急腹症CT诊断腹部外伤PPT课件

1、 创伤是40岁以下死亡的主要原因 创伤死亡中腹部外伤占 10%，致死原因主要为肝损伤 分类： 钝器伤（闭合性损伤,坠落、碰撞、冲击、挤压等钝性暴力引起） 穿透伤（开放性损伤,刀刺、枪弹、弹片所引起）2013-10-22CT 初诊首选检查方案敏感性、特异性高一站式检查2013-10-22技术 不需口服胃肠道对比剂（不需要、不必要） 体外物品，离开扫描野（监护及生命支持设备等） 双臂抱头或置于胸前，或上肢紧贴身体两侧（减少伪影，上肢与身体留有间隙，伪影更明显） 扫描大范围（无遗漏）、大扫描野（减少伪影） 如无禁忌，建议增强（发现实质脏器破裂、尿漏以及活动出血等） 常规时相增强扫描（一般损伤门脉期、

2、排泄期即可） 合理应用窗技术2013-10-22影像诊断需提供信息 有无明确腹外伤改变 若有，损伤脏器，出血、积液、积气量及部位 提示损伤脏器 有无其他合并伤2013-10-22表现 腹腔积液、游离气体 增强对比剂外溢提示活动性出血 裂伤： 线形或斜行区 血肿： 椭圆形或圆形区 挫伤： 模糊的低密度影 器官全部或部分血运中断 包膜下血肿2013-10-22示意图2013-10-22腹腔积血男，37岁，腹外伤就诊肝脾周、结肠旁沟积血手术证实脾脏中下部裂伤2013-10-22点评 腹外伤常见并发症 发现积血，进一步查找损伤脏器 出血首先积聚于损伤部位，继而流向低处 出血形态、密度不一（腹腔间隙特点

3、、出血吸收不规则及间断性出血、腹腔呼吸运动） 增强扫描对比剂外溢，活动性出血的特征表现前哨血块，损伤脏器附近的高密度血凝块，为内脏损伤的敏感征象，提示出血的来源，对诊断肠管、肠系膜、脾脏损伤意义重大2013-10-22脾脏损伤 闭合性腹外伤中，最易损伤的器官(质地脆弱、血供丰富) CT增强扫描评价脾外伤首选检查方案CT平扫：脾脏密度不均脾周积血前哨血块提示脾脏损伤2013-10-22脾损伤分类 撕裂伤 脾实质内不规则线状低密度影 脾脏碎裂 严重创伤，脾脏破裂成多分小碎片 脾内血肿 脾实质内大范围无强化区，密度均匀/不均匀 包膜下血肿 包绕脾实质的半月形或卵圆形液体密度影 梗死 继发血管损伤，常

4、为延及包膜的楔形无强化区，可累及整个脾脏2013-10-22损伤分级2013-10-22易低估损伤程度分级中未涉及：活动出血、挫伤、外伤性梗塞最重要的是： 没有判断非手术治疗的标准 (NOM)级为包膜下血肿，小于面积10%，实质撕裂1cm级包膜下血肿占面积10-50%，实质撕裂1-3 cm级包膜下血肿50%，撕裂大于 3 cm或累及小梁血管级撕裂累及脾段或脾门血管，导致超过25%脾体积缺血级是脾门血管中断或脾实质完全碎裂AAST（the American Association of Surgery of Trauma ) 损伤分级标准2013-10-221.有多处大小不一的低密度区。这些低密

5、度影不是线状的，因此不是裂伤2.伴有肋骨骨折和气胸、皮下气肿3.无对比剂外溢2013-10-22线形低密度裂伤圆形和椭圆形低密度区脾血肿腹腔积液2013-10-222013-10-22围绕脾和肝腹腔积液。椭圆形或圆形低密度区符合脾脏血肿。线性低密度影符合脾前部的裂伤。脾门区对比剂外溢。对比剂外溢，提示活动出血，不宜保守治疗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.活动性出血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外伤后假性动脉瘤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. 包膜下血肿脾内血肿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.)脾门横断脾门横断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，需与脾裂伤鉴别2013-10-22男，37岁，摔伤后腹痛病例2013-10-222013-10-222013-10-22肝脏在后腹部实质性脏器损伤中位居第二位肝损伤是死亡的最常见原因：肝下、 肝静脉、 肝动脉、 门静脉分支丰富肝右叶后段因体积大、位置固定为最易受伤部分。这部分还涉及裸区，伤及该区域，将会导致腹膜后出血而不是腹腔出血肝脏损伤表现形式 包膜下血肿 实质内血肿 撕裂伤 肝破裂2013-10-22最常见，分为浅表、肝门周围、深部3类正常强化肝实质内线状、分

13、枝状、类圆形低密度影通常平行于肝静脉或门静脉结构，延伸至肝脏周边撕裂处可见局限性高密度的新鲜血块，撕裂贯穿肝包膜，常出现腹腔积血累及胆道，形成胆脂瘤或肝外胆汁聚集（初诊难以显示）熊爪征：肝表面平行的线状或从肝门向外的辐射状撕裂，由于放射状、平行的裂痕表现，形似熊爪深部撕裂或撕裂伤连接两侧肝表面，形成肝破裂可形成部分无强化区肝内圆形或类圆形的混杂高密度区，无强化，边界多不清，周围可有肝脏挫伤水肿区包膜下血肿可由钝伤引起，但更常见于医源性损伤，如肝穿刺等，表现为肝周透镜形或新月形积液（密度依出血时间而异），相邻肝实质变平或凹陷2013-10-22级：血肿：包膜下10%表面面积；裂伤：包膜撕裂，涉及

14、实质深度小于1cm级：血肿：包膜下涉及10%-50%表面面积，实质内直径10cm，撕裂涉及实质深度1-3cm，长度小于10cm级：血肿：包膜下大于50%表面面积，扩张性；包膜下血肿破裂伴活动性出血；实质内大于10cm或扩张，裂伤深度超过3cm级：撕裂，实质破裂累及25-75%肝叶，或一个肝叶内1-3个肝段；级：裂伤：实质破裂涉及大于75%肝叶或一个肝叶内3个以上肝段。血管：近肝静脉损伤，级：血管：肝撕脱CT分级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). 肝裂伤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：肝表面平行的线状或从肝门向外的辐射状撕裂，由于放射状、平行的裂痕表现，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腹部钝伤2-3天后，肝实质或包膜下撕裂伤或血肿区可出现气体。肝内气体通常提示感染，但严重钝伤而没有感染时亦可出现，气体来源可能为肝脏缺血、坏死所致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). 约22%的腹部钝伤病人可出现门脉分支周围低密度区，亦称门脉周围轨道征（periportal tracking），撕裂伤附近的门脉周围间隙增宽，提示可能为出血进入门脉周围结缔组织，如果弥漫性改变，可能为补液过多所致中心静脉压升高、张力性气胸、心包填塞等所引起的门脉周围淋巴管扩张。研究显示，肝外伤血肿清除后，解除了对肝淋巴引流的阻塞，该

21、征象可消失轨道征病理基础 各种原因所致血管周围的淋巴回流受阻或淋巴液产生过多导致肝内淋巴瘀滞， 外伤后glisson鞘周围疏松的结缔组织中存留血液；其中肝淋巴动力学异常被认为是最主要和最重要的病理性基础。尚见于活动性肝炎、2013-10-222013-10-22绿色箭头： 椭圆状低密度区符合血肿黄色箭头： 线性形低密度影区符合挫裂伤。（注意此挫裂伤与左侧的门静脉相交）蓝色箭头： 密度不均的低密度区符合挫伤肝周积液液此患者肝脏损伤几乎涉及两叶，但血供正常2013-10-22u肝右叶门静脉中断 ( 4 级)u增强显示对比剂溢出肝脏外缘u腹腔积液2013-10-22多发撕裂伤左侧裂伤表现为星状右侧裂

22、伤表现为树枝状2013-10-22男，26岁，腹部外伤后持续腹痛病例1病例2男，45岁，胸腹部外伤，右腹部疼痛为著手术所见2013-10-22病例3男，46岁，高处坠落伤及胸腹2013-10-22病例4男，40岁，腹部外伤2013-10-222013-10-222013-10-222013-10-22损伤转归 包膜下血肿通常6-8周内吸收 肝内血肿通常6月至数年完全吸收。血肿内的胆汁成分延缓了血块的吸收，还可延缓肝实质损伤的愈合 肝脏挫裂伤可在2-3周内明显好转 肝脏挫裂伤和肝内血肿首次复查CT（7天）常出现密度减低，范围稍有增大；随着病情恢复，病变逐渐吸收，体积缩小、边界清晰、呈圆形或卵圆形

23、，或者以边界清晰的肝囊肿或胆脂瘤形成持续存在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月月肝裂伤随访2013-10-22肝挫裂伤男，48岁，外伤后4小时即行CT检查2天后复查肝脏挫裂伤更加明显，肝脾周积液，双侧胸腔积液、肺挫裂伤，注意右侧肾上腺血肿2013-10-2211天复查，肝内出血较前吸收2013-10-222013-10-2250天复查，出血明显吸收，局部呈类圆形水样低密度灶胰腺损伤2013-10-22 少见，仅占腹部损伤的3-12% 单独损伤少见 通常是复合性损伤的一部分 损伤机制：椎骨、腹壁对胰腺的挤压，如方向盘、自行车把挤压或顶伤 症状隐匿，难以诊断分类（病理） 胰腺挫伤 轻度挫伤 严重

26、挫伤 胰腺断裂伤 部分断裂伤 完全断裂伤2013-10-22 轻度挫伤：胰腺组织水肿或（和）少量出血， 或形成胰腺被膜下小血肿 严重挫伤：胰腺组织失去活力，伴有比较广泛或比较粗的胰管破裂导致胰液外溢 部分断裂伤：胰腺周径1/3、 胰腺周径2/3的裂伤；胰腺周径1/3的裂伤归为严重挫裂伤 完全断裂伤： 胰腺周径2/3的裂伤2013-10-222013-10-22AAST胰腺损伤分级CT改变：挫伤，正常强化胰腺实质内的局限性低密度灶，撕裂、破裂：线状低密度影，通常垂直于胰腺长轴，多位于胰腺颈部、体部（位于脊柱前）活动性出血，少见胰腺局部肿大、胰周间隙模糊、积液可提示胰腺损伤，非特异外伤12小时内，

27、CT难以显示胰腺撕裂或断裂，由于撕裂实质碎片间出血或相互邻近，掩盖破裂表现；随后，外漏的胰液（消化酶）造成水肿、炎症、自身消化反应，损伤显示较为明显CT无法直接显示胰管的完整性，深的撕裂或横断提示胰管破裂ERCP/MRCP显示胰管损伤，后者无创、快速、易操作另一分类方法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)胰体断裂胰周积液胰颈生理性狭窄导致假性胰腺撕裂，冠状位图像可鉴别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). 胰腺裂伤胰管断裂胰液外溢2013-10-22车祸伤患者，生命体征稳定，下腹部轻度压痛胰腺发现有模糊的低密度影，胰尾周围少量液体，左肾前方较明显其余腹腔器

32、官正常，其他部位没有腹腔积液之后病人症状加重，CT复查发现胰周积液增加（未显示），提示该病人是一个独立的胰腺损伤独立的胰腺损伤极其罕见（多为复合伤的一部分），因为胰腺位置较深，受肝、脾和胸骨的保护放射学者认为需要重视可能存在的胰腺损伤病例男，19岁2013-10-222013-10-222013-10-222013-10-222013-10-22术后诊断：胰腺断裂伤2013-10-22肾脏损伤 单独损伤少见，通常是复合性损伤的一部分 多为钝伤 患病或异常的肾脏，较正常肾脏更易损伤（轻微外伤即可能积水肾盂破裂，感染脆弱肾脏碎裂，异位肾、马蹄肾碎裂；外伤较轻，损伤严重时，考虑到基础肾脏病变的可能）

33、 儿童较成人更易发生肾脏损伤（外缘分叶、肾脏相对身体体积大） CT首选检查，明确肾脏损伤的类型和范围2013-10-22分类2013-10-22Michael Federle将肾损伤分为四类：轻度损伤：（75-85%）肾挫伤肾和包膜下血肿不涉及收集系统或髓质的小挫裂伤小段梗死中度损伤：（10%）涉及髓质或收集系统的挫裂伤节段性梗塞重度损伤：（5%）肾碎裂肾梗死收集系统破裂CT改变 肾挫伤，最轻的肾损伤，平扫表现为弥漫性或局限性的肾肿胀，含有点状高密度新鲜出血，增强扫描延迟强化或强化程度降低，常伴有包膜下和肾周出血 肾裂伤，正常强化实质内线状无强化区，常伴有包膜下和肾周出血 肾碎裂，多发线状无强

34、化区，分隔开强化或不强化的肾脏碎片，常撕裂肾段血管，伴有大的肾周血肿 肾蒂损伤，肾梗死或肾淤血性改变（肾脏增大，皮质患者强化，肾静脉内发现血栓可确诊） 集合系统损伤，含对比剂尿液外溢（延迟扫描时间足够长）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)左肾挫伤右肾裂伤，左

35、肾挫伤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侧面刀刺穿透伤患者 小的肾包膜血肿及肾周积血左肾包膜下血肿非膨胀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). 左肾破裂对比剂外溢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右肾裂伤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左肾碎裂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.) 肾蒂损伤，左肾无血供病例1男，46岁，外伤及右腰背部2013-10-222013-10-22病例2男，28岁，胸腹外伤，脾破裂，肾挫裂伤，肾周积血2013-10-22病例3男，41岁，肾周出血，腹膜后血肿2013-10-22病例4女，45岁，摔伤左腰部4小时就诊2013-10-222013-10-222013-10-222013-10-22肾穿后包膜下出血病例5男，23岁，肾脏活检后腰痛1天病

41、例6男，43岁，头胸腹部外伤4小时就诊胆管结石2012-06-172013-10-22右侧肾上腺血肿2013-06-19复查，肾上腺血肿密度增高，肝脾周见有积血2013-10-222012-06-28日复查，肾上腺出血较前有所吸收2013-10-222012-08-03复查，血肿基本吸收2013-10-22输尿管膀胱损伤 输尿管损伤多为医源性损伤，钝伤、穿通伤少见 输尿管腹膜后器官，破裂尿液聚集于输尿管周围间隙，主要在肾周间隙内侧 膀胱损伤见于医源性损伤、钝伤、穿通伤，多有肉眼血尿 膀胱为腹膜间器官，依破裂口位置与腹膜反折关系，尿液可聚集于腹膜腔或腹膜后 CT为首选影像学检查方法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