十二指肠损伤.pptx

十二指肠损伤十二指肠解剖特点n n 十二指肠分为四部分，即十二指肠上部、十二指肠降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、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。内位器官。腹膜后间隙解剖n n 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。腹膜后间隙划分n n 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，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。n nDrawing illustrates the Drawing illustrates the traditional traditional tricompartment model tricompartment model of the retroperitoneum,of the retroperitoneum,which is accordingly which is accordingly divided into the divided into the anterior pararenal anterior pararenal space space(APS)(APS),perirenal,perirenal space space(PS)(PS),and,and posterior pararenal posterior pararenal space space(PPS)(PPS).The.The anterior renal fascia anterior renal fascia(ARF)(ARF),posterior renal,posterior renal fascia fascia(PRF)(PRF),and,and lateroconal fascia lateroconal fascia(LCF)(LCF)divide the spaces.divide the spaces.n nDrawing illustrates the Drawing illustrates the recently modified recently modified tricompartment model,which tricompartment model,which reflects the understanding reflects the understanding that the perirenal fascia is that the perirenal fascia is laminar and variably fused laminar and variably fused and there are interfascial and there are interfascial connections between the connections between the spaces.The retromesenteric spaces.The retromesenteric plane plane(RMP)(RMP),retrorenal space,retrorenal space(RRS)(RRS),and lateroconal space,and lateroconal space are potential interfascial are potential interfascial communications.Perinephric communications.Perinephric septa run between the renal septa run between the renal capsule and the perinephric capsule and the perinephric fascia,allowing subcapsular fascia,allowing subcapsular fluid to communicate with fluid to communicate with the retrorenal space or the retrorenal space or retromesenteric plane.retromesenteric plane.APSAPS=anterior pararenal space,anterior pararenal space,PPSPPS =posterior pararenal space,=posterior pararenal space,PSPS=perirenal space(,).=perirenal space(,).腹膜后两侧同名间隙经内侧的通连n n 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扫描也说明两侧是相通的。n n 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。n n 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。n n 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。n n Mindell的注射实验研究不仅证实Kneeland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。n n 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。肾旁后间隙n n 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。腹膜后间隙向上通连n n 以往以往MeyersMeyers认为肾前后筋膜向上融合并续接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与肝裸区相通，于膈筋膜，因而肾旁前间隙向上与肝裸区相通，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。前和整个膈下关系并不明确。n n 而而LimLim等用等用CTCT扫描发现在新鲜尸体上经右肾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。筋膜，因此理论上推测肾旁前后间隙不向上开放。n n 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。腹膜后间隙向下通连n n 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。n n 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。n n 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。十二指肠损伤机制n n 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。n n 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。临床特征n n 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。X线平片n n 平片可见右肾或腰大肌异常清楚或模糊，有时腹膜后呈“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。CT表现n nCTCT是诊断十二指肠损伤的主要手段。是诊断十二指肠损伤的主要手段。n n非穿透性损伤常常被忽略。非穿透性损伤常常被忽略。n n十二指肠水肿、壁内血肿和肠壁积气可提示十二十二指肠水肿、壁内血肿和肠壁积气可提示十二指肠挫伤。局部肠壁厚度大于指肠挫伤。局部肠壁厚度大于 3mm 3mm（部分学者（部分学者认为大于认为大于4mm 4mm）为十二指肠壁增厚。十二指肠）为十二指肠壁增厚。十二指肠挫伤可保守治疗。挫伤可保守治疗。n n腹膜后口服造影剂溢出、肠外游离气体和肠壁不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。当穿孔位于连续可提示十二指肠穿孔或破裂。当穿孔位于TreitzTreitz韧带时，气体或外溢对比剂可进入腹膜腔韧带时，气体或外溢对比剂可进入腹膜腔内。内。n n因十二指肠与胰腺关系密切，十二指肠损伤常伴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，胰腺损伤存在，CTCT检查时应注意观察。检查时应注意观察。n n 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。n n 若保守治疗两周梗阻仍不能解除，需手术治疗。十二指肠壁内血肿n nTraumatic duodenal Traumatic duodenal intramural hematoma intramural hematoma in a 26-year-old man in a 26-year-old man who had sustained a who had sustained a seat belt injury in a seat belt injury in a high-speed motor high-speed motor vehicle collision.vehicle collision.Abdominal CT scan Abdominal CT scan obtained with oral and obtained with oral and intravenous contrast intravenous contrast material shows wall material shows wall thickening of the third thickening of the third and fourth portions of and fourth portions of the duodenum the duodenum(arrows).No(arrows).No extraluminal air(a extraluminal air(a finding that would finding that would have suggested have suggested perforation)was perforation)was seen.The patient was seen.The patient was treated conservatively treated conservatively and recovered and recovered without intervention without intervention 十二指肠血肿十二指肠血肿n n Large traumatic duodenal hematoma in a 49-year-old man Large traumatic duodenal hematoma in a 49-year-old man who was involved in a motor vehicle collision.The patient who was involved in a motor vehicle collision.The patient was also taking anticoagulants.was also taking anticoagulants.(a)(a)Abdominal CT scan Abdominal CT scan obtained with oral and intravenous contrast material shows obtained with oral and intravenous contrast material shows a large hematoma(arrowheads)displacing the second a large hematoma(arrowheads)displacing the second portion of the duodenum(arrow)anteromedially and portion of the duodenum(arrow)anteromedially and narrowing the duodenal lumen.narrowing the duodenal lumen.(b)(b)Coronal reformatted CT Coronal reformatted CT image depicts the full extent of the duodenal hematoma image depicts the full extent of the duodenal hematoma(arrowheads).(arrowheads).十二指肠降部挫伤n n Grade I Grade I duodenal duodenal injury.Axial CT injury.Axial CT image shows image shows thickening of thickening of the duodenal the duodenal wall(arrow)in wall(arrow)in the descending the descending part without part without evidence of evidence of free air.There free air.There is stranding of is stranding of the the peripancreatic peripancreatic fat.fat.十二指肠水肿n nDuodenal hematoma in Duodenal hematoma in an 11-year-old boy who an 11-year-old boy who had sustained a bicycle had sustained a bicycle handlebar injury.On an handlebar injury.On an abdominal CT scan abdominal CT scan obtained with oral and obtained with oral and intravenous contrast intravenous contrast material,the third material,the third portion of the portion of the duodenum is thickened duodenum is thickened and edematous and edematous(arrowheads).No(arrowheads).No extraluminal air could extraluminal air could be identified to suggest be identified to suggest perforation.The patient perforation.The patient was treated was treated conservatively and conservatively and recovered completely.recovered completely.十二指肠降部破裂n nGrade II duodenal injury.Grade II duodenal injury.(a)(a)Axial CT image shows an enlarged Axial CT image shows an enlarged pancreatic head with mild edema(arrow)(grade I lesion).pancreatic head with mild edema(arrow)(grade I lesion).(b)(b)CT CT image obtained at a lower level shows thickening of the duodenal image obtained at a lower level shows thickening of the duodenal wall in the descending part(black arrow).Adjacent to the wall in the descending part(black arrow).Adjacent to the duodenum is a small collection of extraluminal air(white arrow),duodenum is a small collection of extraluminal air(white arrow),which indicates a small grade II laceration of the wall.which indicates a small grade II laceration of the wall.十二指肠穿孔n nDuodenal perforation in a 28-year-old man who sustained blunt trauma in Duodenal perforation in a 28-year-old man who sustained blunt trauma in a motor vehicle collision.a motor vehicle collision.(a)(a)Abdominal CT scan obtained with Abdominal CT scan obtained with intravenous and oral contrast material shows extraluminal air(arrows)intravenous and oral contrast material shows extraluminal air(arrows)adjacent to the duodenum adjacent to the duodenum(D)(D).Cholecystectomy clips are also present.Cholecystectomy clips are also present.(b)(b)Coronal reformatted CT image shows a large amount of fluid in the Coronal reformatted CT image shows a large amount of fluid in the right anterior pararenal space with a small focus of extraluminal air right anterior pararenal space with a small focus of extraluminal air(arrow),findings that are consistent with a duodenal perforation.The(arrow),findings that are consistent with a duodenal perforation.The perforation was confirmed and repaired at surgery.perforation was confirmed and repaired at surgery.DD=duodenum.=duodenum.十二指肠水平部破裂n nGrade II Grade II duodenal injury.duodenal injury.Axial CT image Axial CT image shows a grade II shows a grade II injury of the injury of the horizontal part of horizontal part of the duodenum the duodenum with small with small collections of collections of extraluminal air extraluminal air(arrows).A(arrows).A subcapsular subcapsular hematoma is hematoma is present at the present at the lower pole of the lower pole of the right liver lobe right liver lobe(arrowhead).(arrowhead).十二指肠破裂n nGrade III duodenal injury.Grade III duodenal injury.(a)(a)Axial CT image shows thickening of the Axial CT image shows thickening of the duodenal wall in the descending part(black arrow).At the transition zone to duodenal wall in the descending part(black arrow).At the transition zone to the horizontal part,there is disruption of the wall(white arrow).Additional the horizontal part,there is disruption of the wall(white arrow).Additional findings include a retroperitoneal hematoma and hypoperfusion of the right findings include a retroperitoneal hematoma and hypoperfusion of the right kidney due to right renal artery occlusion.kidney due to right renal artery occlusion.(b)(b)CT image obtained at a lower CT image obtained at a lower level shows the disruption(black arrow)with a large surrounding level shows the disruption(black arrow)with a large surrounding extraluminal hematoma(white arrow).extraluminal hematoma(white arrow).n nRuptured Ruptured duodenum in a duodenum in a 27-year-old 27-year-old female victim of female victim of a motor vehicle a motor vehicle accident.CT accident.CT scan shows scan shows fluid in the fluid in the duodenum and duodenum and leakage of fluid leakage of fluid into the right into the right anterior anterior pararenal space pararenal space(arrow).(arrow).消化内镜胃窦及胰头活检术后n nAxial CT images in patient with perforation of the second portion of the duodenum 1 day after 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 biopsy.gastroduodenoscopy with endoscopic pancreatic fine-needle aspiration biopsy and gastric biopsy.(a)(a)Unenhanced CT image shows air in anterior pararenal space(white arrow)and right perirenal Unenhanced CT image shows air in anterior pararenal space(white arrow)and right perirenal space(black arrow).space(black arrow).(b)(b)A more caudal image shows a focus of discontinuity(short black arrow)in A more caudal image shows a focus of discontinuity(short black arrow)in the wall of the second portion of the duodenum,with extraluminal extravasation of oral contrast 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 material(long black arrow).Air is also demonstrated in the right posterior pararenal space(long white arrow),right properitoneal compartment(short white arrow),and peritoneal cavity white arrow),right properitoneal compartment(short white arrow),and peritoneal cavity(arrowhead).(arrowhead).(c)(c)Contrast-enhanced CT image obtained 2 years later shows the right anterior renal 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 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).lesion in the pancreatic head is an intraductal papillary mucinous neoplasm(black arrow).消化内镜胰头活检术后n nContrast-enhanced axial CT Contrast-enhanced axial CT images in patient with images in patient with perforation of the second perforation of the second portion of the duodenum after portion of the duodenum after endoscopic pancreatic fine-endoscopic pancreatic fine-needle aspiration biopsy 1 needle aspiration biopsy 1 week earlier.The amount of week earlier.The amount of air in the right perirenal space air in the right perirenal space exceeds that in the right exceeds that in the right anterior pararenal space.anterior pararenal space.内镜检查后n nDuodenal Duodenal perforation perforation after after endoscopy in endoscopy in a 51-year-a 51-year-old man.CT old man.CT scan shows a scan shows a thick-walled,thick-walled,contracted contracted duodenum duodenum with air in with air in the adjacent the adjacent retroperitoneretroperitoneum(arrow).um(arrow).鉴别诊断n n腹膜间位器官破裂，如升降结肠破裂。n n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，右肝上间隙与肝裸区积气的鉴别。n n膀胱破裂。n n腹后壁穿通伤。空肠破裂n n Jejunal perforation in Jejunal perforation in a 66-year-old woman a 66-year-old woman after a motor vehicle after a motor vehicle accident.Axial CT accident.Axial CT image shows image shows hypervascular hypervascular thickened jejunum thickened jejunum with a suspicious with a suspicious defect(curved arrow)defect(curved arrow)and with focal fluid,and with focal fluid,fat stranding,and fat stranding,and extraluminal air extraluminal air(straight arrow)(straight arrow)adjacent to jejunal adjacent to jejunal loops.The patient loops.The patient later underwent later underwent resection of a 20-cm resection of a 20-cm segment of the small segment of the small bowel.No mesenteric bowel.No mesenteric injury was found at injury was found at surgery.surgery.十二指肠溃疡穿孔n nAbdominal pain and Abdominal pain and a perforated a perforated duodenal ulcer in a duodenal ulcer in a 79-year-old man.79-year-old man.CT scan obtained CT scan obtained with oral contrast with oral contrast material shows material shows intraperitoneal intraperitoneal extravasation of extravasation of contrast material contrast material from the lateral from the lateral portion of the portion of the duodenum(white duodenum(white arrow)and leakage arrow)and leakage of contrast mat