从8个方面掌握肠壁增厚疾病的CT诊断(第二部分).ppt

Bowelwallthickening-CT-pattern肠壁增厚-CT形态,RichardGoreandRobinSmithuis翻译邵文静内容仅供参考，如有错误，欢迎批评指正,ProfessorofRadiology,UniversityofChicagoEvanston,ILUSAandtheRijinlandhospitalinLeiderdorp,theNetherlands,WewilldiscussapatternapproachtopatientswithbowelwallthickeningwithspecialatttentiontotheCT-enhancementpatterns.我们将讨论针对肠壁增厚患者的一种形态方法，特别注意CT增强模式,contents目录,Introduction简介Lenghtofbowelwallinvolvement肠壁累及的长度Overviewofenhancementpattern强化模式的概述Type1-WhiteAttenuation类型1-白色密度（高密度）AcuteIBD急性炎症肠病ShockBowel休克肠Type2-GrayAttenuation类型2-灰色密度ChronicCrohnsdisease慢性克罗恩病MesentericIschemia肠系膜缺血Tumor肿瘤Type3-Watertargetsign类型3-水靶征PseudomembranousColitis伪膜膜性肠炎Portalhypertension门静脉高压Spontaneousbacterialperitonitis自发性细菌性腹膜炎Ischemia缺血,contents目录,Type4-Fattargetsign类型4-脂肪靶征Type5-Gas-Pneumatosis类型5-气体-积气Pseudopneumatosis假性积气Portlvenousgas门静脉气体Pneumatosisduetoobstruction梗阻引起的积气Pneumatosisduetotrauma创伤引起的积气Incidentalpneumatosis偶然发现的积气Pneumatosisinmesentericischemia肠系膜缺血中的积气Degreeofmuralthickening肠壁增厚的程度Mesentericabnormalities肠系膜异常Lumencontents肠内容物,第一部分：简介、类型1-白色密度（高密度）、类型2-灰色密度第二部分：类型3-水靶征、类型4-脂肪靶征第三部分：类型5-气体-积气第四部分：壁增厚的程度、肠系膜异常、腔内容物注：文章内容较长，按篇幅长短分为四部分，此为第二部分。感谢您的阅读！未完待续,Type3-Watertargetsign类型3-水靶征,Themostcommontypeofenhancementisthetargetsignwithwaterdensity.最常见的强化类型是水样密度的靶征。,TTargetsign-Water水靶征Portalhypertension门静脉高压Pseudomembranous伪膜Infectionsenterocolitis感染性小肠结肠炎1、Portalhypertension门静脉高压2、Infection感染-shigella志贺氏菌、Salmonella沙门氏菌、EColi大肠杆菌、CMV巨细胞病毒、Crypto隐球菌-Pseudomembcolitis伪膜性结肠炎-AIDS艾滋病3、AcuteUlceratingcolitisandAcuteCrohns急性溃扬性结肠炎和急性克罗恩病4、Thphlitis盲肠炎5、AIDS艾滋病6、Ischemia缺血,Thetargetsigniscausedbytheenhancingmucosaandmuscularispropriawiththeedematoussubmucosainbetween(figure).靶征是由强化的黏膜和固有肌层以及之间的水肿的黏膜下层所致(图)。,注:Lumen肠腔Inuicosa黏膜submucosa黏膜下层muscularis肌层Targetsignwithsubmucosaledema.伴黏膜下水肿的靶征,Pseudomembranouscolitis伪膜性结肠炎,Pseudomembranouscolitis(PMCorsometimescalledcolitisdifficile)isacolitis,thatismostlycausedbythebacteriumClostridiumdifficileduetobacterialovergrowthofthecoloninpatientswhoaretreatedwithbroadpectrumantibiotics.伪膜性结肠炎(PMC或有时称为难辨梭状芽胞杆菌性肠炎)是一种结肠炎,主要由难辨梭状芽胞杆菌引起，由于使用广谱抗生素治疗的患者结肠内细菌过度生长所致。ThediagnosisismadebytestingforthepresenceofCdifficiletoxinsinthestoolorthepresenceofC.difficileitself.通过检测粪便中难辨梭状芽胞杆菌毒素的存在或难辨梭状芽胞杆菌本身的存在来做出诊断。TheendoscopicdetectionofpseudomembranesonthemucosaofthecolonorrectumusedtobediagnosticofPMCbeforetheabovetestsandCTwereavailable.在上述检测之前,内镜发现结肠或直肠粘膜上的假膜过去常常用于诊断PMC,并且CT可诊断该病。,Pseudomembranouscolitis伪膜性结肠炎,RiskfactorsfordevelopingPMCare:形成伪膜性结肠炎的危险因素是:1、broadspectrumantibiotics广谱抗生素2、s/psurgery,shock,burnsS/p手术、休克、烧伤3、cardiacarrest心脏骤停4、proximaltoanobstructioninthecolon靠近结肠的梗阻处5、HUS,ischemiccolitis,uremia溶血性尿毒症综合症、缺血性结肠炎、尿毒症6、leukemia,lymphoma,AIDS白血病、淋巴瘤、艾滋病,Pseudomembranouscolitis伪膜性结肠炎,Patientspresentwithdiarrhea,abdominalpain,andfevercausedbythetoxinsthatareproducedbythebacteria.患者表现为由细菌产生的毒素引起的腹泻、腹痛和发热。Thediseasecanbecomplicatedbyatoxicmegacole.这种疾病可伴发中毒性巨结肠。TheCTfindingsareCT表现是1、Circumferentialanddiffusemuralthickeningwithsubmucosaledema.环状和弥漫性黏膜増厚伴黏膜下水肿.2、Prominenthaustra.突出的结肠袋。3、Eccentricpolypoidwallthickening偏心性的息肉样壁增厚。4、Shaggyluminalcontour.凹凸不平的肠腔轮廓。5、Oralcontrastcanbetrappedbetweenthickfoldssimulatingsinustracts.口服的对比剂可陷于厚的皱襞之间,类似于窦道。,Pseudomembranouscolitiswithdilatationofthesigmoid.伪膜性结肠炎伴乙状结肠扩张HereapatientwithPMC这是一个伪膜性结肠炎患者。Thereisascitesandhyperenhancementofthebowelwallwithsubmucosaledemaandedemainthemesocolon.Hrizk.肠壁明显强化伴黏膜下水肿和结肠系膜水肿。Thedilatedbowelintherightlowerabdomenisactuallytheredundantsigmoid.右下腹部扩张的肠管实际上是冗长的乙状结肠。,Pseudomembranouscolitis伪膜性结肠炎,Pseudomembranouscolitis:膜性结肠炎,Pseudomembranouscolitis伪膜性结肠炎,Portalhypertension门静脉高压,Portalhypertensionisanothercauseofthewatertargetsign.门静脉高压是水靶征的另一个原因。Whenapatienthasportalhypertension,theincreasedpressureistransmittedtotherightcolon.当患者有门静脉高压时,高压被传导至右侧结肠。Thisleadstothegenerationofinflammatorymediatorsandincreasedproductionofnitrousoxide,whichinducestissueinjury.这导致炎症介质的产生和一氧化二氮的产生增加,其导致组织损伤。Thisproducesanisolatedrightsidedcolitis.这产生了孤立的右侧结肠炎。,Thefindingsare:表现为：Cirrihosis-irregularcontouroftheliver肝硬化-肝脏轮廓不规则。Varicesandsplenomegaly静脉曲张和脾大，Ascites腹水，Right-sidedcolitis右侧结肠炎，Aneurysmofthehepaticartery肝动脉的动脉瘤。Thediffernetialdiagnosisis:鉴别诊断是：Portalhypertension门静脉高压,Infectiouscolitis感染性结肠炎，Ischemiccolitis缺血性结肠炎,Spontaneousbacterialperitonitis自发性细菌性腹膜炎,Patientswithportalhypertensionandright-sidedcolitisareatriskfordevelopingspontaneousbacterialperitonitis.门静脉高压和右侧结肠炎患者有发生自发性细菌性腹膜炎的风险。Inthesepatientsthereisvascularectasiaintherightcolon.在这些患者中,有右侧结肠血管扩张。Adiffusecolitiscanbeseenwithgranular,erythematousandmucosalfriability,whichjustlookslikeulceratingcolitis.弥漫性结肠炎可见粒状、红斑和粘膜脆,这看起来像溃疡性结肠炎。Thefollowingitemsmakethesepatientsatriskfordevelopingspontaneousbacterialperitonitis:下列条目使患者处在发生自发性腹膜炎的危险中:1、Fecalmaterialinthelumen肠腔中的粪渣物质2、Highpressureintheportalvein门静脉压力高3、Abnormalpermeablewall,resultinginbacterialtranslocathroughthecolonicwallintotheascites.异常的渗透性导致细菌通过结肠壁进入腹水,Right-sidedcolitisinapatientwithcirrhosisandportalhypertension肝硬化和门脉高压患者的右侧结肠炎。Theendoscopicimagesareofdifferentpatientwithright-sidedcolitis.内镜图像是右侧结肠炎的不同患者。,Typhlitis盲肠炎,Typhlitisisanotherdiseasethatpresentswiththewatertargetsign.盲肠炎是表现为水靶征的另一种疾病。Typhlitisisanecrotizinginflammationofthececum,whichisusuallyseeninpatientswithneutropeniaduetoacuteleukemia,AIDSoraplasticanermia.盲肠炎是盲肠的坏死性炎症,通常见于由急性白血病、艾滋病或再生障碍性贫血引起的中性粒细胞减少症患者。Thereistransmuraledemaandulceration,whichcancauseperforation.有透壁水肿和溃疡,可造成穿孔。Themicro-organismsthatareinvolvedare:Pseudomonas,Candida,CMVandE.coli.涉及的微生物有:假单胞菌,念珠菌,巨细胞病毒和大肠杆菌。,Typhlitis盲肠炎,Thesepatientsareverysickandhavefever,watery-bloodydiarrheaandneutropenia.这些患者病情很重,有发热、水-血样腹泻和中性粒细胞减少症。Neutropeniaisanabnormallylowcountofneutrophils,atypeofwhitebloodcellthathelpsfightoffinfections,particularlythosecausedbybacteriaandfungi.中性粒细胞减少症为中性粒细胞计数异常低,它是一种有助于抗感染的白细胞,尤其是细菌和真菌引起的感染。Whentheneutropeniaissevere-fewerthanabout500cellspermicroliterofblood-bacteria,thatnormallypresentinthemouthanddigestivetractcancauseinfections.当中性粒细胞减少症严重时每毫升血液-细菌约少于500个细胞,正常存在于口腔和消化道中的细菌可引起感染。,Typhlitisinapatientwithneutropenia.盲肠炎患者伴中性粒细胞减少症。,Infectiouscolitis感染性结肠炎,Infectiouscolitis感染性结肠炎Salmonella沙门氏菌Shigella志贺氏菌Campylobacter弯曲杆菌Yersiniaenterocolitica小肠结肠炎耶尔森氏菌Diffusecolitis弥漫性结肠炎E.Coli-大肠杆菌CMV巨细胞病毒Cryptococcus隐球菌Leftcolonandrectosigmoid左侧结肠和直肠乙状结肠Schistosomiasis血吸虫病Rectosigmoid直肠乙状结肠:HSV单纯疱疹病毒Gonorrhea淋病,CMV-colitis.巨细胞病毒结肠炎。,Ischemia缺血,Inyoungpatientsischemiaisusuallyduetotraumaorvasculitis在年轻患者中,缺血常常由于创伤或血管炎引起,HereareimagesofayoungpatientwithSLE.这是一个系统性红斑狼疮的年轻患者的图像。Thereisagray-patternofenhancementofthewholeleft-sidedcolon.整个左侧结肠有灰色强化模式。,Type4-Fattargetsign类型4-脂肪靶征,Submucosalfatwasfirstreportedinpatientswithchroniculcerativecolitisandcrohnsdisease.黏膜下脂肪第一次被报道是在慢性溃疡性结肠炎和克罗恩病患者中。Soonitturnedoutthatsubmucosalfatwasfrequentlyseeninobesepatients,especiallyinthetransverseanddescendingcolon.不久,黏膜下脂肪被证明常见于肥胖患者,尤其是在横结肠和降结肠。Nowthemostcommoncauseofthefattargetsignisobesity.现在脂肪靶征最常见的原因是肥胖。Rapidsubmucosalfataccumulationcanbeseeninpatientsthataretreatedwithchemotherapy.迅速的黏膜下脂肪聚集可见于接受化疗的患者。,Target-fat脂肪靶征1、ChronicUIccolitis慢性溃疡性结肠炎2、Chroniccrohns慢性克罗恩病3、Obesity肥胖myotherapy化疗5、celiacdisease乳糜泻,HereapatientwithCrohn,sdiseaseandafat-targetsign.这是一个克罗恩病和脂肪靶征的患者。7%ofpatientswithCrohn,sdiseasehavesubmucosalfatintheterminalileumandascendingcolon.17%的克罗恩病患者在回肠末端和升结肠有黏膜下脂肪。Itisdependentonthedurationofthedisease.这取决于疾病的持续时间。,Submucosalfatisfrequentlyseeninpatientswithceliacdisease.黏膜下脂肪常见于乳糜泻患者。Especiallyifthereisisolatedfatintheduodenumorintheproximaljejunum,thatisverysuspiciousofcel