十二指腸損傷

1、十二指腸損傷,,十二指腸解剖特點,十二指腸分為四部分，即十二指腸上部、十二指腸降部、十二指腸水平部及十二指腸升部。其中十二指腸降部、十二指腸水平部位于腹膜后，為腹腹外位器官，余為腹膜內(nèi)位器官。,腹膜后間隙解剖,腹膜后間隙是以腹后壁壁層腹膜為前界，腹橫筋膜為后界，上起橫膈，下達盆腔的立體間隙。,腹膜后間隙劃分,關(guān)于腹膜后間隙的劃分，普遍接受的觀點是Meyers于20世紀(jì)60年代末70年代初在Congdon解剖工作研究的基礎(chǔ)上提出的，即以腎

2、筋膜為主要標(biāo)志，將腹膜后間隙分為︰⑴腎旁前間隙﹙APS﹚ ，位于后腹膜與腎前筋膜﹑側(cè)錐筋膜之間。⑵腎周間隙﹙PS﹚ 位于腎前﹑后筋膜之間，呈倒置的錐形。⑶腎旁后間隙﹙PPS﹚，位于腎后筋膜﹑側(cè)錐筋膜和腹橫筋膜之間。,,Drawing illustrates the traditional tricompartment model of the retroperitoneum, which is accordingly divided i

3、nto the anterior pararenal space (APS), perirenal space (PS), and posterior pararenal space (PPS). The anterior renal fascia (ARF), posterior renal fascia (PRF), and lateroconal fascia (LCF) divide the spaces.,,Drawing i

4、llustrates the recently modified tricompartment model, which reflects the understanding that the perirenal fascia is laminar and variably fused and there are interfascial connections between the spaces. The retromesenter

5、ic 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 communica

6、te with the retrorenal space or retromesenteric plane. APS = anterior pararenal space, PPS = posterior pararenal space, PS = perirenal space (,).,腹膜后兩側(cè)同名間隙經(jīng)內(nèi)側(cè)的通連,腎旁前間隙：Meyers通過臨床放射學(xué)觀察到，腎旁前間隙內(nèi)的積液或積氣一般是局限于其來源一側(cè)的。同時，他又指出由于胰

7、腺特殊位置本身就是潛在的通道，可以說腎旁前間隙左右側(cè)是相互通連的；間隙內(nèi)注入對比劑后CT掃描也說明兩側(cè)是相通的。,,腎周間隙：Tobin等用胚胎解剖學(xué)方法證實了1895年Cerota最早關(guān)于腎前，后筋膜的描述。并進一步指出，腎前，后筋膜繞主動脈和腔靜腔與對側(cè)同名筋膜相連續(xù)。推側(cè)兩側(cè)腎周間隙經(jīng)內(nèi)側(cè)相通。 Mitchell和Meyers在胰腺和十二指腸后方，與圍繞腸系膜根部血管的致密結(jié)締組織融合，并不與對側(cè)同名筋膜相續(xù)，這意味著

8、兩側(cè)腎周間隙并不通連。,,而Kneeland的尸體間隙灌注卻發(fā)現(xiàn)兩側(cè)腎周間隙在L3-L5間任何平面以下越過下腔靜脈和腹主動脈前方相通。 Mindell的注射實驗研究不僅證實Kneeland的結(jié)論，還進一步觀察到造影劑并未環(huán)繞血管，僅在大血管前壁組成前述通道的后界，因而提出主動脈和下腔靜脈并不在腎周間隙內(nèi)，而在其后方。,,臨床CT觀察表明，兩側(cè)腎周間隙內(nèi)側(cè)并沒有明顯的筋膜分隔，腎周間隙的血腫和氣體在腎下極或更低的平面相通。,腎

9、旁后間隙,無論是從臨床表現(xiàn)，CT觀察還是注射實驗研究，尚無任何證據(jù)證明雙側(cè)腎旁后間隙經(jīng)內(nèi)側(cè)直接相通。,腹膜后間隙向上通連,以往Meyers認(rèn)為腎前后筋膜向上融合并續(xù)接于膈筋膜，因而腎旁前間隙向上與肝裸區(qū)相通，腎旁后間隙向上續(xù)于薄層的膈下筋膜，至于其向前和整個膈下關(guān)系并不明確。 而Lim等用CT掃描發(fā)現(xiàn)在新鮮尸體上經(jīng)右腎周間隙注入對比劑直接進入肝裸區(qū)，以充分的依據(jù)證明與肝裸區(qū)相通的是腎周間隙而不是腎旁前間隙。腎前后筋膜分別向上

10、融合于后腹膜和膈下筋膜，因此理論上推測腎旁前后間隙不向上開放。,,臨床發(fā)現(xiàn)位于肝裸區(qū)的病變向下可直接進入右腎周間隙，反之，積于右腎周間隙的氣體向上也可達肝裸區(qū)，一些位于右腎周的尿性囊腫甚至可延伸至縱隔和胸腔，這些均提示腎周間隙向上不僅能與膈下間隙相通，還可能通過膈肌裂孔或膈腳與縱隔相通。,腹膜后間隙向下通連,以Rapropoulos為代表的學(xué)者認(rèn)為腎筋膜錐在髂窩封閉成單一的多層筋膜，下方閉合。 現(xiàn)在的學(xué)者多認(rèn)為腎筋膜錐向下開

11、放，錐口下三個間隙相互通連。 Mindell等在注射實驗研究中發(fā)現(xiàn)，腎旁前間隙大劑量注入對比劑﹝240-1000ml﹞，CT觀察錐下、膀胱前、膀胱旁、骶前各間隙均充盈。,十二指腸損傷機制,十二指腸損傷少見，多為上腹穿透傷引起。閉合傷引起者，或由于暴力直接作用（如車禍時方向盤將十二指腸水平段碾軋于脊柱上），或由于暴力引起處于緊閉的幽門和Treitz韌帶之間的閉襻內(nèi)壓力驟升引起脹裂。損傷部位多在2﹑3部（3/4以上）?？梢娪谧?/p>

12、安全帶損傷、減速傷、方向盤或把手損傷，部分見于運動傷、跌傷及打擊上腹部所致。,,十二指腸損傷在腹部損傷中，低于2%，可同時合并胰腺、肝、脾、腎、胃及小腸系膜的損傷?？稍斐墒改c挫傷、十二指腸壁內(nèi)血腫、十二指腸穿孔或破裂，后者是外科治療的適應(yīng)癥。,臨床特征,臨床特征包括白細(xì)胞增多，血清淀粉酶升高和上腹痛。然而，臨床征象常常是模糊的，且是非特異性的。,X線平片,平片可見右腎或腰大肌異常清楚或模糊，有時腹膜后呈“花斑狀”改變（積氣）并逐漸擴

13、展，胃管內(nèi)注入水溶性碘劑可見外溢。一般不采用鋇餐檢查診斷十二指腸破裂。,CT表現(xiàn),CT是診斷十二指腸損傷的主要手段。非穿透性損傷常常被忽略。十二指腸水腫、壁內(nèi)血腫和腸壁積氣可提示十二指腸挫傷。局部腸壁厚度大于 3mm （部分學(xué)者認(rèn)為大于4mm ）為十二指腸壁增厚。十二指腸挫傷可保守治療。腹膜后口服造影劑溢出、腸外游離氣體和腸壁不連續(xù)可提示十二指腸穿孔或破裂。當(dāng)穿孔位于Treitz韌帶時，氣體或外溢對比劑可進入腹膜腔內(nèi)。因十二指腸

14、與胰腺關(guān)系密切，十二指腸損傷常伴胰腺損傷存在，CT檢查時應(yīng)注意觀察。,,十二指腸損傷的一個特殊類型是十二指腸壁內(nèi)血腫，由上腹挫傷引起，大多發(fā)生在兒童，病程進展緩慢，除上腹不適﹑隱痛外，主要表現(xiàn)為高位腸梗阻，有時伴有膽管及胰管的梗阻導(dǎo)致黃疸和淀粉酶升高，右上腹多能摸到腫塊。鋇餐造影可見典型的螺旋簧征。 若保守治療兩周梗阻仍不能解除，需手術(shù)治療。,十二指腸壁內(nèi)血腫,Traumatic duodenal intramural hema

15、toma in a 26-year-old man who had sustained a seat belt injury in a high-speed motor vehicle collision. Abdominal CT scan obtained with oral and intravenous contrast material shows wall thickening of the third and fourth

16、 portions of the duodenum (arrows). No extraluminal air (a finding that would have suggested perforation) was seen. The patient was treated conservatively and recovered without intervention,十二指腸血腫,十二指腸血腫,Large traumatic

17、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 material shows a large h

18、ematoma (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).,

19、十二指腸降部挫傷,Grade I duodenal injury. 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.,十二指腸水腫,Duodenal hematoma i

20、n an 11-year-old boy who had sustained a bicycle handlebar injury. On an abdominal CT scan obtained with oral and intravenous contrast material, the third portion of the duodenum is thickened and edematous (arrowheads).

21、No extraluminal air could be identified to suggest perforation. The patient was treated conservatively and recovered completely.,十二指腸降部破裂,Grade II duodenal injury. (a) Axial CT image shows an enlarged pancreatic head wit

22、h 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 extraluminal air

23、 (white arrow), which indicates a small grade II laceration of the wall.,十二指腸穿孔,Duodenal perforation in a 28-year-old man who sustained blunt trauma in a motor vehicle collision. (a) Abdominal CT scan obtained with intra

24、venous and oral contrast material shows 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

25、 pararenal space with a small focus of extraluminal air (arrow), findings that are consistent with a duodenal perforation. The perforation was confirmed and repaired at surgery. D = duodenum.,十二指腸水平部破裂,Grade II duodenal

26、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 present at the lower pole of the right liver lobe (arro

27、whead).,十二指腸破裂,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 wall (whi

28、te 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

29、a large surrounding extraluminal hematoma (white arrow).,,Ruptured 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 par

30、arenal space (arrow).,消化內(nèi)鏡胃竇及胰頭活檢術(shù)后,Axial CT images in patient with perforation of the second portion of the duodenum 1 day after gastroduodenoscopy with endoscopic pancreatic fine-needle aspiration biopsy and gastric bi

31、opsy. (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 discontinuity (short black arrow) in the wall of the sec

32、ond 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 compartme

33、nt (short white arrow), and peritoneal 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 (arrowh

34、ead). The cystic lesion in the pancreatic head is an intraductal papillary mucinous neoplasm (black arrow).,消化內(nèi)鏡胰頭活檢術(shù)后,Contrast-enhanced axial CT images in patient with perforation of the second portion of the duodenum a

35、fter endoscopic pancreatic fine-needle aspiration biopsy 1 week earlier. The amount of air in the right perirenal space exceeds that in the right anterior pararenal space.,內(nèi)鏡檢查后,Duodenal perforation after endoscopy in a

36、51-year-old man. CT scan shows a thick-walled, contracted duodenum with air in the adjacent retroperitoneum (arrow).,鑒別診斷,腹膜間位器官破裂，如升﹑降結(jié)腸破裂。腹膜內(nèi)位器官破裂，特別是注意Morrison窩積氣與腹膜后間隙積氣的鑒別，右肝上間隙與肝裸區(qū)積氣的鑒別。膀胱破裂。腹后壁穿通傷。,空腸破裂,Jejunal

37、 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 (

38、straight arrow) adjacent to jejunal loops. The patient later underwent resection of a 20-cm segment of the small bowel. No mesenteric injury was found at surgery.,十二指腸潰瘍穿孔,Abdominal pain and a perforated duodenal ulcer i

39、n 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 th

40、e liver (black arrow).,膀胱破裂,Ruptured bladder in a 43-year-old female pedestrian who was struck by a car. (a) Axial abdominal CT image shows intraperitoneal areas of free contrast material (straight arrows) and free air (

41、curved arrow). (b) Axial CT image shows a retroperitoneal area of extraluminal contrast enhancement (arrow). These features mimic those found in bowel injury but, instead, are secondary to a bladder rupture, which was fo

42、und at surgery.,胰腺炎血腫進入十二指壁,Acute pancreatitis and hemorrhage into the lateral duodenal wall, which caused mass effect and narrowing of the duodenal lumen, in a 46-year-old man. CT scan shows extensive stranding of the p

43、eripancreatic fat secondary to pancreatitis. Massive enlargement of the lateral wall of the duodenum is accompanied by a focal area of increased attenuation at the site of the bleeding (black arrow). The duodenal lumen,