1、Bowel wall thickening-CT-pattern肠壁增厚肠壁增厚-CT形态 Richard Gore and Robin SmithuisRichard Gore and Robin Smithuis 翻译 邵文静 内容仅供参考，如有错误，欢迎批评指正Professor of Radiology,University of ChicagoEvanston,IL USA and the Rijinland hospital inLeiderdorp,the NetherlandsWe will discuss a pattern approach to patients with
2、 bowel wall thickening with special atttention to the CT-enhancement patterns.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 Lenght of bowel wall involvement 肠壁累及的长度 Overview of enhancement pattern 强化模式的概述 Type 1-White Attenuation 类型1-白色密度（高密度） Acute IBD 急性炎症肠病 Shock Bowel 休克肠 Type 2-Gra
3、y Attenuation 类型2-灰色密度 Chronic Crohns disease 慢性克罗恩病 Mesenteric Ischemia 肠系膜缺血 Tumor 肿瘤 Type 3-Water target sign 类型3-水靶征 Pseudomembranous Colitis 伪膜膜性肠炎 Portal hypertension 门静脉高压 Spontaneous bacterial peritonitis 自发性细菌性腹膜炎 Ischemia 缺血contents 目录 Type 4-Fat target sign 类型类型4-脂肪靶征脂肪靶征Type 5-Gas-Pneuma
4、tosis 类型类型5-气体气体-积气积气 Pseudopneumatosis 假性积气 Portl venous gas 门静脉气体 Pneumatosis due to obstruction 梗阻引起的积气 Pneumatosis due to trauma 创伤引起的积气 Incidental pneumatosis 偶然发现的积气 Pneumatosis in mesenteric ischemia 肠系膜缺血中的积气 Degree of mural thickening 肠壁增厚的程度肠壁增厚的程度 Mesenteric abnormalities 肠系膜异常肠系膜异常 Lumen
5、 contents 肠内容物肠内容物第一部分：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 Type 3- Water target sign 类型3-水靶征 The most common type of enhancement is the target sign with water density.最常见的强化类型是水样密度的靶征。 T Target sign- Water水靶征水靶征 Por
6、tal hypertension门静脉高压门静脉高压 Pseudomembranous伪膜伪膜 Infections enterocolitis 感染性小肠结肠炎感染性小肠结肠炎 1、Portal hypertension门静脉高压门静脉高压 2、Infection感染感染 -shigella志贺氏菌、 Salmonella沙 门氏菌、 E Coli大肠杆菌、CMV 巨细胞病毒、 Crypto隐球菌 -Pseudomemb colitis伪膜性结肠炎 -AIDS艾滋病 3、 Acute Ulcerating colitis and Acute Crohns急性溃扬性结肠炎急性溃扬性结肠炎 和急
7、性克罗恩病和急性克罗恩病 4、Thphlitis盲肠炎盲肠炎 5、AIDS艾滋病艾滋病 6、Ischemia缺血缺血The target sign is caused by the enhancing mucosa and muscularis propriawith the edematous submucosa in between(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Target sign with submucosal edema.伴黏膜下水肿的靶
8、征Pseudomembranous colitis伪膜性结肠炎 Pseudomembranous colitis(PMC or sometimes called colitis difficile) is a colitis, that is mostly caused by the bacterium Clostridium difficile due to bacterial overgrowth of the colon in patients who are treated with broad pectrum antibiotics.伪膜性结肠炎(PMC或有时称为难辨梭状芽胞杆菌性肠
9、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。 The diagnosis is made by testing for the presence of C difficile toxins in the stool or the presence of C. difficile itself.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。The endoscopic detection of pseudomembranes on the mucosa of the colon or rectum used
10、to be diagnostic of PMC before the above tests and CT were available.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。 Pseudomembranous colitis伪膜性结肠炎Risk factors for developing PMC are:形成伪膜性结肠炎的危险因素是: 1、 broad spectrum antibiotics 广谱抗生素 2、 s/p surgery, shock, burns S/p手术、休克、烧伤 3、 cardiac arrest 心脏骤停 4、
11、proximal to an obstruction in the colon靠近结肠的梗阻处 5、HUS, ischemic colitis, 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Pseudomembranous colitis伪膜性结肠炎Patients present with diarrhea, abdominal pain, and fever caused by the toxins that are produced by the bacteria.患者表现为由细菌产生的毒素引起的腹泻
12、、腹痛和发热。The disease can be complicated by a toxic megacole.这种疾病可伴发中毒性巨结肠。The CT findings are CT表现是 1、Circumferential and diffuse mural thickening with submucosal edema. 环状和弥漫性黏膜増厚伴黏膜下水肿. 2、 Prominent haustra.突出的结肠袋。 3、 Eccentric polypoid wall thickening偏心性的息肉样壁增厚。 4、 Shaggy luminal contour.凹凸不平的肠腔轮廓。
13、 5、 Oral contrast can be trapped between thick folds simulating sinus tracts. 口服的对比剂可陷于厚的皱襞之间,类似于窦道。 Pseudomembranous colitis with dilatation of the sigmoid.伪膜性结肠炎伴乙状结肠扩张 Here a patient with PMC这是一个伪膜性结肠炎患者。There is ascites and hyper enhancement of the bowel wall with submucosal edema and edema in t
14、he mesocolon. Hrizk.肠壁明显强化伴黏膜下水肿和结肠系膜水肿。The dilated bowel in the right lower abdomen is actually the redundant sigmoid.右下腹部扩张的肠管实际上是冗长的乙状结肠。 Pseudomembranous colitis伪膜性结肠炎 Pseudomembranous colitis:膜性结肠炎 Pseudomembranous colitis伪膜性结肠炎Portal hypertension门静脉高压Portal hypertension is another cause of the
15、 water target sign.门静脉高压是水靶征的另一个原因。When a patient has portal hypertension, the increased pressure is transmitted to the right colon.当患者有门静脉高压时,高压被传导至右侧结肠。This leads to the generation of inflammatory mediators and increased production of nitrous oxide, which induces tissue injury.这导致炎症介质的产生和一氧化二氮的产生增
16、加,其导致组织损伤。This produces an isolated right sided colitis.这产生了孤立的右侧结肠炎。The findings are:表现为：Cirrihosis-irregular contour of the liver肝硬化-肝脏轮廓不规则。Varices and splenomegaly静脉曲张和脾大，Ascites腹水，Right-sided colitis右侧结肠炎，Aneurysm of the hepatic artery肝动脉的动脉瘤。The differnetial diagnosis is:鉴别诊断是：Portal hypertens
17、ion门静脉高压,Infectious colitis感染性结肠炎，Ischemic colitis缺血性结肠炎Spontaneous bacterial peritonitis自发性细菌性腹膜炎 Patients with portal hypertension and right-sided colitis are at risk for developing spontaneous bacterial peritonitis. 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。In these patients there is vascular ectasia in the r
18、ight colon.在这些患者中,有右侧结肠血管扩张。A diffuse colitis can be seen with granular, erythematous and mucosal friability, which just looks like ulcerating colitis.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。The following items make these patients at risk for developing spontaneous bacterial peritonitis:下列条目使患者处在发生自发性腹膜炎的危险中:
19、 1、 Fecal material in the lumen肠腔中的粪渣物质 2、 High pressure in the portal vein门静脉压力高 3、Abnormal permeable wall, resulting in bacterial transloca through the colonic wall into the ascites.异常的渗透性 导致细菌通过结肠壁进入腹水Right- sided colitis in a patient with cirrhosis and portal hypertension肝硬化和门脉高压患者的右侧结肠炎。The end
20、oscopic images are of different patient with right- sided colitis.内镜图像是右侧结肠炎的不同患者。Typhlitis盲肠炎Typhlitis is another disease that presents with the water target sign.盲肠炎是表现为水靶征的另一种疾病。Typhlitis is a necrotizing inflammation of the cecum, which is usually seenin patients with neutropenia due to acute le
21、ukemia, AIDS or aplastic anermia.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。There is transmural edema and ulceration, which can cause perforation.有透壁水肿和溃疡,可造成穿孔。The micro-organisms that are involved are: Pseudomonas, Candida, CMV and E.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These patient
22、s are very sick and have fever, watery-bloody diarrhea and neutropenia. 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。Neutropenia is an abnormally low count of neutrophils, a type of white blood cell that helps fight off infections, particularly those caused by bacteria and fungi.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
23、其是细菌和真菌引起的感染。When the neutropenia is severe- fewer than about 500 cells per microliter of blood -bacteria, that normally present in the mouth and digestive tract can cause infections.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。Typhlitis in a patient with neutropenia.盲肠炎患者伴中性粒细胞减少症。 Infectious
24、 colitis感染性结肠炎Infectious colitis感染性结肠炎 Salmonella沙门氏菌 Shigella志贺氏菌 Campylobacter弯曲杆菌 Yersinia enterocolitica小肠结肠炎耶尔森氏菌 Diffuse colitis弥漫性结肠炎 E. Coli-大肠杆菌 CMV巨细胞病毒 Cryptococcus隐球菌Left colon and rectosigmoid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。I
25、schemia缺血In young patients ischemia is usually due to trauma or vasculitis在年轻患者中,缺血常常由于创伤或血管炎引起Here are images of a young patient with SLE.这是一个系统性红斑狼疮的年轻患者的图像。There is a gray-pattern of enhancement of the whole left-sided colon.整个左侧结肠有灰色强化模式。 Type 4-Fat target sign 类型4-脂肪靶征Submucosal fat was first r
26、eported in patients with chronic ulcerative colitis and crohns disease.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。Soon it turned out that submucosal fat was frequently seen in obese patients,especially in the transverse and descending colon.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。Now the most common cause of the fat targ
27、et sign is obesity.现在脂肪靶征最常见的原因是肥胖。Rapid submucosal fat accumulation can be seen in patients that are treated with chemotherapy.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、Chronic UIc colitis 慢性溃疡性结肠炎 2、 Chronic crohns 慢性克罗恩病 3、 Obesity 肥胖 myotherapy化疗 5、 celiac disease乳糜泻Here a patient with Crohn,s dise
28、ase and a fat-target sign.这是一个克罗恩病和脂肪靶征的患者。7% of patients with Crohn,s disease have submucosal fat in the terminal ileum and ascending colon.17%的克罗恩病患者在回肠末端和升结肠有黏膜下脂肪。It is dependent on the duration of the disease.这取决于疾病的持续时间。Submucosal fat is frequently seen in patients with celiac disease.黏膜下脂肪常见于
29、乳糜泻患者。Especially if there is isolated fat in the duodenum or in the proximal jejunum, that is very suspicious of celiac disease.尤其是如果在十二指肠或近端空肠有孤立的脂肪,则非常可疑有乳糜。 These patients also have more pronounced folds in the ileum compared to the jejunum, which is the opposite of the normal finding( figure).与空
30、肠相比,这些患者在回肠也有更显著的皱襞这与正常表现相反(图): The faeces in these patients may contain more fat( blue arrow).这些患者的粪渣可能含有更多的脂肪(蓝色箭头）。 How to deal with submucosal fat?如何对待黏膜下脂肪?1. In a patient without a history of IBD the fat-target sign likely relates to the patients body habitus.在没有炎症性肠病病史的患者中,脂肪靶征可能和患者的身体体质有关。2.
31、 In a patient with belly discomfort with duodenal and proximal jejunal fat or fatty feces: suggest celiac disease.对腹部不适伴十二指肠和近端空肠脂肪或脂肪便的的患者:提示乳糜泻。3. In patients with acute symptoms suggest acute and chronic IBD.急性症状患者提示急性和慢性炎症性肠病。4. If there is only involvement terminal ileum query Crohn,s disease.如果只累及末端回肠怀疑克罗恩病 谢谢! Thanks 第二部分(总共四部分),未完,待续 内容仅供参考,如有错误,欢迎批评指正! 来源: http /www. radiologyassistantnl/en/p53413fd54f908/bowel-wall-thickening-ct-pattemhtml
