十二指肠损伤讲义

十二指肠损伤十二指肠解剖特点十二指肠分为四部分，即十二指肠上部、十二指肠降部、十二指肠水平部及十二指肠升部。其中十二指肠降部、十二指肠水平部位于腹膜后，为腹腹外位器官，余为腹膜内位器官。腹膜后间隙解剖腹膜后间隙是以腹后壁壁层腹膜为前界，腹横筋膜为后界，上起横膈，下达盆腔的立体间隙。腹膜后间隙划分关于腹膜后间隙的划分，普遍接受的观点是Meyers于20世纪60年代末70年代初在Congdon解剖工作研究的基础上提出的，即以肾筋膜为主要标志，将腹膜后间隙分为︰⑴肾旁前间隙﹙APS﹚，位于后腹膜与肾前筋膜﹑侧锥筋膜之间。⑵肾周间隙﹙PS﹚位于肾前﹑后筋膜之间，呈倒置的锥形。⑶肾旁后间隙﹙PPS﹚，位于肾后筋膜﹑侧锥筋膜和腹横筋膜之间。Drawingillustratestherecentlymodifiedtricompartmentmodel,whichreflectstheunderstandingthattheperirenalfasciaislaminarandvariablyfusedandthereareinterfascialconnectionsbetweenthespaces.Theretromesentericplane(RMP),retrorenalspace(RRS),andlateroconalspacearepotentialinterfascialcommunications.Perinephricseptarunbetweentherenalcapsuleandtheperinephricfascia,allowingsubcapsularfluidtocommunicatewiththeretrorenalspaceorretromesentericplane.APS=anteriorpararenalspace,PPS=posteriorpararenalspace,PS=perirenalspace(,).腹膜后两侧同名间隙经内侧的通连肾旁前间隙：Meyers通过临床放射学观察到，肾旁前间隙内的积液或积气一般是局限于其来源一侧的。同时，他又指出由于胰腺特殊位置本身就是潜在的通道，可以说肾旁前间隙左右侧是相互通连的；间隙内注入对比剂后CT扫描也说明两侧是相通的。肾周间隙：Tobin等用胚胎解剖学方法证实了1895年Cerota最早关于肾前，后筋膜的描述。并进一步指出，肾前，后筋膜绕主动脉和腔静腔与对侧同名筋膜相连续。推侧两侧肾周间隙经内侧相通。Mitchell和Meyers在胰腺和十二指肠后方，与围绕肠系膜根部血管的致密结缔组织融合，并不与对侧同名筋膜相续，这意味着两侧肾周间隙并不通连。而Kneeland的尸体间隙灌注却发现两侧肾周间隙在L3-L5间任何平面以下越过下腔静脉和腹主动脉前方相通。Mindell的注射实验研究不仅证实Kneeland的结论，还进一步观察到造影剂并未环绕血管，仅在大血管前壁组成前述通道的后界，因而提出主动脉和下腔静脉并不在肾周间隙内，而在其后方。临床CT观察表明，两侧肾周间隙内侧并没有明显的筋膜分隔，肾周间隙的血肿和气体在肾下极或更低的平面相通。腹膜后间隙向上通连以往Meyers认为肾前后筋膜向上融合并续接于膈筋膜，因而肾旁前间隙向上与肝裸区相通，肾旁后间隙向上续于薄层的膈下筋膜，至于其向前和整个膈下关系并不明确。而Lim等用CT扫描发现在新鲜尸体上经右肾周间隙注入对比剂直接进入肝裸区，以充分的依据证明与肝裸区相通的是肾周间隙而不是肾旁前间隙。肾前后筋膜分别向上融合于后腹膜和膈下筋膜，因此理论上推测肾旁前后间隙不向上开放。临床发现位于肝裸区的病变向下可直接进入右肾周间隙，反之，积于右肾周间隙的气体向上也可达肝裸区，一些位于右肾周的尿性囊肿甚至可延伸至纵隔和胸腔，这些均提示肾周间隙向上不仅能与膈下间隙相通，还可能通过膈肌裂孔或膈脚与纵隔相通。腹膜后间隙向下通连以Rapropoulos为代表的学者认为肾筋膜锥在髂窝封闭成单一的多层筋膜，下方闭合。现在的学者多认为肾筋膜锥向下开放，锥口下三个间隙相互通连。Mindell等在注射实验研究中发现，肾旁前间隙大剂量注入对比剂﹝240-1000ml﹞，CT观察锥下、膀胱前、膀胱旁、骶前各间隙均充盈。十二指肠损伤机制十二指肠损伤少见，多为上腹穿透伤引起。闭合伤引起者，或由于暴力直接作用（如车祸时方向盘将十二指肠水平段碾轧于脊柱上），或由于暴力引起处于紧闭的幽门和Treitz韧带之间的闭襻内压力骤升引起胀裂。损伤部位多在2﹑3部（3/4以上）。可见于座椅安全带损伤、减速伤、方向盘或把手损伤，部分见于运动伤、跌伤及打击上腹部所致。十二指肠损伤在腹部损伤中，低于2%，可同时合并胰腺、肝、脾、肾、胃及小肠系膜的损伤。可造成十二指肠挫伤、十二指肠壁内血肿、十二指肠穿孔或破裂，后者是外科治疗的适应症。临床特征临床特征包括白细胞增多，血清淀粉酶升高和上腹痛。然而，临床征象常常是模糊的，且是非特异性的。X线平片平片可见右肾或腰大肌异常清楚或模糊，有时腹膜后呈“花斑状”改变（积气）并逐渐扩展，胃管内注入水溶性碘剂可见外溢。一般不采用钡餐检查诊断十二指肠破裂。CT表现CT是诊断十二指肠损伤的主要手段。非穿透性损伤常常被忽略。十二指肠水肿、壁内血肿和肠壁积气可提示十二指肠挫伤。局部肠壁厚度大于3mm（部分学者认为大于4mm）为十二指肠壁增厚。十二指肠挫伤可保守治疗。腹膜后口服造影剂溢出、肠外游离气体和肠壁不连续可提示十二指肠穿孔或破裂。当穿孔位于Treitz韧带时，气体或外溢对比剂可进入腹膜腔内。因十二指肠与胰腺关系密切，十二指肠损伤常伴胰腺损伤存在，CT检查时应注意观察。十二指肠损伤的一个特殊类型是十二指肠壁内血肿，由上腹挫伤引起，大多发生在儿童，病程进展缓慢，除上腹不适﹑隐痛外，主要表现为高位肠梗阻，有时伴有胆管及胰管的梗阻导致黄疸和淀粉酶升高，右上腹多能摸到肿块。钡餐造影可见典型的螺旋簧征。若保守治疗两周梗阻仍不能解除，需手术治疗。十二指肠壁内血肿Traumaticduodenalintramuralhematomaina26-year-oldmanwhohadsustainedaseatbeltinjuryinahigh-speedmotorvehiclecollision.AbdominalCTscanobtainedwithoralandintravenouscontrastmaterialshowswallthickeningofthethirdandfourthportionsoftheduodenum(arrows).Noextraluminalair(afindingthatwouldhavesuggestedperforation)wasseen.Thepatientwastreatedconservativelyandrecoveredwithoutintervention十二指肠血肿十二指肠血肿

Largetraumaticduodenalhematomaina49-year-oldmanwhowasinvolvedinamotorvehiclecollision.Thepatientwasalsotakinganticoagulants.(a)AbdominalCTscanobtainedwithoralandintravenouscontrastmaterialshowsalargehematoma(arrowheads)displacingthesecondportionoftheduodenum(arrow)anteromediallyandnarrowingtheduodenallumen.(b)CoronalreformattedCTimagedepictsthefullextentoftheduodenalhematoma(arrowheads).十二指肠降部挫伤

GradeIduodenalinjury.AxialCTimageshowsthickeningoftheduodenalwall(arrow)inthedescendingpartwithoutevidenceoffreeair.Thereisstrandingoftheperipancreaticfat.十二指肠水肿Duodenalhematomainan11-year-oldboywhohadsustainedabicyclehandlebarinjury.OnanabdominalCTscanobtainedwithoralandintravenouscontrastmaterial,thethirdportionoftheduodenumisthickenedandedematous(arrowheads).Noextraluminalaircouldbeidentifiedtosuggestperforation.Thepatientwastreatedconservativelyandrecoveredcompletely.十二指肠降部破裂GradeIIduodenalinjury.(a)AxialCTimageshowsanenlargedpancreaticheadwithmildedema(arrow)(gradeIlesion).(b)CTimageobtainedatalowerlevelshowsthickeningoftheduodenalwallinthedescendingpart(blackarrow).Adjacenttotheduodenumisasmallcollectionofextraluminalair(whitearrow),whichindicatesasmallgradeIIlacerationofthewall.十二指肠穿孔Duodenalperforationina28-year-oldmanwhosustainedblunttraumainamotorvehiclecollision.(a)AbdominalCTscanobtainedwithintravenousandoralcontrastmaterialshowsextraluminalair(arrows)adjacenttotheduodenum(D).Cholecystectomyclipsarealsopresent.(b)CoronalreformattedCTimageshowsalargeamountoffluidintherightanteriorpararenalspacewithasmallfocusofextraluminalair(arrow),findingsthatareconsistentwithaduodenalperforation.Theperforationwasconfirmedandrepairedatsurgery.D=duodenum.十二指肠水平部破裂GradeIIduodenalinjury.AxialCTimageshowsagradeIIinjuryofthehorizontalpartoftheduodenumwithsmallcollectionsofextraluminalair(arrows).Asubcapsularhematomaispresentatthelowerpoleoftherightliverlobe(arrowhead).十二指肠破裂GradeIIIduodenalinjury.(a)AxialCTimageshowsthickeningoftheduodenalwallinthedescendingpart(blackarrow).Atthetransitionzonetothehorizontalpart,thereisdisruptionofthewall(whitearrow).Additionalfindingsincludearetroperitonealhematomaandhypoperfusionoftherightkidneyduetorightrenalarteryocclusion.(b)CTimageobtainedatalowerlevelshowsthedisruption(blackarrow)withalargesurroundingextraluminalhematoma(whitearrow).Rupturedduodenumina27-year-oldfemalevictimofamotorvehicleaccident.CTscanshowsfluidintheduodenumandleakageoffluidintotherightanteriorpararenalspace(arrow).消化内镜胃窦及胰头活检术后AxialCTimagesinpatientwithperforationofthesecondportionoftheduodenum1dayaftergastroduodenoscopywithendoscopicpancreaticfine-needleaspirationbiopsyandgastricbiopsy.(a)UnenhancedCTimageshowsairinanteriorpararenalspace(whitearrow)andrightperirenalspace(blackarrow).(b)Amorecaudalimageshowsafocusofdiscontinuity(shortblackarrow)inthewallofthesecondportionoftheduodenum,withextraluminalextravasationoforalcontrastmaterial(longblackarrow).Airisalsodemonstratedintherightposteriorpararenalspace(longwhitearrow),rightproperitonealcompartment(shortwhitearrow),andperitonealcavity(arrowhead).(c)Contrast-enhancedCTimageobtained2yearslatershowstherightanteriorrenalfascia(whitearrow)toextendtothesecondportionoftheduodenum(arrowhead).Thecysticlesioninthepancreaticheadisanintraductalpapillarymucinousneoplasm(blackarrow).消化内镜胰头活检术后Contrast-enhancedaxialCTimagesinpatientwithperforationofthesecondportionoftheduodenumafterendoscopicpancreaticfine-needleaspirationbiopsy1weekearlier.Theamountofairintherightperirenalspaceexceedsthatintherightanteriorpararenalspace.内镜检查后Duodenalperforationafterendoscopyina51-year-oldman.CTscanshowsathick-walled,contractedduodenumwithairintheadjacentretroperitoneum(arrow).鉴别诊断腹膜间位器官破裂，如升﹑降结肠破裂。腹膜内位器官破裂，特别是注意Morrison窝积气与腹膜后间隙积气的鉴别，右肝上间隙与肝裸区积气的鉴别。膀胱破裂。腹后壁穿通伤。空肠破裂

Jejunalperforationina66-year-oldwomanafteramotorvehicleaccident.AxialCTimageshowshypervascularthickenedjejunumwithasuspiciousdefect(curvedarrow)andwithfocalfluid,fatstranding,andextraluminalair(straightarrow)adjacenttojejunalloops.Thepatientlaterunderwentresectionofa20-cmsegmentofthesmallbowel.Nomesentericinjurywasfoundatsurgery.十二指肠溃疡穿孔Abdominalpainandaperforatedduodenalulcerina79-year-oldman.CTscanobtainedwithoralcontrastmaterialshowsintraperitonealextravasationofcontrastmaterialfromthelateralportionoftheduodenum(whitearrow)andleakageofcontrastmaterialaroundtheliver(blackarrow).膀胱破裂

Rupturedbladder