急腹癥CT診斷腹部外傷PPT課件

1、 創(chuàng)傷是40歲以下死亡的主要原因 創(chuàng)傷死亡中腹部外傷占 10%，致死原因主要為肝損傷 分類： 鈍器傷（閉合性損傷,墜落、碰撞、沖擊、擠壓等鈍性暴力引起） 穿透傷（開放性損傷,刀刺、槍彈、彈片所引起）2013-10-22CT 初診首選檢查方案敏感性、特異性高一站式檢查2013-10-22技術 不需口服胃腸道對比劑（不需要、不必要） 體外物品，離開掃描野（監(jiān)護及生命支持設備等） 雙臂抱頭或置于胸前，或上肢緊貼身體兩側（減少偽影，上肢與身體留有間隙，偽影更明顯） 掃描大范圍（無遺漏）、大掃描野（減少偽影） 如無禁忌，建議增強（發(fā)現(xiàn)實質臟器破裂、尿漏以及活動出血等） 常規(guī)時相增強掃描（一般損傷門脈期、

2、排泄期即可） 合理應用窗技術2013-10-22影像診斷需提供信息 有無明確腹外傷改變 若有，損傷臟器，出血、積液、積氣量及部位 提示損傷臟器 有無其他合并傷2013-10-22表現(xiàn) 腹腔積液、游離氣體 增強對比劑外溢提示活動性出血 裂傷： 線形或斜行區(qū) 血腫： 橢圓形或圓形區(qū) 挫傷： 模糊的低密度影 器官全部或部分血運中斷 包膜下血腫2013-10-22示意圖2013-10-22腹腔積血男，37歲，腹外傷就診肝脾周、結腸旁溝積血手術證實脾臟中下部裂傷2013-10-22點評 腹外傷常見并發(fā)癥 發(fā)現(xiàn)積血，進一步查找損傷臟器 出血首先積聚于損傷部位，繼而流向低處 出血形態(tài)、密度不一（腹腔間隙特點

3、、出血吸收不規(guī)則及間斷性出血、腹腔呼吸運動） 增強掃描對比劑外溢，活動性出血的特征表現(xiàn)前哨血塊，損傷臟器附近的高密度血凝塊，為內臟損傷的敏感征象，提示出血的來源，對診斷腸管、腸系膜、脾臟損傷意義重大2013-10-22脾臟損傷 閉合性腹外傷中，最易損傷的器官(質地脆弱、血供豐富) CT增強掃描評價脾外傷首選檢查方案CT平掃：脾臟密度不均脾周積血前哨血塊提示脾臟損傷2013-10-22脾損傷分類 撕裂傷 脾實質內不規(guī)則線狀低密度影 脾臟碎裂 嚴重創(chuàng)傷，脾臟破裂成多分小碎片 脾內血腫 脾實質內大范圍無強化區(qū)，密度均勻/不均勻 包膜下血腫 包繞脾實質的半月形或卵圓形液體密度影 梗死 繼發(fā)血管損傷，常

4、為延及包膜的楔形無強化區(qū)，可累及整個脾臟2013-10-22損傷分級2013-10-22易低估損傷程度分級中未涉及：活動出血、挫傷、外傷性梗塞最重要的是： 沒有判斷非手術治療的標準 (NOM)級為包膜下血腫，小于面積10%，實質撕裂1cm級包膜下血腫占面積10-50%，實質撕裂1-3 cm級包膜下血腫50%，撕裂大于 3 cm或累及小梁血管級撕裂累及脾段或脾門血管，導致超過25%脾體積缺血級是脾門血管中斷或脾實質完全碎裂AAST（the American Association of Surgery of Trauma ) 損傷分級標準2013-10-221.有多處大小不一的低密度區(qū)。這些低密

5、度影不是線狀的，因此不是裂傷2.伴有肋骨骨折和氣胸、皮下氣腫3.無對比劑外溢2013-10-22線形低密度裂傷圓形和橢圓形低密度區(qū)脾血腫腹腔積液2013-10-222013-10-22圍繞脾和肝腹腔積液。橢圓形或圓形低密度區(qū)符合脾臟血腫。線性低密度影符合脾前部的裂傷。脾門區(qū)對比劑外溢。對比劑外溢，提示活動出血，不宜保守治療2013-10-22Active arterial hemorrhage. Contrast-enhanced multidetector computed tomography image demonstrates a linear focus of extravasate

6、d contrast-enhanced blood (arrow) originating from the spleen. This focus of active hemorrhage is surrounded by a large perisplenic hematoma (h) that is lower in attenuation than the extravasated contrast-enhanced blood. Perihepatic blood (arrowhead) is also evident.活動性出血Splenic pseudoaneurysm (thic

7、k arrow) in a 22-year-old man involved in a motor vehicle accident. Blood is present in the perisplenic space and Morisons pouch (asterisk). Thin arrows point to a left pneumothorax and chest wall emphysema外傷后假性動脈瘤2013-10-22Subcapsular splenic hematoma. Contrast-enhanced computed tomography image de

8、monstrates a lenticular-shaped subcapsular hematoma (H) that indents the underlying splenic parenchyma. A higher attenuation perisplenic hematoma (arrow) is seen posteriorly. P, pancreatic tail; K, left kidney. 包膜下血腫脾內血腫2013-10-22Partial transection of the splenic hilum with active bleeding and mass

9、ive hemoperitoneum. A, B: Computed tomography (CT) scans through the upper pole of the right kidney demonstrate a large amount of hemoperitoneum, virtually absent perfusion of the splenic parenchyma, and active bleeding (arrows) from disrupted hilar vessels. C: CT scan through the lower margin of th

10、e spleen (S) shows some preservation of splenic enhancement consistent with partial hilar transection. A small laceration is noted in the left kidney. (Case courtesy of Christine O Menias, M.D., St. Louis, Missouri.)脾門橫斷脾門橫斷2013-10-22Congenital splenic clefts. A: Computed tomography image demonstrat

11、es a sharply marginated cleft in the posterior tip of the spleen. The smooth, rounded contour of the cleft as it meets the margin of the spleen, as well as the absence of perisplenic hematoma, is helpful in distinguishing a congenital cleft from a parenchymal laceration. B: Another patient with mult

12、iple splenic clefts along the lateral margin of the spleen. 先天性脾裂，需與脾裂傷鑒別2013-10-22男，37歲，摔傷后腹痛病例2013-10-222013-10-222013-10-22肝臟在后腹部實質性臟器損傷中位居第二位肝損傷是死亡的最常見原因：肝下、 肝靜脈、 肝動脈、 門靜脈分支豐富肝右葉后段因體積大、位置固定為最易受傷部分。這部分還涉及裸區(qū)，傷及該區(qū)域，將會導致腹膜后出血而不是腹腔出血肝臟損傷表現(xiàn)形式 包膜下血腫 實質內血腫 撕裂傷 肝破裂2013-10-22最常見，分為淺表、肝門周圍、深部3類正常強化肝實質內線狀、分

13、枝狀、類圓形低密度影通常平行于肝靜脈或門靜脈結構，延伸至肝臟周邊撕裂處可見局限性高密度的新鮮血塊，撕裂貫穿肝包膜，常出現(xiàn)腹腔積血累及膽道，形成膽脂瘤或肝外膽汁聚集（初診難以顯示）熊爪征：肝表面平行的線狀或從肝門向外的輻射狀撕裂，由于放射狀、平行的裂痕表現(xiàn)，形似熊爪深部撕裂或撕裂傷連接兩側肝表面，形成肝破裂可形成部分無強化區(qū)肝內圓形或類圓形的混雜高密度區(qū)，無強化，邊界多不清，周圍可有肝臟挫傷水腫區(qū)包膜下血腫可由鈍傷引起，但更常見于醫(yī)源性損傷，如肝穿刺等，表現(xiàn)為肝周透鏡形或新月形積液（密度依出血時間而異），相鄰肝實質變平或凹陷2013-10-22級：血腫：包膜下10%表面面積；裂傷：包膜撕裂，涉及

14、實質深度小于1cm級：血腫：包膜下涉及10%-50%表面面積，實質內直徑10cm，撕裂涉及實質深度1-3cm，長度小于10cm級：血腫：包膜下大于50%表面面積，擴張性；包膜下血腫破裂伴活動性出血；實質內大于10cm或擴張，裂傷深度超過3cm級：撕裂，實質破裂累及25-75%肝葉，或一個肝葉內1-3個肝段；級：裂傷：實質破裂涉及大于75%肝葉或一個肝葉內3個以上肝段。血管：近肝靜脈損傷，級：血管：肝撕脫CT分級2013-10-222013-10-22Hepatic laceration. Note irregular, low-attenuation laceration in the pos

15、terior right lobe of the liver. High-attenuation foci of clotted blood (arrows) are seen within the area of lacerationHepatic laceration. A, B: Computed tomography images demonstrate an irregular, low-attenuation laceration (arrow) in the right hepatic lobe. Note heterogeneous early arterial phase c

16、ontrast enhancement of the spleen (S). 肝裂傷2013-10-22Bear claw type laceration of the right hepatic lobe. Note roughly parallel, radiating, low-attenuation lacerations involving the dome of the liver. A small amount of perihepatic blood is present (arrow)熊爪征：肝表面平行的線狀或從肝門向外的輻射狀撕裂，由于放射狀、平行的裂痕表現(xiàn)，形似熊爪201

17、3-10-22Hepatic laceration and hematoma. A, B: Computed tomography images demonstrate extensive, irregular laceration and intraparenchymal hematoma (arrows), occupying much of the right lobe of the liver. The injury extends centrally to the confluence of the hepatic veins and inferior vena cava (arro

18、whead). Note associated perihepatic and perisplenic hemorrhage (h). ST, stomachIntrahepatic hematoma with sterile necrosis. Contrast-enhanced computed tomography scan 3 days following blunt abdominal trauma demonstrates intraparenchymal hematoma containing several small bubbles of gas (arrows), pres

19、umably secondary to necrosis within the area of injury. The patient had no evidence of infection and recovered uneventfully. E, pleural effusion腹部鈍傷2-3天后，肝實質或包膜下撕裂傷或血腫區(qū)可出現(xiàn)氣體。肝內氣體通常提示感染，但嚴重鈍傷而沒有感染時亦可出現(xiàn)，氣體來源可能為肝臟缺血、壞死所致2013-10-22Periportal low attenuation. Computed tomography image demonstrates peripo

20、rtal low attenuation (arrows) surrounding the portal triads. A small amount of fluid is seen adjacent to the inferior vena cava (V). 約22%的腹部鈍傷病人可出現(xiàn)門脈分支周圍低密度區(qū)，亦稱門脈周圍軌道征（periportal tracking），撕裂傷附近的門脈周圍間隙增寬，提示可能為出血進入門脈周圍結締組織，如果彌漫性改變，可能為補液過多所致中心靜脈壓升高、張力性氣胸、心包填塞等所引起的門脈周圍淋巴管擴張。研究顯示，肝外傷血腫清除后，解除了對肝淋巴引流的阻塞，該

21、征象可消失軌道征病理基礎 各種原因所致血管周圍的淋巴回流受阻或淋巴液產(chǎn)生過多導致肝內淋巴瘀滯， 外傷后glisson鞘周圍疏松的結締組織中存留血液；其中肝淋巴動力學異常被認為是最主要和最重要的病理性基礎。尚見于活動性肝炎、2013-10-222013-10-22綠色箭頭： 橢圓狀低密度區(qū)符合血腫黃色箭頭： 線性形低密度影區(qū)符合挫裂傷。（注意此挫裂傷與左側的門靜脈相交）藍色箭頭： 密度不均的低密度區(qū)符合挫傷肝周積液液此患者肝臟損傷幾乎涉及兩葉，但血供正常2013-10-22u肝右葉門靜脈中斷 ( 4 級)u增強顯示對比劑溢出肝臟外緣u腹腔積液2013-10-22多發(fā)撕裂傷左側裂傷表現(xiàn)為星狀右側裂

22、傷表現(xiàn)為樹枝狀2013-10-22男，26歲，腹部外傷后持續(xù)腹痛病例1病例2男，45歲，胸腹部外傷，右腹部疼痛為著手術所見2013-10-22病例3男，46歲，高處墜落傷及胸腹2013-10-22病例4男，40歲，腹部外傷2013-10-222013-10-222013-10-222013-10-22損傷轉歸 包膜下血腫通常6-8周內吸收 肝內血腫通常6月至數(shù)年完全吸收。血腫內的膽汁成分延緩了血塊的吸收，還可延緩肝實質損傷的愈合 肝臟挫裂傷可在2-3周內明顯好轉 肝臟挫裂傷和肝內血腫首次復查CT（7天）常出現(xiàn)密度減低，范圍稍有增大；隨著病情恢復，病變逐漸吸收，體積縮小、邊界清晰、呈圓形或卵圓形

23、，或者以邊界清晰的肝囊腫或膽脂瘤形成持續(xù)存在2013-10-222013-10-22Healing hepatic lacerations on serial computed tomography (CT) examinations.A: Initial scan demonstrates bear claw type laceration in the right lobe of the liver. B: Scan 4 days later shows decrease in CT attenuation value and slight increase in size of the

24、hepatic lacerations, probably a result of osmotic absorption of fluid. C: On a scan 3 weeks later, the lacerations have assumed a more rounded configuration, and the margins of the lacerations are better defined. D: Follow-up scan 3 months after the initial injury demonstrates virtually complete res

25、olution of the liver lacerations4天天3周周3月月肝裂傷隨訪2013-10-22肝挫裂傷男，48歲，外傷后4小時即行CT檢查2天后復查肝臟挫裂傷更加明顯，肝脾周積液，雙側胸腔積液、肺挫裂傷，注意右側腎上腺血腫2013-10-2211天復查，肝內出血較前吸收2013-10-222013-10-2250天復查，出血明顯吸收，局部呈類圓形水樣低密度灶胰腺損傷2013-10-22 少見，僅占腹部損傷的3-12% 單獨損傷少見 通常是復合性損傷的一部分 損傷機制：椎骨、腹壁對胰腺的擠壓，如方向盤、自行車把擠壓或頂傷 癥狀隱匿，難以診斷分類（病理） 胰腺挫傷 輕度挫傷 嚴重

26、挫傷 胰腺斷裂傷 部分斷裂傷 完全斷裂傷2013-10-22 輕度挫傷：胰腺組織水腫或（和）少量出血， 或形成胰腺被膜下小血腫 嚴重挫傷：胰腺組織失去活力，伴有比較廣泛或比較粗的胰管破裂導致胰液外溢 部分斷裂傷：胰腺周徑1/3、 胰腺周徑2/3的裂傷；胰腺周徑1/3的裂傷歸為嚴重挫裂傷 完全斷裂傷： 胰腺周徑2/3的裂傷2013-10-222013-10-22AAST胰腺損傷分級CT改變：挫傷，正常強化胰腺實質內的局限性低密度灶，撕裂、破裂：線狀低密度影，通常垂直于胰腺長軸，多位于胰腺頸部、體部（位于脊柱前）活動性出血，少見胰腺局部腫大、胰周間隙模糊、積液可提示胰腺損傷，非特異外傷12小時內，

27、CT難以顯示胰腺撕裂或斷裂，由于撕裂實質碎片間出血或相互鄰近，掩蓋破裂表現(xiàn)；隨后，外漏的胰液（消化酶）造成水腫、炎癥、自身消化反應，損傷顯示較為明顯CT無法直接顯示胰管的完整性，深的撕裂或橫斷提示胰管破裂ERCP/MRCP顯示胰管損傷，后者無創(chuàng)、快速、易操作另一分類方法2013-10-222013-10-22Pseudofracture of the pancreas due to physiologic thinning of the pancreatic neck. A: Computed tomography (CT) scan at the level of the superior

28、mesenteric vein splenic vein confluence demonstrates apparent fracture of the pancreatic neck (open arrow). B: CT scan 1 cm caudal to (A) shows fat in the region of the neck consistent with physiologic thinning. Note also the absence of peripancreatic fluid. Pancreatic laceration. A, B: Computed tom

29、ography images through the pancreas (P) demonstrate peripancreatic fluid (arrowheads) tracking into the left anterior pararenal space. Note irregular, low-attenuation laceration (arrow) extending through the body of the pancreas. Adjacent fluid surrounds the superior mesenteric vein (a). Fluid is al

30、so present in the hepatorenal fossa (asterisk)胰體斷裂胰周積液胰頸生理性狹窄導致假性胰腺撕裂，冠狀位圖像可鑒別2013-10-22Pancreatic laceration with disruption of the pancreatic duct. A: Computed tomography scan demonstrates laceration through the tail of the pancreas (open arrow). Fluid is seen about the tail of the pancreas (solid

31、 arrows) adjacent to the spleen (S). B: Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates disruption of the main pancreatic duct in the tail of the pancreas with extravasation of contrast material (arrows). 胰腺裂傷胰管斷裂胰液外溢2013-10-22車禍傷患者，生命體征穩(wěn)定，下腹部輕度壓痛胰腺發(fā)現(xiàn)有模糊的低密度影，胰尾周圍少量液體，左腎前方較明顯其余腹腔器

32、官正常，其他部位沒有腹腔積液之后病人癥狀加重，CT復查發(fā)現(xiàn)胰周積液增加（未顯示），提示該病人是一個獨立的胰腺損傷獨立的胰腺損傷極其罕見（多為復合傷的一部分），因為胰腺位置較深，受肝、脾和胸骨的保護放射學者認為需要重視可能存在的胰腺損傷病例男，19歲2013-10-222013-10-222013-10-222013-10-222013-10-22術后診斷：胰腺斷裂傷2013-10-22腎臟損傷 單獨損傷少見，通常是復合性損傷的一部分 多為鈍傷 患病或異常的腎臟，較正常腎臟更易損傷（輕微外傷即可能積水腎盂破裂，感染脆弱腎臟碎裂，異位腎、馬蹄腎碎裂；外傷較輕，損傷嚴重時，考慮到基礎腎臟病變的可能）

33、 兒童較成人更易發(fā)生腎臟損傷（外緣分葉、腎臟相對身體體積大） CT首選檢查，明確腎臟損傷的類型和范圍2013-10-22分類2013-10-22Michael Federle將腎損傷分為四類：輕度損傷：（75-85%）腎挫傷腎和包膜下血腫不涉及收集系統(tǒng)或髓質的小挫裂傷小段梗死中度損傷：（10%）涉及髓質或收集系統(tǒng)的挫裂傷節(jié)段性梗塞重度損傷：（5%）腎碎裂腎梗死收集系統(tǒng)破裂CT改變 腎挫傷，最輕的腎損傷，平掃表現(xiàn)為彌漫性或局限性的腎腫脹，含有點狀高密度新鮮出血，增強掃描延遲強化或強化程度降低，常伴有包膜下和腎周出血 腎裂傷，正常強化實質內線狀無強化區(qū)，常伴有包膜下和腎周出血 腎碎裂，多發(fā)線狀無強

34、化區(qū)，分隔開強化或不強化的腎臟碎片，常撕裂腎段血管，伴有大的腎周血腫 腎蒂損傷，腎梗死或腎淤血性改變（腎臟增大，皮質患者強化，腎靜脈內發(fā)現(xiàn)血栓可確診） 集合系統(tǒng)損傷，含對比劑尿液外溢（延遲掃描時間足夠長）2013-10-222013-10-22Renal contusion. Computed tomography image demonstrates a focal area of low attenuation in the posterior aspect of the left kidney representing renal contusion (arrows)左腎挫傷右腎裂傷，左

35、腎挫傷Renal laceration. Computed tomography image at the level of the renal veins demonstrates an irregular, linear, low-attenuation renal laceration (arrow) extending from the right renal hilum to the renal capsule. A left renal contusion (arrowheads) is also present. The hemoperitoneum was related to

36、 concomitant splenic injury2013-10-22側面刀刺穿透傷患者 小的腎包膜血腫及腎周積血左腎包膜下血腫非膨脹2013-10-22Renal fracture. A: Contrast-enhanced computed tomography scan demonstrates fractured left lower renal pole (K) with large perirenal hematoma (H). B: Delayed scan shows extravasation of opacified urine into the perirenal s

37、pace (arrow). 左腎破裂對比劑外溢Renal laceration with perirenal hematoma. Contrast-enhanced computed tomography scan demonstrates a right renal laceration (thick arrow) with associated perirenal hematoma confined by the posterior renal (Gerotas) fascia (thin arrow). The patient also has intraperitoneal blood

38、 (H) from a ruptured spleen右腎裂傷2013-10-22Shattered kidney with large perirenal hematoma. Active bleeding is noted in the left perirenal space anteriorly (straight arrows). Small liver laceration (curved arrow) and blood in the hepatorenal fossa are also evident左腎碎裂Renal pedicle injury with devascula

39、rization of the left kidney. Computed tomography scan at the level of the left renal hilum demonstrates absent perfusion of the left kidney (K). Blood tracks along an unenhanced left renal artery (thick arrow). A diminutive left renal vein (thin arrow) and a small amount of hemorrhage (H) in the lef

40、t anterior pararenal space are also noted. (Case courtesy of Kevin Smith, M.D., Birmingham, Alabama.) 腎蒂損傷，左腎無血供病例1男，46歲，外傷及右腰背部2013-10-222013-10-22病例2男，28歲，胸腹外傷，脾破裂，腎挫裂傷，腎周積血2013-10-22病例3男，41歲，腎周出血，腹膜后血腫2013-10-22病例4女，45歲，摔傷左腰部4小時就診2013-10-222013-10-222013-10-222013-10-22腎穿后包膜下出血病例5男，23歲，腎臟活檢后腰痛1天病

41、例6男，43歲，頭胸腹部外傷4小時就診膽管結石2012-06-172013-10-22右側腎上腺血腫2013-06-19復查，腎上腺血腫密度增高，肝脾周見有積血2013-10-222012-06-28日復查，腎上腺出血較前有所吸收2013-10-222012-08-03復查，血腫基本吸收2013-10-22輸尿管膀胱損傷 輸尿管損傷多為醫(yī)源性損傷，鈍傷、穿通傷少見 輸尿管腹膜后器官，破裂尿液聚集于輸尿管周圍間隙，主要在腎周間隙內側 膀胱損傷見于醫(yī)源性損傷、鈍傷、穿通傷，多有肉眼血尿 膀胱為腹膜間器官，依破裂口位置與腹膜反折關系，尿液可聚集于腹膜腔或腹膜后 CT為首選影像學檢查方法2013-10

42、-222013-10-22Extraperitoneal bladder rupture. A: Transaxial image from a computed tomography cystogram demonstrates extravasation of iodinated contrast material (arrows) from the urinary bladder (B) into the extraperitoneal prevesical space. U, uterus. B: Coronal image demonstrates the site of bladder rupture (arrow). Multiple pelvic fractures are pres