Ecografia interventionala a ficatului

7. Ecografia interventionala

Ultrasonografia interventionala reprezinta un domeniu divers si captivant. Extensia diagnosticului imagistic prin manevre de biopsie sau drenaj al colectiilor intra/perihepatice aduce un plus de valoare metodei ultrasonografice, dar si multiple semne de intrebare si controverse. Prin biopsia ghidata ultrasonografic se asteapta cresterea gradului de acurate diagnostica in hepatopatiile difuze sau localizate, iar prin aplicarea unor proceduri de alcoolizare, drenaj sau radioablatie ghidata, un aport semnificativ la rezolvarea terapeutica a unor cazuri bine selectionate.

7.1. Punctia biopsie hepatica (PBH) in hepatopatiile difuze

Biopsia hepatica percutana reprezinta in continuare standardul de aur in stabilirea diagnosticului, stadializare, predictia prognosticului si raspunsului terapeutic in multe dintre afectiunile ficatului. Folosita in trecut ca singura metoda majora de diagnostic, PBH se confrunta in prezent cu o tendinta evidenta de limitare a aplicatiilor sale. Metodele moderne de diagnostic neinvaziv (ultrasonografia, elastografia, CT, RMN, angiografia) sunt folosite pe scara larga, contribuind la diagnostic alaturi de rezultatele clinice si biologice tot mai laborioase.

Ultrasonografia poate fi utilizata fie la evaluarea initiala a topografiei segmentelor si organelor perihepatice (colecist, colon, rinichi, etc.) (punctie biopsie ecoasistata), fie la ghidajul menevrei de biopsie (punctie biopsie ecoghidata). Punctia oarba este tot mai putin folosita in prezent.

La efectuarea biopsiei sub ghidaj ultrasonografic, se vizualizeaza acul (ecou linear) traversand strat cu strat structurile anatomice: perete toraco-abdominal, capsula hepatica, parenchimul hepatic (fig. 7.1). Profunzimea penetrarii si traiectul acului (evitand rinichiul drept, colonul, colecistul, vasele mari) sunt apreciate in timp real.

Aplicarea concomitenta a modului Doppler color poate identifica mai fidel structurile vasculare de evitat cat si miscarea acului in parenchimul hepatic. Cel mai frecvent folosit este modul gray-scale 2D; acolo unde aparatura permite, utilizarea reprezentarilor anatomice in 3 planuri poate aduce informatie utila, indeosebi in cazul biopsiei leziunilor focale.

Fig. 7.1. Biopsie hepatica efectuata sub ghidaj ultrasonografic. Este bine vizibil acul (ecogenitate liniara) in parenchimul hepatic.

Ultrasonografia ramane utila si in supravegherea post-biopsie (fig. 7.2-7.3). Prin examinari seriate (imediate, la 1h, 3h, 6 h, 24 h) poate evidentia posibilele complicatii: hematom local, hemoperitoneu, hemotorax, pneumotorax, peritonita, fistula arterio-venoasa. Trebuie cunoscut aspectul normal la locul de punctie: traiectul ecogen sub forma a doua linii paralele, generat de urma acului de punctie.

Fig. 7.2. Ultrasonografie efectuata imediat dupa biopsia hepatica la un pacient cu ciroza virala C Child-Pugh B. Se vizualizeaza un mic hematom (transonic) din locul prelevarii, si sufuziunea sanguina (ecogena) pe traiectul acului.

1. Cedrone A, Rapaccini GL, Pompili M, Aliotta A, Trombino C, De Luca F, Caturelli E, Caputo S, Gasbarrini G. Portal vein thrombosis complicating hepatocellular carcinoma. Value of ultrasound-guided fine-needle biopsy of the thrombus in the therapeutic management. Liver 1996;16:94-98.

2. De Sio I, Castellano L, Calandra M, Romano M, Persico M, Del Vecchio-Blanco C. Ultrasound-guided fine needle aspiration biopsy of portal vein thrombosis in liver cirrhosis: results in 15 patients. J Gastroenterol Hepatol 1995;10:662-665.

3. Dodd GD 3rd, Memel DS, Baron RL, Eichner L, Santiguida LA. Portal vein thrombosis in patients with cirrhosis: does sonographic detection of intrathrombus flow allow differentiation of benign and malignant thrombus? Am J Roentgenology 1995;165:573-577.

4. Dodd GD 3rd, Carr BI. Percutaneous biopsy of portal vein thrombus: a new staging technique for hepatocellular carcinoma. Am J Roentgenology 1993;161:229-233.

5. Duchmann JC, Joly JP, Biny JP, Sevestre H, Capron JP. Portal thrombosis and liver cirrhosis. Value of ultrasound-guided puncture-biopsy of the thrombus. Gastroenterol Clin Biol 1995;19:581-586.

6. Dusenbery D, Dodd GD 3rd, Carr BI. Percutaneous fine-needle aspiration of portal vein thrombi as a staging technique for hepatocellular carcinoma. Cytologic findings of 46 patients. Cancer 1995;15:2057-2062.

7. Furuse J, Matsutani S, Yoshikawa M, Ebara M, Saisho H, Tsuchiya Y, Ohto M. Diagnosis of portal vein tumor thrombus by pulsed Doppler ultrasonography. J Clin Ultrasound 1992;20:439-446.

8. Lencioni R, Caramella D, Sanguinetti F, Battola L, Falaschi F, Batolozzi C. Portal vein thrombosis after percutaneous ethanol injection for hepatocellular carcinoma: value of color Doppler sonography in distinguishing chemical and tumor thrombi. Am J Roentgenology 1995;164:1125-1130.

9. Ricci P, Cantisani V, Biancari F, Drud FM, Coniglio M, Di Filippo A, Fasoli F, Passariello R. Contrast-enhanced color Doppler US in malignant portal vein thrombosis. Acta Radiol 2000;41:470-743.

10. Rossi S, Rosa L, Ravetta V, Cascina A, Quaretti P, Azzaretti A, Scagnelli P, Tinelli C, Dionogi P, Calliada F. Contrast-enhanced versus conventional and color Doppler sonography for the detection of thrombosis of the portal and hepatic venous systems. Am J Roentgenology 2006;186:763-773.

11. Shah ZK, McKernan MG, Hahn PF, Sahani DV. Enhancing and expansile portal vein thrombosis: value in the diagnosis of hepatocellular carcinoma in patients with multiple hepatic lesions. Am J Roentgenology 2007;188:1320-1323.

12. Ueno N, Kawamura H, Takahashi H, Fujisawa N, Yoneda M, Kirikoshi H, Sakaguki T, Saito S, Togo S. Characterization of portal vein thrombus with the use of contrast-enhanced sonography. J Ultrasound Med 2006;25:1147-1152.

13. Tanaka K, Numata K, Okazaki H, Nakamura S, Inoue S, Takamura Y. Diagnosis of portal vein thrombosis in patients with hepatocellular carcinoma: efficacy of color Doppler sonography compared with angiography. Am J Roentgenology 1993;160:1279-1283.

14. Tarantino L, Francica G, Sordelli I, Esposito F, Giorgio A, Sorrentino P, de Stefano G, Di Sarno A, Ferraioli G, Sperlongano P. Diagnosis of benign and malignant portal vein thrombosis in cirrhotic patients with hepatocellular carcinoma: color Doppler US, contrast-enhanced US and fine-needle biopsy. Abdom Imaging 2006;31:537-544.

15. Venturi A, Piscaglia F, Silvagni E, Righini R, Fabbrizio B, Cescon M,Bolondi L. Role of real-time contrast-enhanced ultrasound in the assessment of metastatic portal vein thrombosis. Ultraschall Med 2007;28:75-78.

16. Vilana R, Bru C, Bruix J, Castells A, Sole M, Rodes J. Fine-needle aspiration biopsy of portal vein thrombus: value in detecting malignant thrombosis. Am J Roentgenology 1993;160:1285-1287.

17. Wales LR, Miorishima MS, Allan NK. Portal vein thrombosis: diagnosis via percutaneous transhepatic needle. Am J Roentgenology 1980;134:842-844.

18. Wang LY, Lin ZY, Chang WY, Chen SC, Chuang WL, Hsieh MY, Tsai JF, Okuda K. Duplex pulsed Doppler sonography of portal vein thrombosis in hepatocellular carcinoma. J Ultrasound Med 1991;10:265-269.

19. Wu W, Chen MH, Yin SS, Yan K, Fan ZH, Yang W, Dai Y, Huo L, Li JY. The role of contrast-enhanced sonography of focal liver lesions before percutaneous biopsy. Am J Roentgenology 2006;187:752-761.

20. Yang L, Lin LW, Lin XY, Gao SD, He YM, Yang FD, Wue ES, Lin XD. Ultrasound-guided fine needle aspiration biopsy in differential diagnosis of portal vein tumor thrombosis. Hepatobiliary Pancreat Dis Int 2005;4:234-238.