發(fā)布時(shí)間：2018-04-23 14:08

  本文選題：膽道梗阻 + 彌散加權(quán)成像�。� 參考：《大連醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的：探討胰膽管水成像（MRCP）聯(lián)合高分辨率彌散加權(quán)成像(HR-DWI)對(duì)非結(jié)石性肝外膽道梗阻性病變定性診斷的診斷價(jià)值。 材料與方法：回顧性分析2013年8月至2014年2月于我院行上腹部MR檢查的資料完整的43例非結(jié)石性肝外膽道梗阻病例，其中惡性肝外膽道梗阻病例25例，包括膽總管癌18例，壺腹癌3例，十二指腸乳頭癌4例；良性肝外膽道梗阻18例，包括膽管炎15例、十二指腸乳頭炎癥3例；男：女=19：24；年齡61.53±12.54歲。掃描序列包括：軸位T2WI、MRCP及膽道梗阻端連續(xù)多層軸位STD-DWI序列（矩陣128×128、FOV=44x44cm2，S組）和軸位薄層HR-DWI序列（矩陣196×96、FOV=31x15.5cm2，H組），b值均為600s/mm2。兩名腹部影像診斷醫(yī)師在雙盲情況下進(jìn)行圖像分析。主觀分析包括：①根據(jù)膽管梗阻的MRCP影像學(xué)特征，參照Baron等診斷標(biāo)準(zhǔn)評(píng)判其對(duì)良惡性病變的診斷符合率；②兩名觀察者分別對(duì)STD-DWI序列（S組）、HR-DWI序列（H組）圖像質(zhì)量及病變的顯示情況進(jìn)4級(jí)評(píng)分，并采用Kappa一致性檢驗(yàn)來評(píng)價(jià)兩名觀察者評(píng)分的一致性；對(duì)S、H兩組評(píng)分使用卡方檢驗(yàn)組間評(píng)分統(tǒng)計(jì)學(xué)差異；③兩名觀察者共同對(duì)單獨(dú)MRCP序列（A組）、MRCP聯(lián)合T2W（IB組）、MRCP聯(lián)合STD-DW（IC組）、MRCP聯(lián)合HR-DWI（D組）對(duì)病變良惡性進(jìn)行3級(jí)評(píng)分判定，對(duì)四組評(píng)分分別使用卡方檢驗(yàn)進(jìn)行組間統(tǒng)計(jì)學(xué)分析，后使用ROC曲線分析四組對(duì)惡性梗阻病變?cè)\斷的AUC值、準(zhǔn)確率、敏感度、特異度、陽(yáng)性預(yù)測(cè)值、陰性預(yù)測(cè)值�？陀^評(píng)價(jià)包括：①計(jì)算兩組DWI序列的圖像分辨率；②兩名觀察者分別測(cè)量S、H兩組梗阻端病變（a）、鄰近正常膽管壁（b）的ADC值，應(yīng)用ICC檢驗(yàn)兩名觀察者測(cè)量值的一致性，對(duì)S、H兩組所測(cè)a、b兩處的ADC值進(jìn)行Wilcoxon秩和檢驗(yàn)；采用ROC曲線分析H組a、b兩處所測(cè)得的ADC值對(duì)鑒別膽道梗阻端病變的良惡性的診斷效能。 結(jié)果：①M(fèi)RCP良性梗阻征象13例，其診斷良性符合率（7/13，53.85%)；MRCP惡性梗阻征象30例，其診斷惡性符合率（19/30，63.33%）。②兩名觀察者對(duì)STD-DWI的病灶顯示評(píng)分分別為（3.20±0.56vs.3.23±0.61），值0.867；兩名觀察者對(duì)HR-DWI的圖像質(zhì)量評(píng)分分別為（3.81±0.39vs.3.79±0.41），，值0.927；S、H兩組評(píng)分卡方檢驗(yàn)（Χ2=15.878，p=0.009）。③兩名觀察者共同對(duì)A、B、C、D四組掃描方案對(duì)肝外膽道梗阻端病灶定性進(jìn)行3級(jí)評(píng)分，四組組間評(píng)分卡方檢驗(yàn)結(jié)果分別為P值0.05。③兩名觀察者共同對(duì)A、B、C、D四組掃描方案對(duì)肝外膽道梗阻端病灶定性進(jìn)行3級(jí)評(píng)分，評(píng)分結(jié)果分別為：2.49±0.51、2.47±0.67、2.47±0.67、2.42±0.82，AUC值分別為：0.681、0.811、0.854、0.944，準(zhǔn)確率分別為：67.44%、79.07%、83.72%、97.62%，敏感度分別為：64.00%、80.00%、84.00%、100%，特異度分別為：72%、77.8%、83.3%、88.9%，陽(yáng)性預(yù)測(cè)值分別為：76.19%、83.33%、87.50%、92.59%，陰性預(yù)測(cè)值分別為：59.09%、73.68%、78.95%、100%；④S、H組的空間分辨率分別約為3.4，1.6（cm/pixel）；⑤S組a、b部位兩位觀察者測(cè)量的ADC值（×10-3mm2/s）為：（1.81±0.51，2.02±0.46）vs.（1.87±0.61，2.04±0.47），H組a、b部位兩位觀察者測(cè)量的ADC值（×10-3mm2/s）為：（1.78±1.28，1.79±1.15）vs.（1.78±1.33，1.78±1.19），兩名觀察者所測(cè)的數(shù)據(jù)ICC值分別為0.996、0.998、0.970、0.943。S組良惡性梗阻部位a、b兩處的ADC值間差異無(wú)統(tǒng)計(jì)學(xué)意義（Z=-1.330，-1.404；P值0.184，0.160），H組良惡性梗阻部位a、b兩處的ADC值間差異有統(tǒng)計(jì)學(xué)意義（Z=-2.327，-2.413；P值0.020，0.016）。H組a、b部位ADC值診斷惡性膽道梗阻的AUC值為（0.710：0.718）。 結(jié)論：HR-DWI較STD-DWI圖像分辨率高，對(duì)肝外膽道梗阻端病變顯示更為清楚；MRCP聯(lián)合HR-DWI序列大大提高對(duì)肝外膽管惡性病變的診斷效能；HR-DWI的ADC值對(duì)良惡性病變的鑒別有一定幫助。
[Abstract]:Objective: To evaluate the diagnostic value of cholangiopancreatography (MRCP) combined with high resolution diffusion weighted imaging (HR-DWI) for the diagnosis of non calculous extrahepatic biliary obstruction.
Materials and methods: a retrospective analysis of 43 cases of non calculous extrahepatic biliary obstruction from August 2013 to February 2014 in our hospital, including 25 cases of malignant extrahepatic biliary obstruction, including 18 cases of choledochal carcinoma, 3 ampullary carcinoma, 4 duodenal papilla carcinoma, 18 benign extrahepatic biliary obstruction, including bile duct, including bile duct, 43 cases of non calculous extrahepatic biliary obstruction. 15 cases of inflammation and 3 cases of duodenal papilla inflammation, male: female =19:24, age 61.53 + 12.54 years old. The scan sequence includes: axis position T2WI, MRCP and continuous multi-layer STD-DWI sequence of biliary obstruction end (matrix 128 x 128, FOV=44x44cm2, S group) and axial thin layer HR-DWI sequence (matrix 196 * 96, FOV=31x15.5cm2, H group), b values are 600s/mm2. two abdomen shadow Image analysis was performed under double blindness as a diagnostic physician. Subjective analysis included: (1) according to the MRCP imaging features of bile duct obstruction, the diagnostic coincidence rate of benign and malignant lesions was judged by Baron and other diagnostic criteria; (2) two observers were divided into 4 levels of STD-DWI sequence (group S), HR-DWI sequence (group H) image quality and pathological changes. Score, and use Kappa consistency test to evaluate the consistency of two observer scores; for S, group H two scores using chi square test group scores statistical differences; (3) two observers shared a single MRCP sequence (group A), MRCP combined T2W (IB group), MRCP joint STD-DW (IC group), MRCP combined with 3 grades for benign and malignant lesions. The four groups were judged by chi square test for statistical analysis, and then the AUC value, accuracy, sensitivity, specificity, positive predictive value and negative predictive value were analyzed by the ROC curve in the four groups. The objective evaluation included: (1) the resolution of the image of two groups of DWI sequences was calculated; and two observers measured respectively. S, H two groups of obstructive end lesions (a), adjacent normal bile duct wall (b) ADC value, ICC test of the consistency of the measured values of two observers, S, H two groups measured a, B two ADC value at the Wilcoxon rank and test, two measured values for the differential diagnosis of biliary obstruction end lesions of the benign and malignant diagnostic effectiveness.
Results: (1) 13 cases of benign obstruction of MRCP, the benign coincidence rate of diagnosis (7/13,53.85%), the signs of malignant MRCP obstruction in 30 cases, and the malignant coincidence rate (19/30,63.33%). (2) the lesions of two observers were (3.20 + 0.56vs.3.23 + 0.61) and 0.867, and two observers were respectively (3.) of the image quality of HR-DWI, respectively. 81 + 0.39vs.3.79 + 0.41), value 0.927, S, H two score chi square test (2=15.878, p=0.009). (3) two groups of observers shared a grade 3 score on A, B, C, and D four groups on the extrahepatic biliary obstruction end focus, and the scores of the four groups were P values 0.05., two of the two observers, four groups of scanning schemes for the liver The 3 grade score of the external biliary obstruction end focus was made. The results were 2.49 + 0.51,2.47 + 0.67,2.47 + 0.67,2.42 + 0.82 respectively, and the AUC values were 0.681,0.811,0.854,0.944, the accuracy was 67.44%, 79.07%, 83.72%, 97.62%, respectively: 64%, 80%, 84%, 100%, respectively: 72%, 77.8%, 77.8%, 83.3%, Yang, Yang, respectively The predictive values of the sex were 76.19%, 83.33%, 87.50%, 92.59%, and the negative predictive values were 59.09%, 73.68%, 78.95%, 100%; the spatial resolution of group H was 3.4,1.6 (cm/pixel), S group A and ADC value (1.81 + 0.51,2.02 + 0.46) vs. (1.87 + 0.61,2.04 0.47) in B site two observers (1.81 + 0.51,2.02 + 0.46) The ADC value (x 10-3mm2/s) measured by the observer was (1.78 + 1.28,1.79 + 1.15) vs. (1.78 + 1.33,1.78 + 1.19). The ICC values measured by two observers were a of the benign and malignant obstructive sites in the 0.996,0.998,0.970,0.943.S group, and there was no statistical difference between the ADC values of the B two (Z =-1.330). There was a significant difference in the ADC values between the two sites (Z=-2.327, -2.413, P value 0.020,0.016), a in.H group, and ADC value in B position for diagnosing malignant biliary obstruction (0.710:0.718).
Conclusion: the resolution of HR-DWI is higher than that of STD-DWI image, and it is more clear to the extrahepatic biliary obstruction end lesions; MRCP combined with HR-DWI sequence can greatly improve the diagnostic efficiency of extrahepatic bile duct malignant lesions, and the ADC value of HR-DWI has some help for the identification of benign and malignant lesions.

【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R445.2;R657.4

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