No.2 2014.2.21 消化系统七年制2

1腹壁、腹膜腔及腹膜后间隙常用的检查方法1.X线2.CT3.超声4.MRI2正常解剖及变异-平片3CT4嗜酸性肠炎嗜酸性肠炎5腹部腹膜腔的划分1.腹腔间隙：肝上下间隙、肝胃、肝脾、网膜囊上下间隙2.下腹腔间隙：结肠旁沟、结肠下间隙3.盆腔间隙：膀胱直肠凹、膀胱子宫凹、子宫直肠凹6后腹膜腔的划分•肾前间隙：位于腹膜壁层和肾前筋膜之间，内含胰腺、十二指肠、升结肠、降结肠及肠系膜血管。•肾周间隙：位于肾前、后筋膜之间，除有肾脏、肾上腺、肾动脉及肾静脉,还有丰富的脂肪组织，前后筋膜在外侧融合成侧锥筋膜，肾周间隙像一个倒立的圆锥。•肾后间隙：位于肾后筋膜和腹横筋膜之间，内含脂肪、血管、神经和淋巴管。7基本病变的影像诊断腹部平片腹腔积气游离气腹：freepneumoperitoneum局限性气腹：腹腔积液腹腔内高密度影：结石、钙斑腹壁异常89间位结肠10111213gallbladderstone14Nephrolithiasis:AP:highdensitieswithvarioussizeintheupperabdomen;L:thehighdensitiesoverlappedbythespine15腹部异物16输尿管结石Calculusinleftureter1718膀胱巨大结石19腹部CT的异常表现•平扫气体及液体潴留高密度肿块•增强肠系膜腹膜结构异常20膀胱输尿管入口处多发结石2122急性胰腺炎所致腹膜炎症23消化系统常见疾病acuteabdomencommondiseasesofesophagus---stomach,intestine---liver---biliarysystem---pancreas---spleen24Thecommonreasonsofacuteabdomen•Digestivesystem:perforation,obstruction,inflammation•Urinarytract：stone•Gynecology(妇科)：ectopicpregnancy(宫外孕)•Artery血管：aneurism(动脉瘤)aorticdissection(夹层)embolism(栓塞)25肠梗阻intestineobstruction26肠梗阻ileus机械性肠梗阻mechanical动力性肠梗阻dynamic血运性肠梗阻Aterialembolism单纯性肠梗阻SimpleIO绞窄性肠梗阻StrangulatedIO麻痹性肠梗阻paralyticIO痉挛性肠梗阻SpasticIO分类27肠梗阻(intestineobstruction)病因：粘连、炎症、肿瘤、手术等临床症状：腹痛、腹胀、呕吐、停止排便排气腹部包块和腹膜刺激征：绞窄性腹部膨隆，肠鸣音消失:麻痹性28单纯性小肠梗阻(simplesmallintestineobstruction)立位平片•阶梯状气液平(透视可见液面上下变化活跃)•大跨度肠袢•鱼肋征•驼峰征碘剂造影2930肠梗阻的CT表现：回肠远端胆源性结石致肠梗阻3132绞窄性肠梗阻(strangulatedintestineobstruction)•常见病因：扭转、内疝、粘连等•扭转肠段70cm时可出现下列征象：–“假肿瘤”征–“咖啡豆”征–小跨度卷曲：“8”字征、“花瓣”、“香蕉征”等–小肠内长液面征–肠袢空回肠扭转征33343536麻痹性梗阻(paralyticintestineobstruction)•常见病因：急性腹膜炎、腹部术后、低钾症等•X线平片及CT平扫可见：腹部肠腔普遍性中等度积气。立位平片见阶梯状气液面(透视下静止液面)37立位卧位38结肠梗阻(colonobstruction)•病因：肿瘤、炎症、扭转•梗阻近端结肠或小肠胀气扩大并积液•钡剂灌肠可明确原因39胃肠道穿孔(perforationofgastrointestinaltract)•病因：溃疡、肿瘤及炎症•腹部透视或腹部平片：腹腔内积气，游离气腹。4041间位结肠42肠穿孔43肠套叠(intussusception)•为一种特殊类型的肠梗阻，儿童多见于2岁以下小儿(急性)，成人多为肿瘤所致肠套叠，多为慢性过程•分类：小肠、回结肠、结肠型•症状：阵发性腹痛、呕吐、腹部肿块、便血•影像学表现：–平片：全肠梗阻征象–空气灌肠：用于发病24小时以内，可作诊断，亦可作治疗。梗阻端见软组织块影–钡灌肠：•梗阻端见杯口状充盈缺损•套叠鞘之肠壁可呈弹簧弓样征象4445成人肠套叠小儿肠套叠46肠扭转(vovulus)•小肠扭转•乙状结肠扭转(volvulusofthesigmoidcolon)–立位平片见“天平征”(即闭袢扩大伸长气液面)–卧位平片见“川字征”(充气之闭袢)。–钡灌肠：鸟嘴征肠系膜扭转474849食管异物(foreignbodyofesophagus)儿童因误咽含在口内的硬币、别针等，成人常为食物中的鱼刺、碎骨片及脱落假牙等主要症状有呕吐、梗阻感、疼痛、吞咽困难等50•X线检查–不透线异物：异物易停留在食管狭窄处，X线透视、摄片均能见到。圆形物在正位呈片状，侧位呈扁平条状影；长形物其长轴与食管长轴相一致–透线异物：经造影检查可明确，钡棉•CT检查51硬币骨头鱼刺52食管静脉曲张esophagealvarices•Esophagealvaricesresultfromdilatationofsubmucosalveinsintheesophagusactingascollateralvenousdrainageinthepresenceofobstructionelsewhere.•Usuallythisiscausedbycirrhosisoftheliversothatportalbloodflowisreroutedviatheesophagustothesuperiorvenacava.53•pathomechanism病理机制portalhypertensiontheexcessbloodfromtheleftgastricveinandtheshortgastricveinflowintothesubmucosalveinsinthedistalregionofesophagusandtheperioesophagealvenousplexus，thenintotheazygosveinandSVC,whichresultintheesophagealvarices.门V系统高压，大量静脉血液自胃冠状V和胃短V食管远段粘膜下V和食管周围V丛奇静脉上腔V，致胃底V和食管下段V曲张(上行性V曲张)。esophagealvarices食管静脉曲张54门脉高压侧支循环示意图55clinicalsymptoms临床症状Themainsymptomsishaematemesis.Thepatientalwayssufferedfromcirrhosis.主要为呕血(有肝硬化病史)56•Esophagealvaricesareacommon-anddangerouscomplicationofcirrhosis,andthebleedingfromthevaricesisamedicalemergency.EsophagealVaricesEndoscopeview57•食管静脉曲张食管吞钡表现：–轻度：病变局限于下段，粘膜皱襞稍增宽、迂曲，管壁锯齿状，蠕动正常–中度：范围可延至中段，粘膜呈蚯蚓状、串珠状、管腔收缩欠佳，排空延迟–重度：范围更广，甚至全食管，食管明显扩张，不易收缩，腔内可见环状、囊状充盈缺损，但管壁柔软胃底静脉曲张胃钡餐表现：空泡状葡萄样充盈缺损58Esophagealvarices.Bariumswallow.Revealinglongitudinalserpiginousfillingdefectsinmiddleanddistalportionoftheesophagus.5960gastricfundusvarices胃底静脉曲张Fillingdefectlikevacuolusandgrapes空泡状葡萄样充盈缺损61●MR表现门脉造影加MIP重建可显示曲张的食管静脉网，效果近似于血管造影。食管周围可见管状或圆点状流空低信号影●血管造影采用经肠系膜上动脉插管的间接法门静脉造影●CT表现平扫食管壁增厚，食管周围可见管状或圆点状软组织密度影。增强扫描和静脉密度一致，显示更清晰6263CTatmid-chestleveldemonstratesmultipletubularandroundedcontrastenhancedstructuressurroundingtheesophagusandrepresentingperioesophagealvarices(largearrows).Enhancementofthethickenedesophagealwall(smallarrow)isduetoenlargedsubmucosalcontrastenhancedvarices.Oesophagealvarices64AzygosveinHemiazygosvein65贲门失驰缓症achalasiaHistologicalexaminationofesophagususuallydemonstratesdegenerationofthevagusnerveplexusintheregionofthegastro-esophagealjunction,ordegenerationornucleusofvagusnerve.Theendresultisafailureofrelaxationofthegastro-esophagealjunction.迷走神经丛或迷走神经核变性，贲门括约肌不能松弛。66轻度中度重度6768•Clinicalmanifestations临床表现Itisoftenoccurredinfemale,themainsymptomsincludedysphagia，retrosternalblockage.Theclinicalhistoryisverylong.Thepatientmayhaveperiodicalvomiting,andthesymptomscanberelievedbywarmwaterormedicines（suchas654-2oratropine）.女性多于男性，下咽不畅，胸骨后阻塞感，病程长，周期性呕吐，有时可用热水、药物缓解(654-2和阿托品）。69•影像学表现–轻度：食管轻度扩张，食管下端光滑，呈纺锤状、鸟嘴状，有锯齿样收缩–中度：食管中度扩张，4~6cm，典型为鸟嘴状–重度：食管高度扩张，6cm，正位可见纵隔增宽，常有呼吸道并发症70食管癌(carcinomaofesophagus)Esophagealcarcinomaisoneofthemostcommonmalignanttumors,themajorityismale.About80%-90%issqumouscellcarcinomas,andtheothers10%-20%isadeno-carcinomas.Thelesionsareoftenlocatedinthemiddlethirdofesophagus.Themainsymptomsisprogressivedysphagia,accompanyingretrosternalburning-likeorthorn-likepain.71•常见的恶性肿瘤，男多于女，40岁以上•细胞类型：多为鳞状上皮癌，少数为腺癌多见于(食管下端)，以食管中段为好发部位。•临床症状：进行性吞咽困难为主要症状，伴胸骨后疼痛，灼疼、刺疼。72–Definition:thelesionisdefinedhistologicallyascancerlimitedtothemucosaorsubm