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Siêu âm u gan
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U GAN♦ Cô sôû phaân tích khi khaûo saùt böôùu gan - Ñöôøng bôø cuûa böôùu . - Hieän töôïng boùng löng beân. - Kích thöôùc cuûa böôùu . - Soá löôïng . - Ñoä hoài aâm cuûa böôùu (so vôùi neàn
gan). - Ñoä huùt aâm . - Maãu hoài aâm - Caáu truùc hoài aâm beân trong.
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U GAN♦Cô sôû phaân tích khi khaûo saùt
böôùu gan -Thoâng tin veà huyeát ñoäng cuûa u / Doppler +Maãu phaân boá m.m .Maãu hình roã .Maãu hình aûnh m.m ñi vaøo trong u .Maãu h.aû m.m uoáng khuùc .Maãu hoãn hôïp +Höôùng doøng chaûy +Daïng doøng chaûy /Doppler xung hay
Dop.maøu +Vaän toác doøng chaûy / Doppler xung
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U GAN LAØNH TÍNH
♦ 1. Böôùu m ch ạ laønh tính cuûa gan 1.1. U maïch-Hemangioma: Böôùu laønh khaù
thöôøng gaëp. - U maïch mao maïch -Capillary hemangioma: + Phaàn lôùn laø nhieàu noát , ñoâi khi laø 1 + Ña soá < 2cm + Bôø roõ , neùt + Phaân boá ôû ngoaïi vi . + Taêng h.aâ + Taêng cöôøng aâm phía sau nheï + Caáu truùc ñoàng daïng . + Hieäu öùng khoái (-)
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U GAN LAØNH TÍNH
♦1. Böôùu m ch ạ laønh tính cuûa gan
1.1. U maïch-Hemangioma: - U maïch thể hốc -cavernous hemangioma:
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U GAN LAØNH TÍNH♦ 2. Adenoma(u tuyeán) - Thöôøng gaëp ôû nhöõng phuï nöõ duøng
thuoác traùnh thai -Moâ hoïc : tb gan bình thöôøng vaø moâ gan
khoâng ñieån hình (khoâng chöùa tb Kuffer ) -Laâm saøng : khoâng coù tr.chöùng /phaàn
lôùn cas + Tr.chöùng x.huyeát noäi /vôõ u
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U GAN LAØNH TÍNH- Hình aûnh s.aâ: +Khoái giôùi haïn roõ, trôn laùn vì coù bao
rieâng bieät +Taêng h.aâ nheï/nhu moâ gan: (++), coù
theå giaûm h.aâ . +Taêng cöôøng aâm . +Khi khoái u vôõ →caáu truùc h.aâ hoãn hôïp
/ do maùu +Doppler (+) nhöng khaùc vôùi HCC +Giaûm kích thöôùc khi ngöng duøng thuoác
traùnh thai .
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U GAN LAØNH TÍNH♦ 3. Taêng saûn noát khu truù (F.N.H.) 3.1.Ñaïi cöông : -Bieán ñoåi quùa saûn laønh tính -Moâ tb nhö moâ gan bt nhöng khoâng saép
xeáp theo caáu truùc tieåu thuøy -ÔÛ trung taâm coù seïo xô phaân kyø ra
ngoaïi vi vaø maïch trung taâm
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U GAN LAØNH TÍNH
3.2. Hình aûnh S.AÂ :thöôøng khoâng ñieån hình neáu khoâng thaáy h.aû seïo trung taâm
-Khoái giôùi haïn roõ -Ñoä h.aâ : giaûm (++) hoaëc taêng nheï, coù
theå ñoàng h.aâ. -Maãu h.aâ:caáu truùc h.aâ töông ñoái ñ.d -Seïo trung taâm taoï bôûi vaùch xô vaø
maïch maùu :taêng h.aâ hôn so vôùi neàn u . -Doppler : tín hieäu ñoäng maïch trung taâm
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U GAN LAØNH TÍNH♦ 4. U môõ (Lipoma )/u cô- môõ–maïch
maùu( A.M.L). - Giôùi haïn roõ - Khoái raát taêng h.aâ - Huùt aâm (++) - Ñaëc hieäu treân C.T/ ñaäm ñoä môõ♦ 5. Cystadenoma : Laø caáu truùc hoãn hôïp ,
chöùa thaønh phaàn nang ( 1 hoaëc nhieàu ), trong caùc nang coù chöùa caùc vaùch vaø choài ñaëc.
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U GAN AÙC TÍNH ♦ Phaân loaïi :-Ung thö gan thöù phaùt (KGTP) -Ung thö gan nguyeân phaùt (KGNP) +Bieåu moâ teá baøo gan +Bieåu moâ teá baøo oáng maät +Trung moâ (moâ lieân keát )
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K GAN NGUYEÂN PHAÙT1.GIÔÙI THIEÄU - Bieåu moâ teá baøo gan: + Hepatocellular Carcinoma (HCC) + Hepatoblastoma (treû em) - Bieåu moâ teá baøo oáng maät:
Cholangiocarcinoma - Trung moâ : + K lieân keát : AngioSarcoma + K noäi bì oáng maïch . + Caùc Lympho
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K GAN NGUYEÂN PHAÙT2. Beänh nguyeân -Dòch teã hoïc - Chaâu phi (döôùi sa maïc Sahara) , + Chaâu AÙ (Vieãn ñoâng ) : (+++) + Chaâu Myõ, Aâu taây (+/-)- Veà maët beänh nguyeân : + Vieâm gan B + Vieâm gan C => chuoãi : vieâm gan –xô gan – K gan + Taùc nhaân hoaù hoïc :Aflatoxin (Phi
chaâu) + Taùc nhaân khaùc : nhieãm KST, Rl
ch.hoaù
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K GAN NGUYEÂN PHAÙT
3. Giaûi phaãu beänh lyù : - Böôùu baønh tröôùng - Hoãn hôïp : vöøa thaâm nhieãm vöøa
baønh tröôùng . - Thaâm nhieãm lan toaû 4. Beänh lyù hoïc - A.F.P: 20 ng/ml : trung bình >400 ng/ml : (+++) trung gian : (+/-)
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K GAN NGUYEÂN PHAÙT
5.Hình aûnh sieâu aâm cuûa HCC 5.1 Daïng toån thöông khu truù : maãu hình
aûnh SAÂ cuûa HCC : + Noát : ranh giôùi roõ vôùi chuû moâ ,
phaàn lôùn laø 1 , ñoâi khi nhieàu noát . + Khoái : kích thöôùc >5cm
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K GAN NGUYEÂN PHAÙT
Kích thöôùc
Möùc ñoä hoài aâm – soá löôïng (phaàn traêm)Giaûm h.aâ
Ñoàng h.aâ
Taêng h.aâ
Toångcoäng
1-2cm 15(83,3%) 1(5.6) 2(11.1) 18(1002-3cm 9(69.2) 1(7.7) 3(23.1) 13(100)Toång Coäng
24(77.4) 2(6.4) 5(16.1) 31(100)
- Ñoä hoài aâm vaø kích thöôùc cuûa böôùu
-Khi u coù kích thöôùc lôùn hôn thì coù bieåu hieän taêng h.aâ keøm hieän dieän voøng Halo giaûm h.aâ.
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K GAN NGUYEÂN PHAÙT
-Ñoä huùt aâm (+/-) thay ñoåi theo bieán ñoåi moâ hoïc trong u
- Maãu h.aâ : + U vôùi kích thöôùc nhoû > ñoàng daïng + U vôùi kích thöôùc lôùn > khoâng
ñoàng daïng . Maãu hình aûnh “u trong u”
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K GAN NGUYEÂN PHAÙT♦ Maãu hình aûnh ñaëc bieät : + Daïng khaûm xaø cöø- mosaic (u trong u) + Fibrollamelar HCC coù voû boïc , keøm hình
aûnh seïo trung taâm + U coù cuoáng (exotumor) + KGNP vôõ > .h.aû maát lieân tuïc bao gan
vaø baùng (+) 5.2.Daïng thaâm nhieãm : -Maãu hình aûnh gioáng nhö beänh lyù gan
maïn tính lan toûa keøm thuyeân taéc cöûa aùc tính .
-Chaån ñoaùn phaân bieät vôùi vieâm gan tieán trieån
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K GAN NGUYEÂN PHAÙT5.3. Vai troø cuûa SAÂ doppler khaûo
saùt töôùi maùu u vaø m.m gan - T/m cöûa (+++) - T/m treân gan (+) - Daáu hieäu doppler ñaëc tröng cho
HCC .
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K GAN NGUYEÂN PHAÙT- T/m cöûa (+++) : ngoaøi bieåu hieän xoâ
ñaåy, cheøn eùp > xaâm laán m.m +Xuaát hieän caáu truùc coù h.aâ/loøng m.m ,
möùc ñoä h.aâ phuï thuoäc vaøo t.gian hình thaønh .
+Khaåu kính m.m giaõn . +Thuyeân taéc hoaøn toaøn> khoâng thaáy
doøng chaûy(+) +Xuaát hieän tín hieäu ñoäng maïch/ khoái
th.taéc (+++) +Shunt ñoäng maïch-tm /loøng tmc
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K GAN NGUYEÂN PHAÙT- Daáu hieäu doppler ñaëc tröng cho
HCC: +Daïng phaân boá m.m nuoâi
.Maãu hình roã .Maãu maïch m. vaøo trong u +Loaïi m.m :ñoäng maïch (+++) , tmc (+/-) +Daïng doøng chaûy : .Vaän toác cao . RI thaáp . Taàn soá Doppler cao > 4KHZ . Doøng roái - cöûa soå phoå roäng
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K GAN NGUYEÂN PHAÙT♦ 5.4. Chieán löôïc ñieàu trò - Vai troø cuûa caùc phöông tieän hình aûnh
hieâïn nay : CT, MRI , Angiography,- Scintigraphy.- Chöông trình truy tìm HCC vôùi : + SAÂ + Ñònh löôïng AFP + Ñaëc bieät treân beänh nhaân xô gan ,
vieâm gan.
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K GAN NGUYEÂN PHAÙT
♦ 5.5. Ñieàu trò –vai troø cuûa SAÂ can thieäp
-Phaåu thuaät chæ ñònh haøng ñaàu (CHILD A, +/- B).
- Tieâm ethanol + Soá löôïng < 3 + Kích thöôùc <4cm - Phoùng xaï, Lazer trò lieäu taïi choã – - Gaây ngheõn taéc ñoäng maïch (+/- tieâm
thuoác choáng K ) cho loaïi HCC ngoaøi chæ ñònh ph.thuaät (vôùi CHILD B,C)
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K GAN THÖÙ PHAÙT ♦ 1.ÑAÏI CÖÔNG -Ñaëc ñieåm GP cuûa gan +Lieân heä GP vôùi nhieàu cô quan +Giaøu maïch (nhieàu nguoàn ) +Heä lympho vaø lieân voõng noäi moâ +Chöùa nhieàu chaát dinh döôõng -Laâm saøng + Boái caûnh ñaõ bieát tröôùc K nguyeân
phaùt + Tình côø phaùt hieän + Tieân löôïng haïn cheá (nhieàu vò trí treân
caùc thuøy)
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K GAN THÖÙ PHAÙT
2.Hình aûnh sieâu aâm 2.1 Ñaëc ñieåm h.aû -Ña daïng , ña hình thaùi -Soá löôïng : nhieàu oå-Kích thöôùc u : nhieàu kích côû-Vò trí :phaân boá ôû caùc thuøy +Rieâng K ñaïi traøng > xu höôùng vò trí
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K GAN THÖÙ PHAÙT
2.2. Nhöõng noát giaûm h.aâ - Thöôøng gaëp - Ñoä hoài aâm giaûm so vôùi neàn chuû moâ + Soá löôïng quùa nhieàu > hình aûnh nhö chieác
saøn - Ñoä huùt aâm : khoâng thay ñoåi so vôùi nhu moâ
xung quanh 2.3 Nhöõng noát taêng h.aâ - Thöôøng gaëp nhaát - Ñoä hoài aâm taêng hôn so vôùi neàn chuû moâ + Soá löôïng quùa nhieàu > hình aûnh”baõo tuyeát “ - Khaù ñaëc thuø cho K thöù phaùt töø oáng tieâu
hoaù.
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K GAN THÖÙ PHAÙT2.3.Daïng hoaïi töû - Quaù trình hoaïi töû coù theå : + Töï nhieân + Sau hoaù trò lieäu + Sau xaï trò -Hình aûnh s.aâ :vuøng dòch hoaù (roãng h.aâ,
lôïn côïn h.aâ) trung taâm moâ u . - Chaån ñoaùn phaân bieät vôùi apxe2.4. Daïng noát cuùc aùo - Daïng maét boø : trung taâm laø vuøng giaûm
h.aâ, vieàn keá laø taêng h.aâ, vieàn ngoaïi vi laø giaûm h.aâ .
- Chaån ñoaùn # naám gan .
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K GAN THÖÙ PHAÙT 2.5.Daïng voâi hoaù - Hình aûnh voâi hoaù : ñaùm taêng h.aâ, keøm
boùng löng - Thöù phaùt töø : + K bieâûu moâ buoàng tröùng + K nguyeân baøo thaàn kinh + K ñaïi traøng 2.6. Daïng thaâm nhieãm . - Thöông toån kích thöôùc nhoû, nhieàu , raûi
khaép chuû moâ gan ->Khoù phaân ñònh neân taïo hình aûnh thaâm nhieãm
- Chaån ñoaùn khaùc : Vieâm gan maïn
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MỘT SỐ THƯƠNG TỔN KHU TRÚ TẠI GAN
♦ Áp xe gan♦ Nang gan♦ Sán lá gan♦ Chấn thương gan ( dập , tụ máu ..)
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