摘要
第一部分超声造影评价输卵管通畅性的价值
目的不孕症是一种常见疾病,女性因素占60%。女性可由多种因素而致病,其中多种原因可引起的输卵管狭窄、堵塞、蠕动受限使精子或卵子不能通过输卵管是引起女性不孕的重要原因。既往诊断输卵管病变的方法,主要有输卵管通液术、X线子宫输卵管碘油造影(HSG)和腹(宫)腔镜检查等。其中,输卵管通液术主要依靠药液推注时阻力的大小,以及有无反流来判断输卵管的通畅程度,诊断的主观性较大,准确性较差,且不能对阻塞部位作出明确的诊断;腹(宫)腔镜检查是一种有效,确诊率高的检查方法,但它是有创性检查,对器械要求高且操作复杂,具有一定的风险性;HSG是临床上较为常用的评价输卵管通畅性的方法,但医患均受射线辐射,且对碘过敏者检查受限;碘油吸收慢可导致肉芽肿形成、粘连等,油栓进入血循环可引起肺动脉栓塞的风险。本研究应用超声造影剂SonoVue对222例患者进行子宫输卵管超声造影,以探讨在诊断输卵管源性不孕症中应用经阴道超声造影评价输卵管通畅性的应用价值。
方法不孕症妇女222例,常规经阴道二维超声下观察子宫、输卵管及卵巢的相对位置,将造影剂通过双腔子宫输卵管造影导管缓慢注入宫腔内,在B-flow超声模式下观察造影剂在宫腔及输卵管内的显影情况,同时注意推注时压力的大小,及造影结束后子宫直肠窝内无回声区的变化情况,来综合判断输卵管的通畅程度。超声造影结果与输卵管通液术、X线子宫输卵管碘油造影、腹(宫)腔镜检查结果进行对照分析(采用SPSS11.0统计软件,两组间的显著性差异采用χ~2检验)。
结果222例不孕症患者(共计435条输卵管):73例(146条)双侧输卵管通畅;60例(120条)双侧梗阻;4例(8条)双侧通而不畅;56例(112条)一侧通畅,一侧梗阻;10例(20条)一侧通畅,一侧通而不畅;10例(20条)一侧通而不畅,一侧梗阻;9例因输卵管妊娠切除一侧输卵管术后,6例(6条)通畅,3例(3条)通而不畅。140例患者(其中有2例患者因输卵管妊娠切除一侧输卵管,共计278条输卵管)超声造影结果同输卵管通液术检查结果比较,经统计学方法处理,结果提示超声造影法与输卵管通液术准确性有显著性差异(χ~2=18.0,P<0.005);48例患者(共计96条输卵管)超声造影及X线子宫输卵管碘油造影结果示双侧或单侧输卵管梗阻的患者行腹(宫)腔镜检查(包括腹腔镜直视下输卵管通液检查、宫腔镜下经输卵管口插管通液检查和腹腔镜联合检查,通液时加用美兰染液),结果显示超声造影与腹(宫)腔镜检查准确性相似,无显著性差异(χ~2=0.10,P=0.75);超声造影诊断输卵管通畅性的诊断符合率、灵敏度、特异度均高于X线子宫输卵管碘油造影。
结论应用SonoVue经阴道超声子宫输卵管造影是一种安全,简便,准确性高,无损伤,无副作用的检查方法。具有诊断和治疗的作用,是检查输卵管通畅性的较佳的方法。
第二部分超声输卵管造影对输卵管积水的诊断及鉴别诊断
目的输卵管积水是慢性输卵管炎症中较为常见的类型。在输卵管炎后,因输卵管粘连闭锁,粘膜细胞的分泌液积存于管腔内;或因输卵管炎症发生峡部及伞端粘连,阻塞后形成输卵管积脓,当管腔内的脓细胞被吸收后,最终成为水样液体。临床常见原因为人工流产、自然流产、药流、引产、不洁性交、盆腔感染等引起输卵管壁粘连、充血、水肿而阻塞,导致精子与卵子不能够结合,最终形成不孕症。因此明确诊断对进一步的临床治疗有着至关重要的意义。本实验是用经阴道二维超声及超声输卵管造影来探讨超声输卵管造影在输卵管积水的诊断及鉴别诊断上的临床实用价值。
方法28例患者经阴道二维超声重点观察双侧附件区的无回声区与子宫,卵巢的相对位置关系,形态,囊壁,内部结构,移动度,测量并记录无回声区的大小、范围。然后通过双腔子宫输卵管造影导管缓慢向宫腔内注入造影剂,在B-flow超声模式下观察造影剂在宫腔及输卵管内的显影情况。
结果28例患者(共计55条输卵管,1例因输卵管妊娠手术切除一侧输卵管),经阴道二维超声显示诊断为20例一侧输卵管积水,8例双侧输卵管积水。超声造影13例一侧输卵管积水,2例双侧输卵管积水。12例一侧输卵管积水的患者接受了腹腔镜手术治疗,术后结果均与造影结果相符。
结论经阴道二维超声联合应用超声造影可提高输卵管积水诊断的准确率,可为患者提供了安全、有效的检查方法,为临床治疗和手术提供重要的帮助。
Part one Value of Contrast-enhanced Ultrasonography in Diagnosis tubal patency
Objective: Infertility is a common disease and accounting for 60% of female factors. Many reasons could cause oviduct obstruction, such as appendagitis, pelvic inflammation . There are many diagnoses methods, such as hydrotubation , X-ray hysterosalpingography (HSG) , laparoscopy (hysteroscopy ), and so on. Hydrotubation mainly depends on the resistance to determine , and the result is inaccurate. HSG is a commonly used method of clinical., but the patient and the doctor have to receive radiation. The oil may be noxious to the body. If the oil is not absorpted, it will produce granuloma or abdominal cavity infection. laparoscopy (hysteroscopy ) is an effective, confirmed the high rate of inspection method , but it is a invasive examination and with a certain degree of risk. This research evaluates the value of diagnosis and treatment of fallopian tube patency by using hysterosalpingocontrast sonography (HyCoSy) with SonoVue and transvaginal ultrasound for 222 infertile women.
Methods: 222 infertile women were examined by HyCoSy-SonoVue to observe flowing condition in Womb and fallopian tube. Comparing the results with hydrotubation, X-ray hysterosalingography (HSG) and laparoscopy (hysteroscopy).
Result: In the 222 cases, 73 cases were both side of fallopian tube patency, 72 cases were single fallopian tube patency, 13 cases were single partial obstruction, 60 cases were both side of fallopian tube pinning, 4 cases were both partial obstruction. There was a significant difference on pregnancy rates between the HyCoSy-SonoVue and hydrotubation (P<0.05). There was no difference on diagnostic rates of fallopian tube patency between the HyCoSy-SonoVue, laparoscopy (hysteroscopy) (P>0.05), the HyCoSy-SonoVue was higher rate of diagnosis than HSG .
Conclusion: The HyCoSy-SonoVue method is a safety one. This method would be an effective diagnosis in the evaluation of fallopian tube pathology for infertile women.
Part two Value of Contrast-enhanced Ultrasonography in Diagnosis and Differential diagnosis of Hydrosalpinx
Objective: Hydrosalpinx is one of commonly chronic inflammation in the fallopian tube. After salpingitis tubal atresia adhesion, mucosal cells in the secretion of fluid accumulation within the lumen, or isthmic tubal inflammation and adhesions umbrella side, blocking the formation of fallopian tube, when the lumen is absorbed within the suppurative cells , after eventually become liquid water. For a common cause of clinical abortion, spontaneous abortion, medical abortion, induced abortion, the unclean sexual intercourse, pelvic infections caused by tubal wall adhesions, hyperemia, edema and obstruction, resulting in sperm and eggs can not be combined with the ultimate form of infertility. Therefore it is vital of a clear diagnosis for the clinical further treatment. This research used two-dimensional transvaginal ultrasound and HyCoSy-SonoVue to explore value of contrast-enhanced ultrasonography in diagnosis anddifferential diagnosis of Hydrosalpinx.
Methods: 28 cases of patients were examined by two-dimensional transvaginal ultrasound to observe echo-free zone of bilateral annex , to know the relative position of echo-free zone with the uterus and ovary, echo-free zone’s shape, wall, internal structure, mobility, measurement and to record echo-free zone size, scope. And then to slowly inject contrast agent to intrauterine with the double-lumen catheter hysterosalpingography, in the mode of B-flow ultrasound contrast agent were observed in the uterine cavity and fallopian tubes within the developing situation.
Results: 28 cases of patients (a total of 55 fallopian tubes, 1 case of tubal pregnancy due to tubal surgery to remove the side), two-dimensional transvaginal ultrasound showed that 20 cases were diagnosed as the side of hydrosalpinx, 8 cases of bilateral hydrosalpinx. Ultrasound contrast showed 3 cases were diagnosed as the side of hydrosalpinx, 2 cases of bilateral hydrosalpinx. 12 cases of the side of hydrosalpinx patients received laparoscopic surgery, postoperative results were in line with the Ultrasound contrast results. Conclusion : Two-dimensional transvaginal ultrasound combined with ultrasound contrast can increase the accuracy of diagnosis in Hydrosalpinx .It is a safe and effective method for patients and can provide an important help for clinical treatment and surgery.
引文
1. Rowe PJ, Comhaire FH, Hargreave TB ,et al. WHO manual for the standardized investigation and diagnosis of the infertile couple〔M〕. London: Combridge University Press, 1993.
2.韩丽萍,李一冬,刘芳.子宫输卵管造影致肺栓塞40例临床分析.实用妇产科杂志,2001,17(4):240-241.
3.曹海根,王金锐,主编.实用腹部超声.北京:人民卫生出版社,2006.617
4.乐杰.妇产科学.第6版.北京:人民卫生出版社,2004.424.
5.席嘉元.子宫输卵管碘油造影术后输卵管内碘油可长期潴留.介入放射学杂志,2006,5:303-304.
6.马德英,邵文箐,徐永萍,等.宫腔镜在不孕症诊治中的作用[J].现代妇产科进展,2002,11(6):458.
7.胡小良,徐宏生,李延河,等.宫腔镜下输卵管口插管疏通术在不孕症治疗中的应用[J].中国实用妇产科学与产科杂志,2003,19(12):741-742.
8.何晓宇,宋岩峰,黄惠娟,许淑芬.腹腔镜用于女性不孕症诊断的评价[J].中国微创外科杂志,2001,1(3):143-144.
9.高雪梅,吴艳齐.腹腔镜检查不孕症盆腔疾病916例分析[J].实用妇产科杂志,2001,16(2):100-101.
10.李玉萍,何智坚,朱权芝.联合应用宫腔镜腹腔镜和子宫输卵管通液及子宫输卵管碘油造影检查诊断不孕症110例分析.中国实用妇产科与产科杂志,2001,1:47-48.
11.陈常佩,陆兆龄,主编.妇产科彩色多普勒诊断学.北京:人民卫生出版社,1998.25-35.
12.常才,主编.经阴道超声诊断学。北京:科学出版社,1999.37-38.
13.曹海根,王金锐,主编.实用腹部超声.北京:人民卫生出版社,2006.369.
14.廖慧芳,凌永伟.TVS与TAS在妇产科临床应用中的效果比较.赣南医学院学报,2008,28(6):858.
15.章晓梅,武泽.阴道B超在排卵监测中的应用.实用妇产科杂志, 2008,24(8):460-462.
16.董晓燕,李燕娜,姜海英.经阴道超声在异位妊娠诊断及治疗中的应用价值[J].中华医学超声杂志(电子版), 2006, (05).
17.俞雯.经阴道彩色多普勒超声在妇产科中的应用.中国超声医学杂志,1999,15(02):145.
18.杨岳州,叶旭萍,张秋琴,等.经阴道超声引导穿刺治疗盆腔良性囊性肿块的研究[J].中国超声诊断杂志,2004,5(9):663-665.
19.郑宗英,肖莹,曲军英,等.超声引导穿刺注入不同药物治疗卵巢子宫内膜异位囊肿的对比研究[J].中华超声影像杂志,2001,10(3):160～162.
20.李文伦,张华民,付世文,等.经阴道超声引导下后穹窿穿刺治疗输卵管积水及输管卵巢脓肿[J].中华超声影像学杂志,2002,11(12):765-766.
21.杨晓英,王润兰,张静,王晓林.超声心肌造影技术对心肌梗塞患者心肌微循环的定量评价.吉林大学学报:医学版,2008,34(3):526-529.
22. Sitzer M, Furst G, Siebler M, et al. Usefulness of an intravenous contrast medium in the characterization of high-grade internal carotid stenosis with color Doppler-assisted duplex imaging. Stroke,1994, 25(2):385-389.
23. Matsuda Y, Yabuuchi I. Hepatic tumors: US contrast enhancement with CO2 microbubbles. Radiology,1986 Dec,161(3): 701-705.
24. Yucel C, Ozdemir H, Gurel S, et al. Detection and differential diagnosis of hepatic masses using pulse inversion harmonic imaging during the liver-specific late phase of contrast enhancement with Levovist. JCU, 2002, 30(4):203-212.
25. Isozaki T, Numata K, Kiba T, Hara K, Morimoto M, Sakaguchi T, Sekihara H, Kubota T, Shimada H, Morizane T, Tanaka K. Differential diagnosis of hepatic tumors by using contrast enhancement patterns at US. Radiology, 2003 Dec, 229(3):798-805.
26. Numata K, Tanaka K, Kiba T, Matsumoto S, Iwase S, Hara K, Kirikoshi H, Morita K, Saito S, Sekihara H. Nonresectable hepatocellular carcinoma: improved percutaneous ethanol injection therapy guided by CO(2)-enhanced sonography. AJR Am J Roentgenol, 2001 Oct, 177(4):789-798.
27. Koda M, Matsunaga Y, Ueki M, Maeda Y, Mimura K, Okamoto K, Hosho K, Murawaki Y. Qualitative assessment of tumor vascularity in hepatocellular carcinoma by contrast-enhanced coded ultrasound: comparison with arterial phase of dynamic CT and conventional color/power Doppler ultrasound. Eur Radiol , 2004 Jun, 14(6):1100-1108.
28. Liu JB, Goldberg BB, Merton DA, Rawool NM, Needleman L, Forsberg F. The role of contrast-enhanced sonography for radiofrequency ablation of liver tumors. J Ultrasound Med, 2001 May, 20(5):517-523.
29. Kennedy JE, ter Haar GR, Wu F, Gleeson FV, Roberts IS, Middleton MR, Cranston D. Contrast-enhanced ultrasound assessment of tissue response to high-intensity focused ultrasound. Ultrasound Med Biol, 2004 Jun, 30(6):851-854.
30.于晓玲,董宝玮,梁萍,唐杰,苏莉,于德江,程志刚.超声造影评价肝癌微波治疗疗效的初步应用.中华肝胆外科杂志,2001, 7: 153-155.
31.罗葆明,文艳玲,智慧,段红艳,杨海云,冯霞.实时谐波超声造影在肝肿瘤消融治疗中的应用.中国超声医学杂志,2005,21:522-524.
32. Claudon M , Plouin PF, Baxter GM, et al. Renal arteries in patients at risk of the echo-enhance SH U 508A at color and spectral Doppler US. Levovist Renal Artery Stenosis Study Group. Radiology, 2000, 214(3):739-746.
33.牟善初,王新明,敖建华,等.经静脉超声造影二次谐波成像对异体移植肾脏的研究.中国超声医学杂志,2000,16(11):826-828.
34.戴晴,姜玉新,常欣,等.超声造影对肾脏占位病变的诊断意义.中华泌尿外科杂志,1999,20(4):199-201.
35. Yang WT, Metreweli C, Lam PK, et al. Benign and malignant breast masses and axillary nodes:evaluation with echo-enhanced color power Doppler US. Radiology, 2001, 220(3): 759-802.
36. Amodio F, Di Martino S, Esposito S, et al. Role of flowmetric analysis and of color-Doppler ultrasonography with contrast media in the different phases and follow-up of Graves’disease. Radiol Med (Torino) , 2001, 102(4):233-237.
37.任小龙,周晓东,郑敏娟,等.超声造影在子宫肌瘤与腺肌瘤鉴别诊断中的价值.中华超声影像学杂志,2006,15(10): 770-772.
38.戴晴,刘真真,姜玉新,等.经阴道超声造影在附件包块诊断中的应用研究.中华超声影像学杂志,2006,15(9):693-697.
39.杨敬春,唐杰,罗渝昆,等.经直肠超声造影在前列腺外腺良恶性病变鉴别诊断中的作用.中华超声影像学杂志,2007,16(11):979-981.
40.张新玲,郑荣琴,黄冬梅,等.双氧水声学造影评价输卵管的通畅性.中国超声诊断杂志,2004,5(4):271-273.
41.巩箫音,周晓东,郑敏娟,等.输卵管妊娠高强度聚焦超声治疗后输卵管通畅性的超声晶氧造影研究.临床超声医学杂志,2007,9(3):135-137.
42. Schneider M. Contrast media in ultrasonography: from synthesis to clinical use. The SonoVue example. Ann Cardiol Angeiol (Paris), 2002, 51(4):218-220.
43. Bob Hardy, Systems RH, Albuquerque C, et al. Measurement of water vapor in sulphur hexafluoride. SF MBW Calibration.Wettingen, Switzerland , 2000:1-3.
44.刘丽萍,王智彪. SonoVueTM一种新型超声对比剂的研究进展.国外医学生物医学工程分册,2005,28(1):40-42.
45. Morel DR, Schwieger 1, Hohn L, et al. Human pharmacokinetics and safety evaluation of SonoVue, a new contrast agent for ultrasound imaging. Invest Radiol, 2000, 35(1): 80-85.
46. Bokor D, Chambers JB, Rees PJ, et al. Clinical safety of SonoVue, a new contrast agent for ultrasound imaging, in healthy volunteers and in patients with chronic obstructive pulmonary disease. Invest Radiol, 2001, 36(2): 104-109.
47.水旭娟,焦岩,陆恩慈,等.超声晶氧子宫输卵管超声造影113例分析.中华超声影像学杂志,2005,14(7):560.
48. Chiao R, Mo L, Hall A, et al .“B-mode blood flow imaging”Abstract for Scientific Paper submitted to AIUM Annual. Convention San Francisco,2000,4:2-5.
49. Ausushi U. Kazuo Y . B-Mode flow imaging of the carotid artery. Stroke, 2001,32(9):2055-2057.
50. Mehmet Y, Muharren T, Turhan C, et al. B-Flow imaging of internal carotid artery stenosis: comparison with power Doppler image and digital subtractionangiography . J Clin Ultrasound,2004,32(5):243-248.
51.宋烨,陈苏宁,姜伟庆,等.探讨二维超声血流显像技术在下肢深静脉倒流性疾病中的价值.中国医学影像技术,2003 ,19(1):48-50
52. Furuse J,Maru Y, Mera M,et a1.Visualization of blood flow in hepatic vessels and hepatocellular carcinoma using B-flow sonography . J Clin Ultrasound, 2001,29(1):1-6.
53.邱鹏远,黎文,朱文艳.经阴道彩超诊断输卵管积水的应用价值.实用医技杂志,2008,15(22):2874-2875.
54.王慧芳,奈志红,卢峻,等.超声诊断输卵管积水误诊原因的分析.中国超声诊断杂志,2004,5(6):462-464.