指肠损伤课件

1、十二指肠损伤1十二指肠损伤1十二指肠解剖特点 十二指肠分为四部分，即十二指肠上部、十二指肠降部、十二指肠水平部及十二指肠升部。其中十二指肠降部、十二指肠水平部位于腹膜后，为腹腹外位器官，余为腹膜内位器官。2十二指肠解剖特点 十二指肠分为四部分，即十二指肠上腹膜后间隙解剖 腹膜后间隙是以腹后壁壁层腹膜为前界，腹横筋膜为后界，上起横膈，下达盆腔的立体间隙。3腹膜后间隙解剖 腹膜后间隙是以腹后壁壁层腹膜为前界腹膜后间隙划分 关于腹膜后间隙的划分，普遍接受的观点是Meyers于20世纪60年代末70年代初在Congdon解剖工作研究的基础上提出的，即以肾筋膜为主要标志，将腹膜后间隙分为肾旁前间隙APS

2、 ，位于后腹膜与肾前筋膜侧锥筋膜之间。肾周间隙PS 位于肾前后筋膜之间，呈倒置的锥形。肾旁后间隙PPS，位于肾后筋膜侧锥筋膜和腹横筋膜之间。4腹膜后间隙划分 关于腹膜后间隙的划分，普遍接受的观Drawing illustrates the traditional tricompartment model of the retroperitoneum, which is accordingly divided into the anterior pararenal space (APS), perirenal space (PS), and posterior pararenal space (

3、PPS). The anterior renal fascia (ARF), posterior renal fascia (PRF), and lateroconal fascia (LCF) divide the spaces. 5Drawing illustrates the traditDrawing illustrates the recently modified tricompartment model, which reflects the understanding that the perirenal fascia is laminar and variably fused

4、 and there are interfascial connections between the spaces. The retromesenteric plane (RMP), retrorenal space (RRS), and lateroconal space are potential interfascial communications. Perinephric septa run between the renal capsule and the perinephric fascia, allowing subcapsular fluid to communicate

5、with the retrorenal space or retromesenteric plane. APS = anterior pararenal space, PPS = posterior pararenal space, PS = perirenal space (,). 6Drawing illustrates the recent腹膜后两侧同名间隙经内侧的通连 肾旁前间隙：Meyers通过临床放射学观察到，肾旁前间隙内的积液或积气一般是局限于其来源一侧的。同时，他又指出由于胰腺特殊位置本身就是潜在的通道，可以说肾旁前间隙左右侧是相互通连的；间隙内注入对比剂后CT扫描也说明两侧是

6、相通的。7腹膜后两侧同名间隙经内侧的通连 肾旁前间隙：Mey 肾周间隙：Tobin等用胚胎解剖学方法证实了1895年Cerota最早关于肾前，后筋膜的描述。并进一步指出，肾前，后筋膜绕主动脉和腔静腔与对侧同名筋膜相连续。推侧两侧肾周间隙经内侧相通。 Mitchell和Meyers在胰腺和十二指肠后方，与围绕肠系膜根部血管的致密结缔组织融合，并不与对侧同名筋膜相续，这意味着两侧肾周间隙并不通连。8 肾周间隙：Tobin等用胚胎解剖学方法证实了18 而Kneeland的尸体间隙灌注却发现两侧肾周间隙在L3-L5间任何平面以下越过下腔静脉和腹主动脉前方相通。 Mindell的注射实验研究不仅证实Kn

7、eeland的结论，还进一步观察到造影剂并未环绕血管，仅在大血管前壁组成前述通道的后界，因而提出主动脉和下腔静脉并不在肾周间隙内，而在其后方。9 而Kneeland的尸体间隙灌注却发现两侧肾周间 临床CT观察表明，两侧肾周间隙内侧并没有明显的筋膜分隔，肾周间隙的血肿和气体在肾下极或更低的平面相通。10 临床CT观察表明，两侧肾周间隙内侧并没有明显的筋肾旁后间隙 无论是从临床表现，CT观察还是注射实验研究，尚无任何证据证明双侧肾旁后间隙经内侧直接相通。11肾旁后间隙 无论是从临床表现，CT观察还是注射实验腹膜后间隙向上通连 以往Meyers认为肾前后筋膜向上融合并续接于膈筋膜，因而肾旁前间隙向上

8、与肝裸区相通，肾旁后间隙向上续于薄层的膈下筋膜，至于其向前和整个膈下关系并不明确。 而Lim等用CT扫描发现在新鲜尸体上经右肾周间隙注入对比剂直接进入肝裸区，以充分的依据证明与肝裸区相通的是肾周间隙而不是肾旁前间隙。肾前后筋膜分别向上融合于后腹膜和膈下筋膜，因此理论上推测肾旁前后间隙不向上开放。12腹膜后间隙向上通连 以往Meyers认为肾前后筋膜 临床发现位于肝裸区的病变向下可直接进入右肾周间隙，反之，积于右肾周间隙的气体向上也可达肝裸区，一些位于右肾周的尿性囊肿甚至可延伸至纵隔和胸腔，这些均提示肾周间隙向上不仅能与膈下间隙相通，还可能通过膈肌裂孔或膈脚与纵隔相通。13 临床发现位于肝裸区的

9、病变向下可直接进入右肾周间隙腹膜后间隙向下通连 以Rapropoulos为代表的学者认为肾筋膜锥在髂窝封闭成单一的多层筋膜，下方闭合。 现在的学者多认为肾筋膜锥向下开放，锥口下三个间隙相互通连。 Mindell等在注射实验研究中发现，肾旁前间隙大剂量注入对比剂240-1000ml，CT观察锥下、膀胱前、膀胱旁、骶前各间隙均充盈。14腹膜后间隙向下通连 以Rapropoulos为代表十二指肠损伤机制 十二指肠损伤少见，多为上腹穿透伤引起。闭合伤引起者，或由于暴力直接作用（如车祸时方向盘将十二指肠水平段碾轧于脊柱上），或由于暴力引起处于紧闭的幽门和Treitz韧带之间的闭襻内压力骤升引起胀裂。损伤

10、部位多在23部（3/4以上）。可见于座椅安全带损伤、减速伤、方向盘或把手损伤，部分见于运动伤、跌伤及打击上腹部所致。15十二指肠损伤机制 十二指肠损伤少见，多为上腹穿透伤 十二指肠损伤在腹部损伤中，低于2%，可同时合并胰腺、肝、脾、肾、胃及小肠系膜的损伤。可造成十二指肠挫伤、十二指肠壁内血肿、十二指肠穿孔或破裂，后者是外科治疗的适应症。16 十二指肠损伤在腹部损伤中，低于2%，可同时合并胰临床特征 临床特征包括白细胞增多，血清淀粉酶升高和上腹痛。然而，临床征象常常是模糊的，且是非特异性的。17临床特征 临床特征包括白细胞增多，血清淀粉酶升高和X线平片 平片可见右肾或腰大肌异常清楚或模糊，有时腹

11、膜后呈“花斑状”改变（积气）并逐渐扩展，胃管内注入水溶性碘剂可见外溢。一般不采用钡餐检查诊断十二指肠破裂。18X线平片 平片可见右肾或腰大肌异常清楚或模糊，有时CT表现CT是诊断十二指肠损伤的主要手段。非穿透性损伤常常被忽略。十二指肠水肿、壁内血肿和肠壁积气可提示十二指肠挫伤。局部肠壁厚度大于 3mm （部分学者认为大于4mm ）为十二指肠壁增厚。十二指肠挫伤可保守治疗。腹膜后口服造影剂溢出、肠外游离气体和肠壁不连续可提示十二指肠穿孔或破裂。当穿孔位于Treitz韧带时，气体或外溢对比剂可进入腹膜腔内。因十二指肠与胰腺关系密切，十二指肠损伤常伴胰腺损伤存在，CT检查时应注意观察。19CT表现C

12、T是诊断十二指肠损伤的主要手段。19 十二指肠损伤的一个特殊类型是十二指肠壁内血肿，由上腹挫伤引起，大多发生在儿童，病程进展缓慢，除上腹不适隐痛外，主要表现为高位肠梗阻，有时伴有胆管及胰管的梗阻导致黄疸和淀粉酶升高，右上腹多能摸到肿块。钡餐造影可见典型的螺旋簧征。 若保守治疗两周梗阻仍不能解除，需手术治疗。20 十二指肠损伤的一个特殊类型是十二指肠壁内血肿，由十二指肠壁内血肿Traumatic duodenal intramural hematoma in a 26-year-old man who had sustained a seat belt injury in a high-spee

13、d motor vehicle collision. Abdominal CT scan obtained with oral and intravenous contrast material shows wall thickening of the third and fourth portions of the duodenum (arrows). No extraluminal air (a finding that would have suggested perforation) was seen. The patient was treated conservatively an

14、d recovered without intervention 21十二指肠壁内血肿Traumatic duodenal int十二指肠血肿22十二指肠血肿22十二指肠血肿Large traumatic duodenal hematoma in a 49-year-old man who was involved in a motor vehicle collision. The patient was also taking anticoagulants. (a) Abdominal CT scan obtained with oral and intravenous contrast m

15、aterial shows a large hematoma (arrowheads) displacing the second portion of the duodenum (arrow) anteromedially and narrowing the duodenal lumen. (b) Coronal reformatted CT image depicts the full extent of the duodenal hematoma (arrowheads). 23十二指肠血肿Large traumatic duodena十二指肠降部挫伤Grade I duodenal i

16、njury. Axial CT image shows thickening of the duodenal wall (arrow) in the descending part without evidence of free air. There is stranding of the peripancreatic fat. 24十二指肠降部挫伤Grade I duodenal inju十二指肠水肿Duodenal hematoma in an 11-year-old boy who had sustained a bicycle handlebar injury. On an abdo

17、minal CT scan obtained with oral and intravenous contrast material, the third portion of the duodenum is thickened and edematous (arrowheads). No extraluminal air could be identified to suggest perforation. The patient was treated conservatively and recovered completely. 25十二指肠水肿Duodenal hematoma in

18、 an 十二指肠降部破裂Grade II duodenal injury. (a) Axial CT image shows an enlarged pancreatic head with mild edema (arrow) (grade I lesion). (b) CT image obtained at a lower level shows thickening of the duodenal wall in the descending part (black arrow). Adjacent to the duodenum is a small collection of ex

19、traluminal air (white arrow), which indicates a small grade II laceration of the wall. 26十二指肠降部破裂Grade II duodenal inju十二指肠穿孔Duodenal perforation in a 28-year-old man who sustained blunt trauma in a motor vehicle collision. (a) Abdominal CT scan obtained with intravenous and oral contrast material s

20、hows extraluminal air (arrows) adjacent to the duodenum (D). Cholecystectomy clips are also present. (b) Coronal reformatted CT image shows a large amount of fluid in the right anterior pararenal space with a small focus of extraluminal air (arrow), findings that are consistent with a duodenal perfo

21、ration. The perforation was confirmed and repaired at surgery. D = duodenum. 27十二指肠穿孔Duodenal perforation in 十二指肠水平部破裂Grade II duodenal injury. Axial CT image shows a grade II injury of the horizontal part of the duodenum with small collections of extraluminal air (arrows). A subcapsular hematoma is

22、 present at the lower pole of the right liver lobe (arrowhead). 28十二指肠水平部破裂Grade II duodenal inj十二指肠破裂Grade III duodenal injury. (a) Axial CT image shows thickening of the duodenal wall in the descending part (black arrow). At the transition zone to the horizontal part, there is disruption of the wa

23、ll (white arrow). Additional findings include a retroperitoneal hematoma and hypoperfusion of the right kidney due to right renal artery occlusion. (b) CT image obtained at a lower level shows the disruption (black arrow) with a large surrounding extraluminal hematoma (white arrow). 29十二指肠破裂Grade II

24、I duodenal injurRuptured duodenum in a 27-year-old female victim of a motor vehicle accident. CT scan shows fluid in the duodenum and leakage of fluid into the right anterior pararenal space (arrow). 30Ruptured duodenum in a 27-year消化内镜胃窦及胰头活检术后Axial CT images in patient with perforation of the seco

25、nd portion of the duodenum 1 day after gastroduodenoscopy with endoscopic pancreatic fine-needle aspiration biopsy and gastric biopsy. (a) Unenhanced CT image shows air in anterior pararenal space (white arrow) and right perirenal space (black arrow). (b) A more caudal image shows a focus of discont

26、inuity (short black arrow) in the wall of the second portion of the duodenum, with extraluminal extravasation of oral contrast material (long black arrow). Air is also demonstrated in the right posterior pararenal space (long white arrow), right properitoneal compartment (short white arrow), and per

27、itoneal cavity (arrowhead). (c) Contrast-enhanced CT image obtained 2 years later shows the right anterior renal fascia (white arrow) to extend to the second portion of the duodenum (arrowhead). The cystic lesion in the pancreatic head is an intraductal papillary mucinous neoplasm (black arrow). 31消

28、化内镜胃窦及胰头活检术后Axial CT images i消化内镜胰头活检术后Contrast-enhanced axial CT images in patient with perforation of the second portion of the duodenum after endoscopic pancreatic fine-needle aspiration biopsy 1 week earlier. The amount of air in the right perirenal space exceeds that in the right anterior parar

29、enal space. 32消化内镜胰头活检术后Contrast-enhanced ax内镜检查后Duodenal perforation after endoscopy in a 51-year-old man. CT scan shows a thick-walled, contracted duodenum with air in the adjacent retroperitoneum (arrow). 33内镜检查后Duodenal perforation afte鉴别诊断腹膜间位器官破裂，如升降结肠破裂。腹膜内位器官破裂，特别是注意Morrison窝积气与腹膜后间隙积气的鉴别，右肝

30、上间隙与肝裸区积气的鉴别。膀胱破裂。腹后壁穿通伤。34鉴别诊断腹膜间位器官破裂，如升降结肠破裂。34空肠破裂Jejunal perforation in a 66-year-old woman after a motor vehicle accident. Axial CT image shows hypervascular thickened jejunum with a suspicious defect (curved arrow) and with focal fluid, fat stranding, and extraluminal air (straight arrow) adj

31、acent to jejunal loops. The patient later underwent resection of a 20-cm segment of the small bowel. No mesenteric injury was found at surgery. 35空肠破裂Jejunal perforation in a 十二指肠溃疡穿孔Abdominal pain and a perforated duodenal ulcer in a 79-year-old man. CT scan obtained with oral contrast material shows intraperitoneal extravasation of contrast material from the lateral portion of the duodenum (white arrow) and leakage of contrast material around the liver (