摘要
目的探讨区域性门静脉高压症（RPH）的cT和MRI检查影像学特征。方法采用回顾性队列研究方法。收集2014年2月至2018年2月内蒙古医科大学附属医院收治的31例RPH和同期31例肝硬化门静脉高压症（CPH）患者的临床病理资料，分别设为RPH组和CPH组。RPH组病因：慢性胰腺炎合并胰腺假性囊肿21例，胰体尾部癌5例，胰腺实性假乳头状瘤、胰腺浆液性囊腺瘤、胃间质瘤、腹膜后转移瘤、左肾癌各1例。CPH组病因：乙型病毒性肝炎后肝硬化27例（4例合并肝癌转移灶），酒精性肝硬化3例．胆汁淤积性肝硬化1例。患者行CT和（或）MRI检查。RPH组患者主要针对原发病治疗。CPH组治疗主要为降低门静脉压力。观察指标：（1）两组患者影像学特征。（2）治疗和随访情况。采用门诊和电话方式进行随访，了解患者治疗后门静脉高压症控制情况。随访时间截至2018年2月。正态分布的计量资料以x±s表示，组间比较采用t检验。偏态分布的计量资料以肘（范围）表示，组间比较采用Mann—Whitney秩和检验。计数资料比较采用χ^2检验。结果（1）两组患者影像学特征：RPH组31例患者中，12例单纯行CT检查,2例单纯行MRI检查，17例联合行CT和MRI检查。CPH组31例患者中，12例单纯行CT检查,19例联合行CT和MRI检查。RPH组患者胃底静脉曲张例数、合并食管静脉曲张例数、胃周静脉曲张数目、门静脉主干直径、脾静脉直径、肝体积、脾体积、肝脾体积比分别为11例、1例、49支、（13．9±2．9）mm、（12．0±2．8）mm、1383cm^3（1005～1637cm^3）、271cm^3（199～311cm^3）、5．5±2．0；CPH组患者上述指标分别为24例、21例、33支、（16．3±1．7）mm、（10．5±3．2）mm、1087cm^3（916～1536cm^3）、603cm^3（415～869cm^3）、2．2±0．9。两组患者胃底静脉曲张例数、合并食管静脉曲张例数、胃周静脉曲张数目、门静脉主干直径、脾体积、肝脾体积比比较，差异均有统计学意义（χ^2=11．088，28．182，8．940，t=4．430，Z=6．205，t=8．544．P〈0．05）；脾静脉直径、肝体积两组患者比较，差异均无统计学意义（t=1．974，Z=1．162，P〈0．05）。RPH组31例患者中，2例胰腺假性囊肿误诊为胰腺癌，其余患者均经影像学检查准确诊断；CPH组31例患者中，3例肝转移灶CT检查未能发现，其余患者均经影像学检查准确诊断。RPH组31例患者中，脾静脉闭塞2例．脾静脉重度狭窄17例，中度狭窄10例，轻度狭窄2例。CPH组31例患者脾静脉以扩张为主，未见明确狭窄。（2）治疗和随访情况：两组患者均获得术后随访，随访时间为6～48个月，中位随访时间为21个月。RPH组31例患者中，21例慢性胰腺炎合并胰腺假性囊肿患者行胰腺假性囊肿穿刺引流术7例，其中6例门静脉高压症控制差，1例控制尚可；行胰肠内引流术4例，其中1例4年后再次行胰肠吻合术，3例门静脉高压症控制良好；行脾切除联合胃周血管离断术3例，门静脉高压症控制良好；行保守治疗7例．门静脉高压症控制较好。5例胰体尾部癌患者行胰体尾切除＋脾切除术2例，门静脉高压症控制良好：行非手术综合治疗3例，1年后死于原发病。1例胰腺实性假乳头状瘤、1例胰腺浆液性囊腺瘤、1例胃间质瘤患者分别行相应手术切除，门静脉高压症控制良好。1例腹膜后转移瘤、1例左肾癌患者行非手术综合治疗，门静脉高压症控制尚可。CPH组31例患者以保肝治疗为主，其中8例新发脐周静脉曲张，7例1年内再发上消化道出血，5例新发腹壁静脉曲张，3例脾体积继续增大，8例门静脉高压症控制尚可。结论RPH存在胰腺、脾脏或腹膜后疾病，尤其是胰腺疾病等原发疾病，孤立性胃底静脉曲张，胃周静脉曲张．脾静脉阻塞而门静脉主干和肝功能正常是其主要影像学特征。手术切除原发肿瘤，合理行脾切除术是RPH有效治疗方法。
Objective To investigate the features of computed tomography （CT） and magnetic resonance imaging （MRI） of regional portal hypertension （RPH） . Methods The retrospective cohort study was conducted. The elinicopathological data of 31 patients with PHR in the RPH group and 31 patients with liver cirrhotic portal hypertension （CPH） in the CPH group who were admitted to the Affiliated Hospital of Inner Mongolia Medical University between February 2014 and February 2018 were collected. Etiologies of patients in the RPH group included 21 of chronic pancreatitis complicated with pancreatic pseudocyst, 5 of carcinoma of pancreatic body and tail, 1 of solid pseudopapillary tumor of the pancreas, 1 of pancreatic serotls cystoadenoma, 1 of gastric stromal tumor, 1 of retroperitoneal metastatic tumor and 1 of left renal carcinoma. Etiologies of patients in the CPH group included 27 of liver cirrhosis after viral hepatitis type B （4 complicated with liver metastasis ） , 3 of alcoholic cirrhosis and 1 of cholestatic cirrhosis. All the patients underwent CT and MRI examinations. Patients in the RPH group were mainly treated the primary diseases and patients in the CPH group were decreased portal vein pressure. Observation indicators： （ 1 ） imaging features of patients in the two groups; （2） treatment and follow-up situations. Follow-up using outpatient examination and telephone interview were performed to detect management of portal hypertension after treatment up to February 2018. Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed by the t test. Measurement data were represented as M （range） and comparison between groups was analyzed by the Mann-Whitney rank sum test. Count data were compared with chi-square test. Results （ 1 ） Imaging features of patients in the two groups ： of 31 patients in the RPH group, 12 underwent CT examination, 2 underwent MRI examination, and 17 underwent CT combine with MRI examination. Of 31 patients in the CPH group, 12 underwent CT examination and 19 underwent CT combined with MRI examination. The number of patients with varices in the gastric fundus, the number of patients with combined esophageal varices, the number of perigastric varices, diameter of main portal vein, diameter of splenic vein, liver volume, splenic volume, hepatosplenic volume ratio were 11, 1, 49, （ 13.9±2. 9）mm, （ 12. 0±2. 8）mm, 1 383 cm^3 （range, 1 005-1 637 cm^3） , 271 cm^3（range, 199-311 cm^3） and 5.5±2.0 in the RHP group and 24, 21, 33, （16.3±1.7） mm, （ 10. 5±3.2） mm, 1 087 cm^3（range, 916-1 536 cm^3 ）, 603 cm^3（range, 415-869 cm^3 ） and 2.2±0. 9 in the CHP group, with statistically significant differences in the number of patients with varices in the gastric fundus, the number of patients with combined esophageal varices, the number of perigastric varices, diameter of main portal vein, splenic volume, hepatosplenic volume ratio between the two groups （χ^2 = 11. 088, 28. 182, 8. 940, t = 4. 430, Z= 6. 205, t = 8. 544, P〈0. 05） and with no statistically significant differences in the diameter of splenic vein and liver volume between the two groups （t= 1. 974, Z= 1. 162, P〈0. 05）. Of 31 patients in the RPH group, 2 with pancreatic pseudocyst were misdiagnosed as pancreatic cancer and 29 were diagnosed accurately by imaging examinations. Of 31 patients in the CPH group, 3 with liver metastasis were undetected by CT examination and the other 28 were diagnosed accurately by imaging examinations. Splenic vein occlusion, severe splenic vein stenosis, moderate splenic vein stenosis and mild splenic vein stenosis were detected in 2, 17, 10 and 2 of 31 patients in the RHP group. All the 31 patients in the CHP group mainly had dilation in splenic veins, with no clear stenosis. （2） Treatment and follow-up situations： patients in the two groups were followed up for 6-48 months, with a median time of 21 months. Of 21 patients with chronic pancreatitis complicated with pancreatic pseudocyst in the RPH group, 7 underwent pancreatic pseudocyst puncture and drainage, 6 of them had poor control on portal hypertension and 1 had moderate control ; 4 underwent pancreaticoenteric drainage, 1 of them underwent pancreaticojejunostomy 4 years later and 3 of them had good control on portal hypertension ; 3 undergoing splenectomy combined with perigastrectomy had good control on portal hypertension; 7 undergoing conservative treatment had good control on portal hypertension. Of 5 patients with carcinoma of pancreatic body and tail in the RHP group, 2 undergoing distal pancreatectomy combined with splenectomy had good control on portal hypertension and 3 undergoing non-operative combined therapy died of primary disease one year later. One, 1 and 1 patient with solid pseudopapillary tumor of the pancreas, pancreatic serotls cystoadenoma and gastric stromal tumor respectively in the RHP group underwent relative surgical treatments and had good control on portal hypertension. One and 1 patient with retroperitoneal metastatic tumor and left renal carcinoma respectively in the RHP group underwent non-operative combined therapy and had good control on portal hypertension. All the 31 patients in the CHP group were mainly treated with protection of liver function, 8 of them were encounted with medusa head, 7 with upper gastrointestinal rehemorrhage within one year, 5 with subcutaneous varicose vein of abdominal wall, 3 with continuing increase of spleen volume and 8 had good control on portal hypertension. Conclusions RHP are existed in pancreatic, splenic or peritoneal diseases, especially the pancreatic primary diseases. The main imaging features of RHP include isolated gastric varices, perigastric varices and splenic vein occlusion without normal main portal vein and liver function. Surgical resection of primary tumor and reasonable splenectomy are effective therapy.
作者
王泽锋
肖瑞
杨景瑞
周江
任建军
Wang Zefeng;Xiao Rui;Yang Jingrui;Zhou Jiang;Ren Jianjun(Department of Radiology,the Affiliated Hospital of Inner Mongolia Medical University,Hohhot 010050,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2018年第10期1045-1051,共7页
Chinese Journal of Digestive Surgery
基金
内蒙古自治区自然科学基金（2017MS0834）
内蒙古医科大学教坛新秀项目（NYJTXX201812）
内蒙古医科大学临床医学教学研究项目（NYJXGG2017127）
作者简介
通信作者：任建军，Email：renjj．ok@163．com
