放射教学课件：小肠结肠影像学

1、小肠结肠影像学第一部分小肠疾病Department of Radiology,Shengjing Hospital of CMU32022/8/3内容肠结核小肠Crohn病小肠良恶性肿瘤小肠吸收不良综合征肠结核Department of Radiology,Shengjing Hospital of CMU52022/8/3概述多继发于肺结核，常与腹膜结核和肠系膜淋巴结结核并存好发于青壮年，40岁以下占90%，女多于男好发于回盲部，占6080%，其次为空肠、回肠及十二指肠二、三段病理：溃疡型和增殖型，二者很难截然区分Department of Radiology,Shengjing Hospi

2、tal of CMU62022/8/3临床表现右下腹隐痛或钝痛腹泻与便秘交替腹部肿块 增殖型：右下腹境界不清肿块，较固定 溃疡型：伴有局限性腹膜炎或肠系膜淋巴结结核肠梗阻或肠瘘Department of Radiology,Shengjing Hospital of CMU72022/8/3X线表现溃疡型： 早期：激惹 ，“跳跃”征，粘膜皱襞紊乱，多发小龛影，肠壁锯齿状 后期：管腔不规则狭窄，形态较固定，近段肠管扩张 增殖型：肉芽组织增生，肠管缩短、僵直，粘膜皱襞紊乱，多数息肉样充盈缺损回盲瓣受侵，增生肥厚，盲肠内侧壁凹陷变形，近段小肠扩张Department of Radiology,She

3、ngjing Hospital of CMU82022/8/3溃疡型Department of Radiology,Shengjing Hospital of CMU92022/8/3末段回肠增殖型肠结核Department of Radiology,Shengjing Hospital of CMU102022/8/3增殖型肠结核 盲肠缩短Department of Radiology,Shengjing Hospital of CMU112022/8/3CT表现限局性狭窄，肠壁轻度增厚小肠不全梗阻以回盲部为中心，累及范围较长盲升结肠变形、缩短，回盲部上移回盲瓣缩窄或增宽口服造影剂CT扫描可

4、出现 “跳跃征”Department of Radiology,Shengjing Hospital of CMU122022/8/3盲肠肠壁增厚，肠腔狭窄结肠系膜内散在淋巴结小肠Crohn病Department of Radiology,Shengjing Hospital of CMU142022/8/3概述多源性综合性疾病，与免疫、感染和遗传有关又称“节段性肠炎” 、“肉芽肿性小肠结肠炎”病理：胃肠道、肠系膜及局部淋巴结的非特异炎性肉芽肿性病变可累及全部胃肠道，节段性分布Department of Radiology,Shengjing Hospital of CMU152022/8/3

5、临床表现好发于青壮年起病缓慢右下腹痛腹泻腹块全身症状Department of Radiology,Shengjing Hospital of CMU162022/8/3钡餐检查 粘膜皱襞不规则增粗（肠管）线样征早期：水肿及痉挛晚期：肠壁纤维组织增生口疮样溃疡尖刺状影（切线位）“靶征”（正面像）纵行及横行溃疡Department of Radiology,Shengjing Hospital of CMU172022/8/3钡餐检查 鹅卵石征肿块瘘管节段性和跳跃性非对称性肠间距加大Department of Radiology,Shengjing Hospital of CMU182022/8

6、/3鹅卵石征Department of Radiology,Shengjing Hospital of CMU192022/8/3纵行及横行溃疡Department of Radiology,Shengjing Hospital of CMU202022/8/3节段性跳跃性病变，粘膜皱襞粗乱非对称性病变，肠系膜侧较重 Department of Radiology,Shengjing Hospital of CMU212022/8/3口疮样溃疡：肠壁边缘的尖刺状影Department of Radiology,Shengjing Hospital of CMU222022/8/3晚期：肠壁纤维

7、组织增生 管腔狭窄、僵硬 “线样征” ，形态固定，狭窄近段肠管明显扩张Department of Radiology,Shengjing Hospital of CMU232022/8/3肠系膜侧纵行溃疡小肠肿瘤（复习）Department of Radiology,Shengjing Hospital of CMU252022/8/3小肠腺癌小肠平滑肌瘤和平滑肌肉瘤小肠淋巴瘤Department of Radiology,Shengjing Hospital of CMU262022/8/3回肠腺癌Department of Radiology,Shengjing Hospital of C

8、MU272022/8/3 空肠腺癌肝转移Department of Radiology,Shengjing Hospital of CMU282022/8/3小肠平滑肌肉瘤Department of Radiology,Shengjing Hospital of CMU292022/8/3 小肠平滑肌瘤小肠淋巴瘤Department of Radiology,Shengjing Hospital of CMU312022/8/3病因病理起源：肠壁粘膜下层淋巴组织向外可侵入浆膜层、肠系膜及淋巴结向内浸润粘膜，使其变平、僵硬肠管可窄亦可稍宽与正常肠管的分界不及癌肿明显一般无局限结节状肿块或明显的溃

9、疡形成Department of Radiology,Shengjing Hospital of CMU322022/8/3临床表现腹部钝痛 肠壁神经丛受淋巴肉瘤浸润、压迫不规律发烧和腹泻很少有便血Department of Radiology,Shengjing Hospital of CMU332022/8/3造影表现多发大小不等结节状充盈缺损，部分可伴溃疡肠壁增厚、僵硬，管腔不规则狭窄或狭窄-扩张相间存在，病变范围较长单发息肉样充盈缺损肠管动脉瘤样扩张（粘膜下神经丛或肌层受侵）向肠腔外侵犯，表现为小肠外压移位及肠壁浸润征象，受累肠管常粘连而固定Department of Radiolog

10、y,Shengjing Hospital of CMU342022/8/3CT表现肠壁增厚：平均2-2.5cm。正常与病变组织间无明确分界肠腔内肿块：多呈息肉状，密度均匀，边界较清楚；突出于肠壁外和浆膜表面的肿块动脉瘤样扩张肠系膜与后腹膜受累：多为非何杰金淋巴瘤。不规则结节状肿块，相邻肠袢移位。肠系膜和腹膜后增大淋巴结包绕肠系膜血管及其周围脂肪形成“三明治征”Department of Radiology,Shengjing Hospital of CMU352022/8/3Department of Radiology,Shengjing Hospital of CMU362022/8/3

11、小肠淋巴瘤Department of Radiology,Shengjing Hospital of CMU372022/8/3Department of Radiology,Shengjing Hospital of CMU382022/8/3 三明治征小肠功能紊乱Department of Radiology,Shengjing Hospital of CMU402022/8/3病因病理原发性小肠吸收不良综合征的病因尚未肯定继发性小肠吸收不良综合征的病因可能是小肠或肠系膜的器质性疾患（如炎症或肿瘤）引起的吸收障碍Department of Radiology,Shengjing Hospi

12、tal of CMU412022/8/3临床表现 继发性小肠吸收不良综合征主要为腹部原发病变症状原发性小肠吸收不良综合征可有腹痛、腹胀、腹泻或泻秘交替等胃肠道消化不良表现Department of Radiology,Shengjing Hospital of CMU422022/8/3影像学表现小肠运动功能改变： 早期：运动快，3090分钟达到达直肠，肠壁张力高。钡剂雪片状分布 后期：运动减低，肠腔极度扩张，钡剂滞留，肠腔腊肠样充盈。6小时后才到盲肠肠曲呈分节充盈现象：肠壁不规则节段性痉挛粘膜皱襞改变： 早期：粘膜皱襞粗糙、紊乱、不现则，钡剂呈散在颗粒状分布 后期：粘膜皱襞平坦、模糊、消失D

13、epartment of Radiology,Shengjing Hospital of CMU432022/8/3第二部分结肠疾病Department of Radiology,Shengjing Hospital of CMU452022/8/3 内容掌握的内容溃疡性结肠炎结肠直肠癌 了解的内容缺血坏死性结肠炎结肠息肉慢性阑尾炎 阑尾周围脓肿结肠憩室溃疡性结肠炎 Ulcerative colitisDepartment of Radiology,Shengjing Hospital of CMU472022/8/3病因病理原因不明的结肠慢性溃疡性炎症特征：发作期与缓解期交替出现首先侵犯直肠

14、，以后沿结肠长轴往上发展早期局部结肠粘膜广泛充血水肿，形成无数微小脓肿，破溃后形成大小不等的溃疡愈合期粘膜下层大量纤维组织增生，沿结肠长轴肠腔变窄，肠管缩短，形似直筒状Department of Radiology,Shengjing Hospital of CMU482022/8/3临床表现 起病缓慢，病程可长达10年以上，多有间歇的缓解期发作期大便带血或腹泻，腹痛伴里急后重，严重时有发热、贫血、消瘦、食欲减退等全身症状Department of Radiology,Shengjing Hospital of CMU492022/8/3影像学表现急性期：肠腔向心性狭窄，钡剂排空迅速，可出现“

15、线样征”。边缘连续性齿状突出、钮扣状龛影，龛影底部双重轮廓亚急性期：粘膜皱襞紊乱、息肉状充缺，称为“卵石征”，有时粘膜皱襞变平或消失慢性期：肠腔轻度狭窄，结肠袋变浅或消失晚期：腊肠样改变，肠管对称性狭窄，远端与近端逐渐移行Department of Radiology,Shengjing Hospital of CMU502022/8/3急性期 Department of Radiology,Shengjing Hospital of CMU512022/8/3 晚期结肠直肠癌Department of Radiology,Shengjing Hospital of CMU532022/8/3

16、病因病理结肠直肠癌为较常见的消化道癌肿，其发病率仅次于胃癌和食管癌。多分布在直肠和乙状结肠。大体病理上可分为增生型、浸润型、溃疡型。组织学上大多数为腺癌。Department of Radiology,Shengjing Hospital of CMU542022/8/3临床表现常见为胃肠道功能不良，如消化不良、胃纳不佳、腹胀和恶心呕吐等。常有贫血、乏力、消瘦，以及便血或腹泻、便秘交替史，肿瘤增生较大时，可扪及腹块。肠管狭窄的浸润型结肠癌易发生肠梗阻。Department of Radiology,Shengjing Hospital of CMU552022/8/3影像学表现：钡灌肠增生型：

17、向腔内生长的菜花状或息肉状充盈缺损，外缘不规整，境界清楚，局部粘膜皱襞破坏消失。肿块较大引起钡剂通过受阻，可扪及肿块。浸润型：多呈向心性环形狭窄，僵硬，边缘光滑，病变区与正常肠管分界清楚，粘膜皱襞破坏消失，结肠袋消失，常伴有梗阻。溃疡型：肿瘤生长如扁平碟状，主要表现为腔内不规则龛影，在肠壁一侧可出现半月征，龛影周围有宽狭不一的环堤，有指压迹。 Department of Radiology,Shengjing Hospital of CMU562022/8/3乙状结肠早期癌：小肿块 Department of Radiology,Shengjing Hospital of CMU572022/

18、8/3 乙状结肠癌（Borrmann 型）Department of Radiology,Shengjing Hospital of CMU582022/8/3溃疡型Department of Radiology,Shengjing Hospital of CMU592022/8/3口服法结肠造影：苹果核征浸润型病理：横结肠高分化腺癌Department of Radiology,Shengjing Hospital of CMU602022/8/3CT表现浆膜与周围脏器受侵：浆膜面模糊、毛糙,肠周脂肪密度增高,其内见索条、小斑片影肿块累及周围器官：肿块与周围脏器脂肪间隙模糊或消失, 肿块与之

19、完全融合,邻近器官内出现异常肿块、体积显著增大、密度异常 输尿管受侵：一侧肾盂、输尿管积水Department of Radiology,Shengjing Hospital of CMU612022/8/3CT表现淋巴结转移：直径10。增强：较大的淋巴结中心低密度。肠系膜及系膜根部淋巴结可融合腹膜转移：网膜、系膜脂肪密度增高，其内小结节、斑片影。结肠旁沟种植。壁层腹膜结节状增厚。晚期：网膜饼、腹水肠梗阻：梗阻段见以肠管为中心的软组织肿块,增强后肿块不均匀强化肠套叠：癌肿引起套叠段相对较短，局部轮廓欠规则Department of Radiology,Shengjing Hospital of

20、 CMU622022/8/3横结肠Borrmann型癌: 增厚肠壁均匀强化,肠腔狭窄,环堤与周围肠壁斜坡状过渡Department of Radiology,Shengjing Hospital of CMU632022/8/3升结肠Borrmann型癌：肿块突入肠腔内,与周围肠壁分界清楚,浆膜面光滑Department of Radiology,Shengjing Hospital of CMU642022/8/3 结肠容积重建 和仿真内窥镜Department of Radiology,Shengjing Hospital of CMU652022/8/3Department of Rad

21、iology,Shengjing Hospital of CMU662022/8/3 直肠癌Department of Radiology,Shengjing Hospital of CMU672022/8/3 直肠癌Borrmann型Department of Radiology,Shengjing Hospital of CMU682022/8/3 直肠癌C-C+Department of Radiology,Shengjing Hospital of CMU692022/8/3Department of Radiology,Shengjing Hospital of CMU702022/

22、8/3T1WIT2WI 直肠癌缺血坏死性结肠炎Department of Radiology,Shengjing Hospital of CMU722022/8/3概述病因：腹部手术、感染、肿瘤、心血管疾患引起结肠血管栓塞、损伤或梗塞病理：肠壁水肿、粘膜下层或肌层内出血、溃疡、肠壁纤维化 分三个阶段：一过性、 坏死性、狭窄性Department of Radiology,Shengjing Hospital of CMU732022/8/3影像表现：钡灌肠粘膜皱襞粗大结肠袋变形或消失，肠管痉挛肠壁两侧不对称花边状或指压状外缘“横脊征”：横行增粗的粘膜皱襞多发龛影：尖刺状或纽扣状修复愈合期：肠壁

23、系膜侧变平直、僵硬，对侧出现假憩室；管状向心性狭窄Department of Radiology,Shengjing Hospital of CMU742022/8/3CT肠壁节段性增厚，肠腔不规则狭窄肠壁内、肠系膜静脉内及门脉内积气肠系膜上动、静脉内血栓肝内门脉分支出现气体Department of Radiology,Shengjing Hospital of CMU752022/8/3 缺血坏死性结肠炎 升结肠肠壁节段性增厚，肠壁密度不均 肠腔不规则狭窄。 溃疡形成结肠息肉 Polyp of colonDepartment of Radiology,Shengjing Hospital

24、of CMU772022/8/3概述最常见的良性肿瘤，好发于直肠和乙状结肠。多见于儿童（2-7岁）。多数单发息肉广泛累及结肠和小肠称为息肉病。 有家族遗传因素，恶变率高病理：炎性，腺瘤临床：无痛性慢性血便。便血发生在排便终了时，量少、色红，覆盖在粪便上，不与其混合并发肠套叠出现急腹症，果酱样便Department of Radiology,Shengjing Hospital of CMU782022/8/3影像学表现（钡灌肠）肠腔内轮廓光整的充盈缺损多发息肉呈大小不等充盈缺损带蒂的息肉显示长蒂，有一定活动度息肉病：直肠、结肠大小不等的充缺，粘膜相出现无数轮廓光整葡萄状的块影，充满肠腔Department of Radiology,Shengjing Hospital of CMU792022/8/3乙状结肠息肉Department of Radiology,Shengjing Hospital of CMU802022/8/3带蒂息肉Department of Radiology,Shengjing Hospital of CMU812022/8/3 乙状结肠 多发腺瘤性息肉阑尾炎Department of Radiology,Shengjing Hospital of CMU832022/8/3慢性阑尾炎概述急性阑尾炎转化而来腔内粪石、异物、寄生虫等导致管腔梗