医学精品课件：胃十二指肠 2015

1、胃十二指肠,Stomach Duodenal,气钡双重造影是最常用和重要的方法,注意点： 透视与照片结合 形态与功能并重 充盈下适当加压 辅助药物的合理使用,多相影像的分析： 充盈相；加压相； 粘膜相；双重相,影像解剖,溃疡病,胃 溃 疡,好发于2050岁。十二指肠溃疡发病率是胃溃疡的 5倍。反复、周期性、节律性上腹部疼痛,不良的饮食嗜好 有损胃粘膜的药物 紧张、过度刺激,诱发,胃酸水平紊乱,胃溃疡,1cm大小 急性溃疡,多发急性溃疡,发病机制,病理改变,浅表溃疡,溃疡,穿透性溃疡1cm,穿孔性溃疡,溃疡从粘膜开始，侵犯粘膜下层，常达肌层。直径多为520mm，深510 mm。溃疡口部周围呈炎症

2、水肿,病理改变,浅表溃疡,溃疡,穿透性溃疡1cm,穿孔性溃疡,穿透性溃疡慢性溃疡深达浆膜层。 胼胝性溃疡溃疡周围有坚实的纤维组织增生,病理改变,浅表溃疡,溃疡,穿透性溃疡1cm,穿孔性溃疡,溃疡疤痕变形和狭窄 复合性溃疡胃和十二指肠同时溃疡。 溃疡恶性变见于胃溃疡,病理改变,溃疡的形态 圆形、线性,胃溃疡影像表现,1）龛 影,1、圆形溃疡,龛影口部由于水肿向溃疡腔内翻卷的粘膜,龛影口部由于水肿向溃疡腔内翻卷的粘膜,1)龛 影,特殊类型的溃疡 穿透性溃疡，穿孔性溃疡，胼胝性溃疡,1)龛 影,穿透性溃疡,气体 液体 钡剂,溃疡底光滑整齐,2)溃疡底部,龛影口部的水肿带 是良性龛影的特征，常见表现如

3、下： （1）粘膜线 （2）项圈征 （3）狭颈征 粘膜皱襞均匀性向龛影口部纠集 是良性龛影的另一个特征,3）溃疡口,口部粘膜线,溃疡堤 粘膜线 项圈征,3）溃疡口,龛影口部的粘膜线,溃疡堤 粘膜线 项圈征,3）溃疡口,口部的粘膜线,溃疡堤 粘膜线 项圈征,3）溃疡口,项圈征,溃疡堤 粘膜线 项圈征,3）溃疡口,溃疡堤 粘膜线 项圈征,狭颈征,口部明显狭小,3）溃疡口,胃角小溃疡，周围粘膜向口部集中,4）粘膜纠集,胃体小弯侧溃疡，周围粘膜向口部集中,4）粘膜纠集,粘膜皱襞纠集,4）粘膜纠集,粘膜皱襞纠集,4）粘膜纠集,4）粘膜纠集,良性溃疡,4）粘膜纠集,龛影 切迹 胃小弯缩短,5）胃变形,5）胃

4、变形,小弯溃疡，小弯缩短，蜗牛胃,5）胃变形,幽门溃疡，幽门变形狭窄,6）幽门梗阻,幽门梗阻造成胃扩张,6）幽门梗阻,2、线性溃疡,线性疤痕） 小弯溃疡 纤维增生 小弯缩短 呈蜗牛胃,2、线性溃疡,3、多发溃疡,4、特殊部位溃疡,胃远处溃疡,胃近端溃疡,4、特殊部位溃疡,十二指肠溃疡,十 二 指 肠 溃 疡,好发于2050岁。十二指肠溃疡发病率是胃溃疡的 5倍。反复、周期性、节律性上腹部疼痛,影像解剖,十二指肠,球部,降段,水平段,幽门管,十 二 指 肠 溃 疡 影 像 表 现,正常十二指肠球部,十 二 指 肠 溃 疡,90%发生在球部，多在后壁,球部溃疡 （壶腹部溃疡,圆形溃疡伴一侧变形,球

5、部溃疡 球部变形,Contrast-enhanced axial CT scan through the liver shows a collection of air anterior to the liver, as depicted in the diagram in Image 15. Also note the air surrounding the gallbladder and the leakage of water-soluble contrast material from a perforated duodenal ulcer,Nonenhanced axial CT t

6、hrough the tip of the liver in the same patient as in Images 18 and 19 show leakage of oral contrast material (arrows) from a perforated gastric ulcer,Left) Upper GI barium series in a patient who presented with acute abdominal pain. Note the duodenal ulcer crater and air within the ligamentum teres

7、 (arrow). (Right) Follow-up barium study shows that the barium leak and air within the ligamentum teres (arrow) persists,胃癌,一、早期胃癌,隆起型 凹陷型 浅表平坦型,Japanese classification of early gastric cancer,早 期 胃 癌,浅表平坦型,Early gastric cancer. A type IIc lesion is manifested by shallow, irregular areas of ulcerati

8、on and nodularity (arrows) in the gastric antrum,Early gastric cancer (type III) in 66-year-old woman. AC, Transverse dynamic contrast-enhanced CT images show enhancing tumor from arterial phase to delayed phase. There is a low-attenuation strip (arrow) representing the submucosal layer in outer tum

9、or border; this finding suggests pathologic stage T1. Also shown is a well-enhanced lymph node (arrowhead) in infrapyloric region. D, Coronal MPR shows well-enhanced mucosal tumor (arrow) with visible outer submucosal layer and clear fat plane around gastric wall. E, Photomicrograph shows submucosal

10、 invasion of early gastric cancer (pT1). (Hematoxylin-eosin stain; original magnification, 10.) F, Virtual gastroscopy image shows excavated lesion (arrow) at gastric antrum. G, Conventional gastroscopy revealed a similar excavated ulcerated lesion (arrow,隆起型,隆起型,Abdominal CT revealed a submucosal l

11、esion in the gastric wall,A.CTVE示胃体上部表浅隆起型病变； B.胃镜示胃体上部局部浅表性隆起性病变，与CTVE的表现类似,A,B,粘膜破坏,凹陷型,早 期 胃 癌,早 期 胃 癌,胃溃疡恶变,粘膜杵状增粗中断,正常胃粘膜,凹陷型,凹陷型,早 期 胃 癌,粘膜皱襞平坦,浅表平坦型,早 期 胃 癌,肿瘤胃微皱襞改变：胃小沟 破坏、消失，呈不规则条纹,浅表平坦型,浅表平坦型,二、进展期胃癌,Borrmann classification of advanced gastric cancer,粘膜破坏，龛影口部隆起成环堤,进展期胃癌,病理分型 蕈伞型（息肉型、肿块型、增

12、生型） 浸润型 溃疡型,临床表现 上腹痛，吐咖啡色血或柏油样便，上腹部肿块,充盈缺损 胃腔狭窄 龛影 粘膜破坏、消失中断 癌变区蠕动消失,进展期胃癌常见X线表现,1、各类型胃癌影像表现,Borr I 型 巨块型，蕈伞型 Borr II 型 局限溃疡型 Borr III型 浸润溃疡型 Borr IV 型 弥漫浸润型,进 展 期 胃 癌,胃角肿块阴影，双重造影勾画出肿瘤的轮廓,Borr I 型 巨块型，蕈伞型,进 展 期 胃 癌,Borr I 型 巨块型，蕈伞型,充盈缺损,Borr I 型 巨块型，蕈伞型,进 展 期 胃 癌,Borr I 型 巨块型，蕈伞型,进 展 期 胃 癌,进 展 期 胃 癌

13、,Borr I 型 巨块型，蕈伞型,Gastric gastrointestinal stromal tumor (GIST). In 63-year-old woman with gastric GIST, axial contrast-enhanced CT scan of upper abdomen shows large heterogeneously enhancing tumor in stomach and ulcer filled with oral contrast agent (arrow,Polypoid gastric carcinoma. A polypoid mas

14、s (arrow) is seen on the greater curvature of the stomach,Advanced T3 gastric cancer (Borrmann type I + II) in 65-year-old man. A, Coronal oblique arterial phase MPR shows well-enhanced hyperintense mucosal tumor with a nodular outer border of the stomach and reticular strands (arrow) in the fat pla

15、ne contiguous with the outer border of the tumor; these findings suggest pathologic stage T3. B, Coronal oblique delayed phase MPR image shows transmural hyperintense tumor with irregular outer border of the stomach and reticular strands (arrow) in the fat plane contiguous with the outer border of t

16、he tumor in antrum of stomach; these findings suggest pathologic stage T3. C, Gross and, D, histologic specimen show extraserosal invasion of gastric cancer (pT3). (Hematoxylin-eosin stain; original magnification, 5.) E, Virtual gastroscopy image shows protruding mass (arrow) with ulcerated tumor. F

17、, Conventional gastroscopy showed a similar finding (arrow,Secondary achalasia（失弛缓） caused by gastric carcinoma. View of stomach from the same examination (Fig. 1) reveals a diffusely infiltrating carcinoma of gastric body and fundus that has invaded the distal esophagus,Plain abdominal radiographic

18、 findings of gastric carcinoma. Close-up view from an abdominal radiograph shows a soft tissue mass (arrows) indenting the lesser curvature of the gas-filled stomach. This was a polypoid gastric carcinoma,Synchronous gastric carcinomas. Two discrete polypoid masses (arrows) are seen in the stomach d

19、ue to separate primary gastric carcinomas,Menetriers disease. In this patient, masslike protrusions of the folds are seen on the greater curvature of the gastric body on a barium study. This appearance could be mistaken for a polypoid gastric carcinoma. The distal antrum is relatively spared,Mntrier

20、 disease causes the ridges along the inside of the stomach wallcalled rugaeto enlarge, forming giant folds in the lining of the stomach. The rugae enlarge because of an overgrowth of surface mucous cells of the stomach,H. pylori causing localized polypoid gastritis. Focally thickened, lobulated fold

21、s are seen in the gastric body (arrows). These findings are worrisome for a localized lymphoma or submucosally infiltrating carcinoma. In this patient, however, endoscopic biopsy specimens revealed H. pylori gastritis without evidence of tumor,Borr II 型 局限溃疡型,Spot radiograph of the vertically orient

22、ed gastric antrum from a double-contrast upper GI series. The normal areae gastricae pattern of the stomach is replaced by a 4 cm area of coarsely lobulated mucosal nodules (long arrows). Centrally, a flat depression is coated, but not filled, with barium (short arrow). Large, round and polygonal no

23、dules of varying size (2-5 mm) surround the flat depression,Ulcerated gastric carcinoma. Double-contrast view of the stomach shows a relatively large mass that is etched in white (large arrows) near the lesser curvature of the gastric body. Also note a second curvilinear density (small arrows) due t

24、o barium coating the rim of an unfilled central ulcer. (From Laufer I, Levine MS eds: Double Contrast Gastrointestinal Radiology, 2nd ed. Philadelphia, WB Saunders, 1992.,Advanced T2 gastric cancer in 56-year-old man. A, Transverse CT image shows focal well-enhanced hyperintense mucosal tumor (arrow

25、) with visible outer low-attenuation strip and a clear fat plane around the tumor; these findings suggest pathologic stage T1. B, Coronal oblique MPR shows focal transmural involvement of the hyperintense mucosal tumor (arrow) in the superior aspect of the gastric antrum; this finding suggests patho

26、logic stage T2. This lesion proved to be a subserosal invasion of gastric cancer (pT2,A 轴位CT增强胃窦部大弯侧胃壁局限增厚强化，中心可见溃疡形成；图 B MPR示胃窦部大弯侧胃壁局限增厚强化，中心可见表浅溃疡形成，增厚胃壁外缘光整；图 C CTVE 示胃窦部凹凸不平，周围可见小结节状隆起；图 D SSD示胃窦部大弯侧胃壁局限性凹陷；图 E 胃镜示胃窦部局限性溃疡性病变，溃疡中心可见少量白苔附着；图 F 手术标本所见与CTVE类似,A,B,C,D,E,C,Borr III型 浸润溃疡型,肿瘤周围粘膜受侵犯而

27、变平僵硬,Borr III型 浸润溃疡型,A) Abdominal computed tomography (CT) revealed enhanced thickness of the gastric wall and multiple liver metastases. (B) Gastroscopy revealed a Borrmann type III tumor on the lesser curvature in the midportion of the stomach,Borr III型 浸润溃疡型,Advanced gastric cancer (Borrmann type

28、 III) in 50-year-old woman. A, Virtual gastroscopy image shows typical ulcerated carcinoma in stomach body. B, Surgical specimen shows a similar lesion. CE, Transverse dynamic contrast-enhanced CT images obtained in, C, arterial phase, D, portal venous phase, and, E, delayed phase show transmural, g

29、radually enhancing tumor (arrow) with smooth outer border of gastric wall; these findings suggest pathologic stage T2. F, Photomicrograph shows subserosal invasion of gastric cancer (pT2). (Hematoxylin-eosin stain; original magnification, 5.,Borr III型 浸润溃疡型,Advanced T4 gastric cancer in 59-year-old

30、woman. A, Transverse CT image shows well-enhanced tumor with adjacent fat plane infiltration (arrow) adjacent to transverse colon with normal morphology; these findings suggest pathologic stage T3. B, Coronal oblique MPR shows obliteration of fat planes (arrow) between cancer and transverse colon an

31、d direct tumor invasion of the superior margin of transverse colon; these findings suggest pathologic stage T4. C, D, Gross specimens show direct colonic invasion (arrow) of gastric cancer (pT4,Borr III型 浸润溃疡型,Ulcerated gastric carcinoma. (See Fig. 11) Prone compression view shows the mass as a radi

32、olucent filling defect (black arrows) on the anterior wall of the stomach. Note how the central ulcer (white arrows) fills with barium when the patient is in the prone position. The ulcer has a convex inner border and an intraluminal location, demonstrating the features of a Carman-Kirkland meniscus

33、 complex. (From Laufer I, Levine MS eds: Double Contrast Gastrointestinal Radiology, 2nd ed. Philadelphia, WB Saunders, 1992.,胃腔狭窄僵硬,Borr IV 型 弥漫浸润型,进 展 期 胃 癌,Plain abdominal radiographic findings of gastric carcinoma. In this patient, the gas-filled stomach has a narrowed, tubular appearance (arrow

34、) due to a scirrhous carcinoma (linitis plastica,Borr IV 型 弥漫浸润型,Borr IV 型 弥漫浸润型,Figure 1: Contrast enhanced CT of the abdomen showing pathologic thickening of gastric wall (a), multiple enlarged lymphnodes (b), ascites and an enhancing solid mass in the left ovary (c,淋巴结转移,Advanced gastric cancer i

35、n 63-year-old woman. Coronal oblique MPR shows cluster of enhancing small nodes (arrows) around infrapyloric region. Histopathologic examination revealed metastatic nodes. One enlarged solitary node with poorly enhancing ovoid shape (arrowhead) is seen along greater curvature. However, pathologic ex

36、amination showed a reactive pattern,56-year-old man with gastric mucosa-associated lymphoid tissue (MALT) lymphoma. CT scan shows circular growth of MALT lymphoma (arrow) at gastric angle mimicking carcinoma. As with most gastrointestinal lymphomas, there is no luminal stenosis,2、特殊部位的胃癌,贲门癌 胃窦癌,胃底肿

37、块阴影,贲门癌,贲门癌,Secondary achalasia or pseudoachalasia. Fluoroscopy in this patient revealed esophageal dilatation and aperistalsis. However, there is irregular tapering of the esophagogastric region due to gastric carcinoma,Spot radiograph from double-contrast upper GI series with patient in right late

38、ral, but erect position obtained while the barium bolus is passing through the distal esophagus. The normal, thin radiating folds of the gastric cardia have been replaced by large, nodular folds (large arrows). Nodular mucosa is seen in the distalmost 1 cm of esophagus (small arrow,Spot radiograph o

39、btained during double-contrast upper GI series with patient in right side down position (right lateral). The folds of the gastric cardia are mildly thickened and slightly nodular (arrows,Esophageal involvement by gastric lymphoma. Irregular narrowing (arrows) of distal esophagus due to contiguous sp

40、read of lymphoma from gastric fundus. Carcinoma of gastric cardia invading the distal esophagus could produce identical findings. (From Levine MS: Radiology of the Esophagus. Philadelphia, WBSaunders, 1989.,Direct esophageal invasion by carcinoma of the gastric cardia. Double contrast view of the fu

41、ndus shows obliteration of the normal anatomic landmarks at the cardia with a centrally ulcerated polypoid lesion (straight arrows) extending into the distal esophagus (curved arrow). (From Levine MS, Laufer I, Thompson JJ: Carcinoma of the gastric cardia in young people. AJR 140:69-72, 1983, by Ame

42、rican Roentgen Ray Society.,Direct esophageal invasion by gastric carcinoma. Lateral view of the gastric fundus shows a large fundal mass (black arrows) containing an eccentric area of ulceration (white arrow). This patient had a primary gastric carcinoma invading the distal esophagus. (From Levine

43、MS: Radiology of the Esophagus. Philadelphia, WB Saunders, 1989.,溃疡,Advanced esophageal carcinoma with a squamous cell metastasis to the stomach. There is a giant submucosal mass (black arrows) in the gastric fundus, containing a triangular area of central ulceration (white arrows). A malignant gast

44、rointestinal stromal tumor could produce similar findings. (From Levine MS: Radiology of the Esophagus. Philadelphia, WB Saunders, 1989.,Figure 2 : Conglomerate mass of gastric varices (also known as tumorous varices). Barium study shows a large, lobulated submucosal mass (arrows) on the medial aspe

45、ct of the gastric fundus. Although this lesion could be mistaken for a malignant gastrointestinal stromal tumor or even a polypoid carcinoma, note its smooth, undulating contour,这是贲门癌吗,胃窦癌,胃良性溃疡与恶性溃疡鉴别,观察要点 龛影的形状 龛影的位置 龛影口部和周围粘膜情况 附近胃壁,龛影周围出现小结节状充盈缺损，如指压迹； 周围粘膜皱襞杵状增粗和中断； 龛影周围不规则或边缘出现尖角征； 治疗过程龛影增大,胃溃

46、疡恶变,指压征,胃溃疡恶变,龛影口部出现指压征，粘膜不规则增粗中断,胃溃疡恶变,胃良性溃疡？恶性溃疡,Spot radiograph of the upper gastric body from a double-contrast upper GI series. There is a shallow, barium etched crater (C). Small, 2-3 mm, round and polygonal radiolucent nodules line the surface of the ulcer. Nodular folds (arrows) radiate towa

47、rd the ulcer forming a nodular collar of tissue around the edge of the crater. The tumor is about 4 cm in greatest surface dimension, but remains relatively flat,Spot radiograph from double-contrast upper GI series. There is a 1.5 cm area containing five polygonal, flat nodular elevations 25 mm in g

48、reatest dimension (arrowheads). Barium fills the spaces between nodules. At least five folds radiate to this region. The folds have clubbed, lobulated heads (arrows,胃窦癌与胃窦炎的X线鉴别诊断,观察要点 粘膜皱襞 轮廓 胃壁柔软度 蠕动 病变与正常分界 有否肿块,胃窦良恶性狭窄的鉴别,Figure 3 : Gastric outlet obstruction caused by an annular carcinoma of th

49、e antrum. There is irregular narrowing of the distal antrum (arrow) with proximal dilatation of the stomach. (From Eisenberg RL: Gastrointestinal Radiology: A Pattern Approach, 3rd ed. Philadelphia, JB Lippincott, 1996.,H. pylori causing localized polypoid gastritis. Focally thickened, lobulated fol

50、ds are seen in the gastric antrum. These findings are worrisome for a localized lymphoma or submucosally infiltrating carcinoma. In this patient, however, endoscopic biopsy specimens revealed H. pylori gastritis without evidence of tumor,胃肉瘤,Sarcoma of the stomach （Gastrointestinal Stromal Tumors GI

51、ST,淋巴瘤特点,病灶明显，临床情况却不差 病变虽然广泛，但胃蠕动与收缩存在 胃粘膜广泛增粗，形态固定 胃内多发或广泛肿块伴溃疡 其他部位淋巴瘤表现,平滑肌肉瘤特点,分型：胃内；胃外；混合型（哑铃） 临床：无特异性 影像：光滑或分叶的充盈缺损+溃疡,Gastrointestinal stromal tumor (GIST). Image obtained 1 year later in the same patient .The mass has increased in size. A GIST was found at surgery,Gastric gastrointestinal st

52、romal tumor in a 49-year-old woman. The mass was found incidentally during an upper GI workup for peptic disease. The smooth appearance suggests a submucosal process,Gastrointestinal stromal tumor (GIST). CT scan obtained in the same patient shows the same GIST. It appears as an intramural mass with

53、 both exophytic and endophytic components,Gastrointestinal stromal tumor with central bulls eye appearance, which is compatible with contrast material collection in an ulceration,Gastric gastrointestinal stromal tumor (GIST) en face. Upper GI image obtained during the single contrast enhancement por

54、tion shows an incidentally found mass. The smooth borders suggest a submucosal process. At surgery, a GIST was found,Gastric gastrointestinal stromal tumor with huge exophytic component, which has become ulcerated. Barium collects in the exophytic ulcer crater (arrows,Gastrointestinal stromal tumor

55、(GIST). CT scan obtained in the patient in Image 12 demonstrates the GIST with large exophytic（外生性） ulceration (arrows,Malignant gastrointestinal stromal tumor on CT. A large, heterogeneous exogastric mass (asterisk) is seen arising from the posterior wall of the stomach. An ulcer crater (arrow) on

56、the posterior wall of the stomach identifies the gastric wall as the origin of this mass. The heterogeneous enhancement and large size of the lesion strongly correlate with malignant histology,Malignant gastrointestinal stromal tumor on CT. In this patient, a heterogeneous exogastric mass is seen in

57、sinuating between the stomach and pancreas,mass,stomach,Malignant gastrointestinal stromal tumor on CT. In this patient, a gas- and fluid-filled mass projects posteriorly from the stomach. Although uncommon, this degree of necrosis can occur with malignant GISTs,Exogastric malignant gastrointestinal

58、 stromal tumor. CT scan reveals a giant heterogeneous mass with multiple low-density areas due to necrosis of tumor. This heterogeneous appearance is characteristic of malignant GISTs on CT. (Courtesy of Hans Herlinger, MD, Philadelphia, PA.,Malignant gastrointestinal stromal tumor with necrosis on

59、CT. Non-contrast-enhanced CT scan shows a water-attenuation mass arising from the anterolateral wall of the stomach,Malignant gastrointestinal stromal tumor on CT. Off-axis coronal volume-rendered MDCT image shows a large mass arising from the lesser curvature of the stomach. The wall of the lesion (arrowheads) is irregularly thi