a. Vessel dissection, tumor rupture
b. Ischemic bowel
c. Obstruction
d. Perforation
因此適合分析肚痛的工具從 KUB, sono, CT均需視History以及其他臨床症狀而定。
2. Q：Acute cholecystitis中，影像學發現哪個不是診斷的criteria?
a. Wall tickening
b. Fluid accumulation next to GB.
c. Gall bladder stone inside.
d. Length>8cm
e. Wideth>4cm
A: d. 因有個人差異。Acute cholecystitis中95%有發現GB stone.
3. What’s Courvoisier's law?
References: http://www.springerlink.com/content/g78076558l257j41/
Courvoisier described 187 cases of common bile duct obstruction, observing that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. The classic explanation for Courvoisier’s finding is based on the process that presence of gallstones come repeated episodes of infection and subsequent fibrosis of the gallbladder.
a. In the event that a gallstone causes the obstruction, the gallbladder is shrunken owing to fibrosis and is unlikely to be distensible and, hence, palpable.
b. With other causes of obstruction, the gallbladder distends as a result of the back-pressure from obstructed bile flow. However, recent experiments show that gallbladders are equally distensible in vitro, irrespective of the pathology, suggesting that chronicity of the obstruction is the key. Chronically elevated intraductal pressures are more likely to develop with malignant obstruction owing to the progressive nature of the disease. Gallstones cause obstruction in an intermittent fashion, which is generally not consistent enough to produce such a chronic rise in pressure.
目前臨床的應用是如果在一黃疸的病人有painless GB or CBD, 則懷疑可能有ampulla maliganancy. （of pancreas)
4. Acute, chronic cholecystitis 的sonography.
a. Clinical s/s: Harrison, Sabiston 有相關reference可參考。舉凡疼痛的時間pattern, acute通常都會持續一天以上。Chronic則多半發作多於1hr但少超過24hr。
i. sono上因為chronic造成的纖維化，所以不會有dilate GB, 而可見wall thickening and fibrosis.
ii. Acute 則可能見到BTI obstruction的too many tubes sign. (與 hereditary hepatic telangiectasia 可用doppler 區分)
b. Rx: 治療方式也不相同。而在chronic cholecystits, Abx以及 PTGBD多半是不需要的。（後者因為fibrosis, 難以approach)
From uptodate: A meta-analysis of 12 controlled trials concluded that early cholecystectomy (ranging from immediate cholecystectomy to cholecystectomy within seven days of symptoms) was the preferred approach.
Although there is consensus that incidentally discovered asymptomatic gallstones should not be treated, once a patient develops symptoms or complications related to gallstones (such as acute cholecystitis), treatment to eliminate the gallstones should be recommended, because the likelihood of subsequent symptoms or complications is high. The National Cooperative Gallstone Study demonstrated that the risk of recurrent symptoms was approximately 70 percent during the two years following initial presentation
5. Pneumobilia 以及portal venous gas的區分。（這大家應該已經很熟了，簡單複習一下）
因為分布的不同，Biliary tract多半從周圍往中央集中，而portal vein則是侷限在中央，可作為一判斷線索。另外如果sonography中有高反差的gas存在時，可參考移動速度，在portal vein的air移動較快。à聯想：r/o ischemic bowel
6. Chilaiditi syndrome
多半是因為T-colon的一些variant造成看起來類似pneumoperitoneum的sign.
上圖from radiographics, 下圖from wikipedia.
7. 在sonography下，if hydronephrosis noted, 懷疑stone obstruction，在U/3 or L/3較易trace到。（看到pelvic dilate不一定是hydronephosis，有可能是renal vessel or cyst, 可從有無跟pelvis相連以及doppler協助ddx)
8. Renal pelvis 內髒髒的，ddx: pyelonephritis, tumor。
9. 如果在renal hilum處看到slight increased echoic lesion, ddx: UCC, blood clot, RCC with pelvis invasion, sinus lipomatosis(rare cause hydronephrosis). If stone, it will be hyperechoic.
10. Pseudokidney: ddx:
a. bowel tumor, colon CA or GIST.
b. Duplicated kidney
c. Intussusception.
感謝精心地整理分享^^
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