imaging and accurate characterization of pancreatic and peripancreatic
3、 pathology.accurate characterization of pancreatic and peripancreatic pathology.慢性胰腺炎是一种炎症性疾病，其特征是对胰腺逐步和不可逆转慢性胰腺炎是一种炎症性疾病，其特征是对胰腺逐步和不可逆转的结构性损坏，导致外分泌和内分泌功能的永久性受损。的结构性损坏，导致外分泌和内分泌功能的永久性受损。 ERCP ERCP是诊断早期慢性胰腺炎的金标准，但它是侵入性检查。是诊断早期慢性胰腺炎的金标准，但它是侵入性检查。 在在CTCT或或ERCPERCP为禁忌或不能耐受时，为禁忌或不能耐受时，MRIMRI可作为替代。可作为替代。M
4、RIMRI提供非侵入性提供非侵入性胆胰管成像和胰腺及胰周病变的征象。胆胰管成像和胰腺及胰周病变的征象。 2ppt课件The diagnosis of chronic pancreatitis on MRI is based on The diagnosis of chronic pancreatitis on MRI is based on signal intensity and enhancement changes as well as on signal intensity and enhancement changes as well as on morphologic abnorm
5、alities in the pancreatic parenchyma, morphologic abnormalities in the pancreatic parenchyma, pancreatic duct, and biliary tract. The imaging features of pancreatic duct, and biliary tract. The imaging features of chronic pancreatitis can be divided into early and late chronic pancreatitis can be di
6、vided into early and late findings. findings. 慢性胰腺炎慢性胰腺炎MRIMRI诊断是基于信号强度和增强的变诊断是基于信号强度和增强的变化，以及胰腺实质，胰管和胆道形态的异常。慢化，以及胰腺实质，胰管和胆道形态的异常。慢性胰腺炎的影像特征可分为早期表现和晚期表现。性胰腺炎的影像特征可分为早期表现和晚期表现。 3ppt课件Early findings include low-signal-intensity pancreas on T1-Early findings include low-signal-intensity pancreas on T1
7、-weighted fat-suppressed images, decreased and delayed weighted fat-suppressed images, decreased and delayed enhancement after IV contrast administration, and dilated enhancement after IV contrast administration, and dilated side branches. Late findings include parenchymal atrophy side branches. Lat
8、e findings include parenchymal atrophy or enlargement, pseudocysts, and dilatation and beading of or enlargement, pseudocysts, and dilatation and beading of the pancreatic duct often with intraductal calcifications.the pancreatic duct often with intraductal calcifications.早期表现包括早期表现包括T1T1加权脂肪抑制图像上呈低
9、信号，加权脂肪抑制图像上呈低信号，延迟强化或强化程度减低，侧支扩张。晚期表现延迟强化或强化程度减低，侧支扩张。晚期表现包括实质萎缩或肿大，假性囊肿，胰管扩张或呈包括实质萎缩或肿大，假性囊肿，胰管扩张或呈串珠样，导管内常伴钙化。串珠样，导管内常伴钙化。 4ppt课件MRI allows early recognition of chronic pancreatitis MRI allows early recognition of chronic pancreatitis based on changes in pancreatic signal intensity; these based o
10、n changes in pancreatic signal intensity; these changes are best visualized on unenhanced and changes are best visualized on unenhanced and gadolinium-enhanced T1-weighted fat-suppressed gadolinium-enhanced T1-weighted fat-suppressed images (Fig. images (Fig. 1A1A, , 1B1B, , 1C1C, , 1D1D). ). MRIMRI
11、可以早期识别慢性胰腺炎胰腺信号强度的变可以早期识别慢性胰腺炎胰腺信号强度的变化，平扫和增强化，平扫和增强T1T1加权脂肪抑制图像显示信号变加权脂肪抑制图像显示信号变化最佳（图化最佳（图1A1A，1B1B，1C1C，1D1D）。）。 5ppt课件Fig.1A. 1B.Fig.1A. 1B.Fig. 1A. 24-year-old woman with small pancreatic duct stone Fig. 1A. 24-year-old woman with small pancreatic duct stone causing duct obstruction and segment
12、al pancreatitis. Axial T2-causing duct obstruction and segmental pancreatitis. Axial T2-weighted HASTE image shows slightly increased signal intensity of weighted HASTE image shows slightly increased signal intensity of pancreatic tail (pancreatic tail (arrowarrow) with mild dilatation of pancreatic
13、 duct.Axial ) with mild dilatation of pancreatic duct.Axial T1-weighted fat-suppressed spoiled gradient-echo image shows T1-weighted fat-suppressed spoiled gradient-echo image shows abnormal low signal intensity of pancreatic tail (abnormal low signal intensity of pancreatic tail (arrowarrow) while
14、) while remainder of pancreas has normal bright signal intensity.remainder of pancreas has normal bright signal intensity.2424岁，女。小胰管结石引起胆道梗阻和节段性胰腺炎。岁，女。小胰管结石引起胆道梗阻和节段性胰腺炎。T2WIT2WI胰尾信号轻度胰尾信号轻度升高，胰管轻度扩张（箭头）。升高，胰管轻度扩张（箭头）。 T1WI T1WI显示胰尾异常低信号（箭头），胰腺显示胰尾异常低信号（箭头），胰腺其余部分信号强度正常，为高信号。其余部分信号强度正常，为高信号。6ppt课件
15、Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo image obtained Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo image obtained during arterial phase shows delayed enhancement of pancreatic tail (during arterial phase shows delayed enhancement of pancreatic tail (arrowa
16、rrow) relative to ) relative to normal pancreas due to fibrosis. Patient later developed atrophic changes in this area normal pancreas due to fibrosis. Patient later developed atrophic changes in this area that led to resection of pancreatic tail.Contrast-enhanced CT scan shows punctate that led to
17、resection of pancreatic tail.Contrast-enhanced CT scan shows punctate high-density focus (high-density focus (arrowarrow) in pancreatic duct representing small intraductal stone. ) in pancreatic duct representing small intraductal stone. This example illustrates the advantage of CT in showing tiny i
18、ntraductal stone that This example illustrates the advantage of CT in showing tiny intraductal stone that was not seen on MRI. It, however, also illustrates the advantage of MRI in showing was not seen on MRI. It, however, also illustrates the advantage of MRI in showing changes of signal intensity
19、associated with chronic pancreatitis that are not visible on changes of signal intensity associated with chronic pancreatitis that are not visible on CT.CT.动脉期增强动脉期增强T1WIT1WI示因纤维化胰尾较正常胰腺强化延迟（箭头），此处后来呈萎缩性改示因纤维化胰尾较正常胰腺强化延迟（箭头），此处后来呈萎缩性改变，导致实行胰尾切除术。对比增强变，导致实行胰尾切除术。对比增强CTCT扫描显示胰管内小结石。这个例子说明了扫描显示胰管内小结石。这
20、个例子说明了CTCT的的优势在于显示微小的管内结石，而在优势在于显示微小的管内结石，而在MRIMRI未显示。然而，它也显示出磁共振成像的优未显示。然而，它也显示出磁共振成像的优点：可显示出慢性胰腺炎信号强度的变化与关系，此在点：可显示出慢性胰腺炎信号强度的变化与关系，此在CTCT上是不可见的。上是不可见的。 Fig.1C.1D. Fig.1C.1D. 7ppt课件Chronic inflammation and fibrosis diminish the proteinaceous Chronic inflammation and fibrosis diminish the proteinac
21、eous fluid content of the pancreas, resulting in the loss of the usual fluid content of the pancreas, resulting in the loss of the usual high signal intensity on T1-weighted fat-suppressed images. high signal intensity on T1-weighted fat-suppressed images. The normal pancreas enhances uniformly and
22、intensely on early The normal pancreas enhances uniformly and intensely on early arterial phase contrast-enhanced T1-weighted images and arterial phase contrast-enhanced T1-weighted images and exhibits rapid washout of gadolinium on subsequent images. exhibits rapid washout of gadolinium on subseque
23、nt images. 慢性炎症和纤维化减少胰腺的蛋白质含量，使得在慢性炎症和纤维化减少胰腺的蛋白质含量，使得在T1T1加加权脂肪抑制图像上高信号消失。正常胰腺动脉期均匀明显权脂肪抑制图像上高信号消失。正常胰腺动脉期均匀明显强化，并快速廓清。强化，并快速廓清。 8ppt课件In contrast, a pancreas with chronic fibrosis and glandular In contrast, a pancreas with chronic fibrosis and glandular atrophy exhibits decreased and heterogeneous
24、 enhancement on atrophy exhibits decreased and heterogeneous enhancement on early arterial phase images and increased relative enhancement early arterial phase images and increased relative enhancement on delayed images (Fig. on delayed images (Fig. 2A2A, , 2B2B, , 2C2C). ). 相比之下，慢性纤维化并腺体萎缩的胰腺在早相比之下
25、，慢性纤维化并腺体萎缩的胰腺在早动脉期强化程度减低并强化不均匀，延迟图像动脉期强化程度减低并强化不均匀，延迟图像上强化程度相对升高（图上强化程度相对升高（图2A2A，2B2B，2C2C）9ppt课件Fig. 2A. 2B. Fig. 2A. 46-year-old man with history of chronic pancreatitis due to 46-year-old man with history of chronic pancreatitis due to alcohol abuse. Axial T1-weighted fat-suppressed spoiled gra
26、dient-echo alcohol abuse. Axial T1-weighted fat-suppressed spoiled gradient-echo image shows atrophy of pancreatic parenchyma and irregular dilatation of image shows atrophy of pancreatic parenchyma and irregular dilatation of main pancreatic duct (main pancreatic duct (arrowsarrows), changes sugges
27、tive of chronic pancreatitis. ), changes suggestive of chronic pancreatitis. Calcifications are not as well seen on MRI as on CT.Axial enhanced T1-Calcifications are not as well seen on MRI as on CT.Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo image obtained during weighted fat-su
28、ppressed spoiled gradient-echo image obtained during arterial phase shows diffusely decreased pancreatic enhancement relative to arterial phase shows diffusely decreased pancreatic enhancement relative to marked enhancement seen normally. This decreased enhancement relates marked enhancement seen no
29、rmally. This decreased enhancement relates to fibrosis due to chronic pancreatitis. Dilated pancreatic duct (to fibrosis due to chronic pancreatitis. Dilated pancreatic duct (arrowsarrows) is ) is visualized more clearly after contrast administration.visualized more clearly after contrast administra
30、tion.4646岁，男，因酗酒致慢性胰腺炎。岁，男，因酗酒致慢性胰腺炎。T1WIT1WI显示胰腺实质的萎缩和不规则扩张的主胰管显示胰腺实质的萎缩和不规则扩张的主胰管（箭头），提示慢性胰腺炎的变化。钙化在（箭头），提示慢性胰腺炎的变化。钙化在MRIMRI和和CTCT上都没有看到。上都没有看到。 动脉期增强动脉期增强T1WIT1WI显示胰腺因慢性炎症引起的纤维化而强化弥漫性降低，而非通常看到的显著增显示胰腺因慢性炎症引起的纤维化而强化弥漫性降低，而非通常看到的显著增强。胰管扩张（箭头）显示更清。强。胰管扩张（箭头）显示更清。10ppt课件Duct Abnormalities胰管异常 MRCP i
31、s highly accurate for identifying pancreas MRCP is highly accurate for identifying pancreas divisum (divisum (Fig. 6Fig. 6). However, its association with ). However, its association with pancreatitis remains controversial. Duct abnormalities pancreatitis remains controversial. Duct abnormalities su
32、ch as dilatation, irregularity, and stones and such as dilatation, irregularity, and stones and complications of chronic pancreatitis such as complications of chronic pancreatitis such as pseudocysts are best depicted by thin-section T2-pseudocysts are best depicted by thin-section T2-weighted HASTE
33、 or single-shot fast spin-echo and weighted HASTE or single-shot fast spin-echo and thick-slab T2-weighted half-Fourier RARE MRCP thick-slab T2-weighted half-Fourier RARE MRCP images. images. MRCPMRCP发现胰腺分裂的准确度很高（图发现胰腺分裂的准确度很高（图6 6）。然而，它与胰腺）。然而，它与胰腺炎的关系仍存在争议。胰管异常，如扩张，不规则，结石和并炎的关系仍存在争议。胰管异常，如扩张，不规则，结
34、石和并发症如假性囊肿，在薄层发症如假性囊肿，在薄层T2T2加权加权HASTEHASTE或或MRCPMRCP显示最佳。显示最佳。11ppt课件Fig. 6. 53-year-old woman with history of cholecystectomy Fig. 6. 53-year-old woman with history of cholecystectomy who presented with jaundice, abnormal results on liver who presented with jaundice, abnormal results on liver func
35、tion tests, and pancreas divisum. Axial T2-weighted image function tests, and pancreas divisum. Axial T2-weighted image shows noncommunicating main pancreatic duct (straight shows noncommunicating main pancreatic duct (straight arrow) and accessory duct (curved arrow) draining separately arrow) and
36、accessory duct (curved arrow) draining separately into duodenum.into duodenum.图图6 6， 53 53，女。胆囊切除术后，黄疸，肝功能异常，胰腺分裂症。轴，女。胆囊切除术后，黄疸，肝功能异常，胰腺分裂症。轴位位T2WIT2WI显示轴向显示轴向T2T2加权图像显示，互不沟通的主胰管（直箭头）和配加权图像显示，互不沟通的主胰管（直箭头）和配胰管（弯箭头）分别进入十二指肠引流。胰管（弯箭头）分别进入十二指肠引流。Fig. 6. Fig. 6. 12ppt课件MRCP is accurate in depicting str
37、ictures of MRCP is accurate in depicting strictures of the pancreatic duct or biliary tract (the pancreatic duct or biliary tract (Fig. 7Fig. 7). In ). In equivocal cases, ductal distention by contrast equivocal cases, ductal distention by contrast injection during ERCP may be helpful. The injection
38、 during ERCP may be helpful. The beaded main pancreatic duct with its dilated beaded main pancreatic duct with its dilated side branches may have a chain-of-lakes side branches may have a chain-of-lakes appearance when more extensive (appearance when more extensive (Fig. 8Fig. 8). ). MRCP MRCP可准确的描绘
39、胰管或胆管的狭窄（图可准确的描绘胰管或胆管的狭窄（图7 7）。）。在模棱两可的情况下，在在模棱两可的情况下，在ERCPERCP过程中导管注射造影过程中导管注射造影剂扩张胰胆管可能会有帮助。当病变广泛时，串珠剂扩张胰胆管可能会有帮助。当病变广泛时，串珠样主胰管和扩张的侧枝，可能有连锁湖样改变。样主胰管和扩张的侧枝，可能有连锁湖样改变。 13ppt课件Fig. 7. 62-year-old woman with history of chronic Fig. 7. 62-year-old woman with history of chronic pancreatitis and pseudocy
40、sts. Coronal T2-weighted thick-pancreatitis and pseudocysts. Coronal T2-weighted thick-slab RARE image shows stricture (straight arrow) of slab RARE image shows stricture (straight arrow) of pancreatic duct at level of pancreatic head. Upstream pancreatic duct at level of pancreatic head. Upstream p
41、ancreatic duct is dilated and irregular, and there is mild pancreatic duct is dilated and irregular, and there is mild dilatation of side branches. Note diverticulum (curved arrow) dilatation of side branches. Note diverticulum (curved arrow) arising from duodenum.arising from duodenum. 图图7 7。 62 62
42、，女。慢性胰腺炎，假性囊肿。冠状，女。慢性胰腺炎，假性囊肿。冠状T2WIT2WI显示胰头水平胰显示胰头水平胰管狭窄（直箭头）。上游胰管不规则扩张，侧枝轻度扩张。注意十二管狭窄（直箭头）。上游胰管不规则扩张，侧枝轻度扩张。注意十二指肠憩室（弯箭头）。指肠憩室（弯箭头）。Fig. 7. Fig. 7. 14ppt课件Fig. 8. 69-year-old man with chronic pancreatitis. Axial T2-Fig. 8. 69-year-old man with chronic pancreatitis. Axial T2-weighted HASTE image sh
43、ows irregular dilated main weighted HASTE image shows irregular dilated main pancreatic duct and side branches giving chain-of-lakes pancreatic duct and side branches giving chain-of-lakes appearance. Note atrophic changes in pancreas and signal-appearance. Note atrophic changes in pancreas and sign
44、al-void areas (arrows) related to calcifications from chronic void areas (arrows) related to calcifications from chronic pancreatitis.pancreatitis.图图8 8。6969岁，男。慢性胰腺炎。轴向岁，男。慢性胰腺炎。轴向T2WIT2WI显示不规则扩张的主胰管显示不规则扩张的主胰管和侧枝，连锁湖外观。可见胰腺萎缩及无信号钙化区（箭头）。和侧枝，连锁湖外观。可见胰腺萎缩及无信号钙化区（箭头）。Fig. 8. Fig. 8. 15ppt课件CT is more
45、 sensitive than MRI for the CT is more sensitive than MRI for the detection of calcifications associated with detection of calcifications associated with chronic pancreatitis; however, MRI best chronic pancreatitis; however, MRI best depicts intraductal stones and duct depicts intraductal stones and
46、 duct obstruction (Figs. 9A, 9B and 10). Unlike obstruction (Figs. 9A, 9B and 10). Unlike ERCP, MRCP can show the dilated duct ERCP, MRCP can show the dilated duct upstream from an obstructing stone. upstream from an obstructing stone. Nevertheless, visualizing intraductal stones Nevertheless, visua
47、lizing intraductal stones not surrounded by fluid may be difficult on not surrounded by fluid may be difficult on MRI (Fig. 1A, 1B, 1C, 1D).MRI (Fig. 1A, 1B, 1C, 1D).对慢性胰腺炎的钙化检测，对慢性胰腺炎的钙化检测，CTCT比比MRIMRI敏感，然而，敏感，然而，MRIMRI显示管内结石和胰胆管阻塞最佳（图显示管内结石和胰胆管阻塞最佳（图9A9A，9B9B和和1010）。不同于）。不同于ERCPERCP，MRCPMRCP能显示上游扩
48、能显示上游扩张导管。然而，张导管。然而，MRIMRI诊断不被液体包围的导管内诊断不被液体包围的导管内结石困难（图结石困难（图1A1A，1B1B，1C1C，1D1D）。）。16ppt课件Fig. 9A. 46-year-old man with history of chronic pancreatitis due Fig. 9A. 46-year-old man with history of chronic pancreatitis due to alcohol abuse. Axial contrast-enhanced CT scan shows multiple to alcohol
49、abuse. Axial contrast-enhanced CT scan shows multiple calcifications in pancreatic head. It is difficult to determine that a calcifications in pancreatic head. It is difficult to determine that a stone is in pancreatic duct. Calcifications are seen commonly in stone is in pancreatic duct. Calcificat
50、ions are seen commonly in chronic alcohol-related pancreatitis, as in this patient.Axial T2-chronic alcohol-related pancreatitis, as in this patient.Axial T2-weighted HASTE image shows stone (arrow) in main pancreatic duct weighted HASTE image shows stone (arrow) in main pancreatic duct delineated b
