IDUS对胆胰管疾病的应用体会.ppt

Advances of IDUS in Diagnosis for Billiary DiseasesXiaoping ZouDepartment of GastroenterologyNanjing Drum Tower HospitalNanjing University School of MedicineNanjing,ChinaIntra-ductal Ultrasonography,IDUSAdvantages of IDUS With a finer probe,can get approach to the With a finer probe,can get approach to the target site through working channel of the target site through working channel of the endoscopyendoscopy Get clearer images without the interference of Get clearer images without the interference of air and fatair and fat Probe with higher frequency is enabled with a Probe with higher frequency is enabled with a close distanceclose distance Images of high resolutionImages of high resolutionIDUS vs.routine EUS The tubular structure of pancreato-billiary duct The tubular structure of pancreato-billiary duct facilitate the acoustical couplingfacilitate the acoustical coupling Fluid in duct can be used as medium of ultrasoundFluid in duct can be used as medium of ultrasound The diameter of the duct is slightly larger than thant The diameter of the duct is slightly larger than thant of the probeof the probe Higher frequencyHigher frequency (12-30MHz)(12-30MHz)Better image resolutionBetter image resolutionType of probe Electronic circular scan Synchronized double section scan Mechanical radial scanImages of normal billiary duct 2-3 layers2-3 layers Smooth layer with homogenous Smooth layer with homogenous echoecho First layer:hyper-echogenicity,First layer:hyper-echogenicity,represents the interphaserepresents the interphase Second layer:hypo-echogenicity,Second layer:hypo-echogenicity,represents mucosal and represents mucosal and muscularis propria layersmuscularis propria layers Outer layer:hyper-echogenicity,Outer layer:hyper-echogenicity,the echo of fat and interface the echo of fat and interface between serosa and other organs between serosa and other organs Clinical applicationBilliary ductBilliary duct Suspected stone in billiary ductSuspected stone in billiary duct Differentiation for stenosisDifferentiation for stenosis Tumor stagingTumor stagingPancreatic ductPancreatic duct Differentiation for stenosisDifferentiation for stenosis Tumor stagingTumor staging Showing details of cystic neoplasmsShowing details of cystic neoplasms Localization of neuro-endocrine tumors not detcted by EUS Localization of neuro-endocrine tumors not detcted by EUSSuspected stone in CBDCBD stonesN=35 N=35（with suspected stoneswith suspected stones）Of 21 patients with stones not detected by ERCP,IDUS Of 21 patients with stones not detected by ERCP,IDUS identified 8,in which 7 were proved by ESTidentified 8,in which 7 were proved by EST Of 5 patients with suspected stones under ERCP,IDUS Of 5 patients with suspected stones under ERCP,IDUS identified them as bubblesidentified them as bubbles IDUS changed the clinical strategies in 13IDUS changed the clinical strategies in 13 (37%)patients(37%)patientsCatanzaro,A,Pfau,P,Isenberg,GA,Wong,RC.Clinical utility of intraductal US for evaluation of choledocholithiasis.Gastrointest Endosc 2003;57:648.N=62N=62 Detect rate of Detect rate of cholangiographycholangiography:87%:87%IDUSIDUS combined with combined with cholangiographycholangiography:97%:97%IDUS in cholangiocarcinoma and differentiation between benign and malignant strictureFeatures of cholangiocarcinoma under IDUS Mass of hypo-echo,infiltrating the surrounding tissueMass of hypo-echo,infiltrating the surrounding tissue Heterogeneous echo inside the massHeterogeneous echo inside the mass Serrated or irregular marginSerrated or irregular margin Surface of papillary protrusionSurface of papillary protrusion Destruction of normal bile ductDestruction of normal bile duct Suspected lymphadenectasisSuspected lymphadenectasisCholangiocarcinoma StagingStaging Detection of early lesionsDetection of early lesions Identify the margin along the ductIdentify the margin along the duct Determine the infiltration of pancreasDetermine the infiltration of pancreas Determine the infiltration of portal veinDetermine the infiltration of portal vein Determine the infiltration of right hepatic arteryDetermine the infiltration of right hepatic arteryCholangiocarcinoma N=?,local staging,compared with pT stagingN=?,local staging,compared with pT staging Accuracy of EUS:54%Accuracy of EUS:54%Accuracy of IDUS:77%Accuracy of IDUS:77%IDUS was especially useful for tumors in middle section of IDUS was especially useful for tumors in middle section of CBD and portal fissureCBD and portal fissure With poor penetration,unable to make M and N With poor penetration,unable to make M and N stagingstaging Unable to perform FNAUnable to perform FNAMenzel,J,Domschke,W.Intraductal ultrasonography(IDUS)of the pancreato-biliary duct system.Personal experience and review of literature.Eur J Ultrasound 1999;10:105.Tamada,K,Kanai,N,Tomiyama,T,et al.Prediction of the histologic type of bile duct cancer by using intraductal ultrasonography.Abdom Imaging 1999;24:484.Features of malignant strictureMass of hypo-echo Heterogeneous echo Irregular marginPapillary protrusionDestruction of bile ductEnlarged LNStricture of bile duct IDUS Sensibility:89%Specificity:50%Accuracy:76%Biopsy via percutaneous cholangioscopy Sensibility:93%Specificity:100%Accuracy:95%