彩超在诊断小儿先天性肠旋转不良中的应用价值

发布时间：2018-03-05 09:14

本文选题：彩超　切入点：肠旋转不良　出处：《泰山医学院》2013年硕士论文　论文类型：学位论文

【摘要】：目的分析小儿先天性肠旋转不良的声像图特征，结合手术及病理结果，总结该病的特征性表现，评价超声在诊断小儿先天性肠旋转不良的应用价值，为进一步提高超声在诊断小儿先天性肠旋转不良的准确性进行分析研究。资料与方法 1临床资料对自2011年12月~2012年12月在山东大学齐鲁儿童医院因呕吐就诊并被医师怀疑为消化道畸形的62例患儿进行了超声影像与手术病理对照分析。男39例，女23例，男女比例1.7：1。入院时间:出生数小时～7天32例,7～28天15例，28天~1岁9例，大于1岁6例。62例患儿因不同程度的呕吐就诊。伴有便血7例，伴有黄疸23例，营养不良20例。24例患儿临床检查发现胃肠型，38例仅见腹部略胀；20例伴有不同程度的水电解质紊乱。11例患儿在胎儿时期诊断为羊水过多，，可疑消化道畸形。 2仪器设备与检查方法 philips iu22、HDI5000彩超仪，采用线阵探头L12-5，频率8-12HZ。检查前根据患儿情况，适当喂奶或喝水充盈胃腔。患儿先取侧卧位观察幽门发育及开闭情况以及十二指球部肠充盈情况。然后患儿取仰卧位，全腹探测，注意观察十二指肠、小肠、大肠等是否存在梗阻、扩张及狭窄等。并注意肠管的蠕动及充气情况，这也是消化道先天畸形的超声诊断与鉴别诊断的重要环节。然后着重于上腹部横切面在胰腺头部寻找SMA和SMV根部,由上至下缓慢移动探头，注重观察肠系膜上动脉与肠系膜上静脉的位置关系，直至两者消失，尤其注意使用彩色多普勒动态观察肠系膜上静脉的走形及血管扩张情况。横断面及纵断面扫查相结合由上到下全腹探测。结果 62例患儿中，经手术及病理证实的57例患者，术前均行超声检查，其中肠旋转不良41例，超声诊断44例；36例伴发肠扭转，8例为单纯性。十二指肠膜状狭窄及闭锁10例，超声诊断10例；环状胰腺3例，超声诊断3例；肠重复畸形2例，超声诊断2例。急性肠套叠1例，超声诊断1例，无明显外科疾患者2例。12例患儿合并两种及以上畸形，5例肠旋转不良患儿合并十二指肠膜状狭窄；3例合并小肠闭锁；2例合并先天性巨结肠；8例合并不同类型的先天性心脏病；3例患者为21-3体综合征。 1肠旋转不良 ①36例伴发扭转的肠旋转不良患儿，超声检查可见SMV围绕SMA旋转，呈“漩涡征”。于腹主动脉前方肠系膜根部可见直径约2cm的低回声包块，呈螺旋状，边界清，边缘规整，随探头由上向下可见该包块呈顺时针旋转约180°~720°不等,肠系膜血管可见不同程度的扩张，宽度约在0.2~0.8cm。彩色多普勒显示包块内呈红蓝相间的漩涡状血流环绕，外层为静脉，内层为动脉血流信号。手术证实为肠旋转不良并肠扭转。 ②超声诊断的8例单纯性肠旋转不良患者。其中4例SMV位于SMA的左侧者，结合消化道检查结果证实为肠旋转不良。4例SMV位于SMA的前方者，经消化道造影证实1例为单纯的肠旋转不良，其他3例肠管位置正常，并无旋转不良征象。考虑为血管位置的正常变异。 2其他消化道疾病 ①超声诊断的10例十二指肠膜状狭窄或闭锁患儿均经手术证实。表现为为胃腔和十二指肠明显扩张，扩张的十二指肠远端呈一盲端或仅通过一裂隙样小孔与远端肠管相通远端肠管萎瘪，远端肠管充气明显减少，患者肠系膜血管位置未见异常。 ②超声诊断的3例环状胰腺患者均经手术及病理证实。表现为胃腔和十二指肠明显扩张，扩张的十二指肠远端可见胰腺组织环绕。远端肠管萎瘪，充气明显减少。患者肠系膜血管位置未见异常。 ③超声诊断的1例肠套叠患者。表现为于患者的右上腹腹探及直径约3.5cm的“靶环样”征象，内可见淋巴结回声，长轴为“套筒征”，诊断为肠套叠，行空气灌肠术后复查，该征象消失。患儿症状消失。 ④超声诊断的2例肠腔内型囊性肠重复畸形患儿。于患儿右下腹回肠远端见一囊样结构，壁厚有分层，似肠管壁结构，患者近段肠管梗阻扩张，超声诊断为腔内型囊性肠重复畸形，经手术证实。结论通过观察肠系膜上动脉与肠系膜上静脉的位置关系的变化是诊断肠旋转不良的重要方法。当肠旋转不良伴发中肠扭转后超声可通过“漩涡征”这一特征性表现进行诊断，且诊断符合率较高。当肠旋转不良不伴发扭转时，若不仔细观察超声容易漏诊，这时应重点观察肠系膜上静脉与肠系膜上动脉的关系，当肠系膜上静脉位于肠系膜上动脉的左侧时，可确诊为肠旋转不良。当肠系膜上静脉位于肠系膜上动脉的前方时，应慎重探测排除或确诊本病（该情况仅有25%为本病），必要时应结合消化道造影检查综合做出判断。肠旋转不良是最常见的十二指肠梗阻性疾病，由于该病症状与其他小肠梗阻性疾病临床表现差别不大，因此在检查中应注意鉴别诊断，提高诊断的准确率。此外，注意观察是否伴有其他消化道畸形的存在，以便手术及时处理。超声检查准确快捷，简单方便，无辐射，在诊断肠旋转不良中有重要的应用价值。
[Abstract]:objective
Analysis of sonographic characteristics of children with congenital intestinal malrotation, combined with surgical and pathological results, summarize the features of the disease, evaluate the clinical value of ultrasound in the diagnosis of congenital intestinal malrotation, to further improve the analysis of ultrasound in the diagnosis of congenital intestinal malrotation in children's accuracy.
Information and methods
1 clinical data
From December 2011 December ~2012 in Qilu children's Hospital of Shandong University hospital and physician because of vomiting was suspected in 62 cases of digestive tract malformation were compared and analyzed the ultrasonography and pathology. 39 cases were male, 23 were female, male to female ratio of 1.7:1. admission time: born a few hours to 7 days in 32 cases, 15 cases of 7~28 days. 28 days ~1 years in 9 cases, more than 1 years old in 6 cases of.62 patients with different degree of vomiting. 7 cases were accompanied by blood in the stool, jaundice in 23 cases, 20 cases of malnutrition in.24 patients clinical examination found 38 cases of gastrointestinal type, abdomen slightly swelling; 20 cases of hydropower with different degree electrolyte disorders in.11 patients the children in the fetal period for the diagnosis of polyhydramnios, suspicious digestive tract malformation.
2 instruments and inspection methods
Philips iu22, HDI5000 color Doppler ultrasound, the probe frequency L12-5, 8-12HZ. check before according to the situation of children proper feeding or water filling the stomach cavity. Children take the lateral position and development of open and close observation of Helicobacter pylori and twelve duodenal intestinal filling. Then the infants in supine position, observe the whole abdominal exploration, duodenum, small intestine. E. the existence of such obstruction, dilatation and stricture. And pay attention to the intestinal peristalsis and inflation, which is an important part of digestive tract congenital malformation of the ultrasound diagnosis and differential diagnosis. Then focuses on the abdominal transverse section in pancreatic head for SMA and SMV from roots, slow moving probe, focusing on observing the relative position of mesenteric artery and the superior mesenteric vein, until the two disappeared, especially pay attention to the use of color Doppler dynamic observation of superior mesenteric vein shape and vascular dilatation. Cross and longitudinal Cross section scan is a combination of upper and lower whole abdomen detection.
Result
In 62 cases, 57 patients were confirmed by surgery and pathology of the patients underwent preoperative ultrasonography, including intestinal malrotation in 41 cases, ultrasound diagnosis of 44 cases; 36 cases with volvulus, 8 cases. 10 cases of duodenal membranous stenosis and atresia, ultrasound diagnosis of 10 cases; 3 cases of annular pancreas ultrasound diagnosis, 3 cases; 2 cases were intestinal duplication, ultrasound diagnosis of 2 cases. 1 cases of acute intussusception, ultrasound diagnosis of 1 cases of patients with no obvious surgical disease, 2 cases of.12 patients with two or more kinds of malformation, 5 cases of intestinal malrotation in children complicated with duodenal membranous stenosis; 3 cases with intestinal atresia in 2 cases; associated with congenital megacolon; 8 cases with different types of congenital heart disease; 3 cases of 21-3 body syndrome.
1 intestinal malrotation
A total of 36 cases with intestinal malrotation in hair torsion, ultrasonography shows SMV around the SMA rotation, a "whirlpool". In front of the abdominal aorta mesenteric root diameter of 2cm visible hypoechoic mass, spiral, clear boundary, edge neat, with the probe from up to down the visible mass clockwise rotated about 180 DEG ~720 DEG range, mesenteric vessels showed different degrees of expansion, the width is displayed in the 0.2~0.8cm. color Doppler mass in a swirling flow around the red and blue, the outer layer of the inner vein, artery blood flow signal. Surgery confirmed intestinal malrotation and volvulus.
The ultrasonic diagnosis of 8 cases of intestinal malrotation. Patients including 4 cases of SMV located in the left side of the SMA, combined with the road test results was confirmed by digestion of intestinal malrotation in.4 cases of SMV located in the front of SMA, the digestive tract confirmed 1 cases of simple intestinal malrotation, other 3 cases were normal, no malrotation signs. Considered as a normal vascular variation position.
2 other digestive tract diseases
The ultrasonic diagnosis of 10 cases of duodenal membranous stenosis or atresia were confirmed by surgery. As for stomach and duodenum were dilated, dilatation of the distal duodenum is a blind end or only through a slit like orifice and distal bowel communicated the distal bowel shrinking, distal bowel filling gas significantly reduced, mesenteric vascular patients had no position abnormal.
(2) 3 cases of annular pancreas diagnosed by ultrasonography were confirmed by operation and pathology. The gastric cavity and duodenum were obviously dilated, and the distal duodenal tissue was surrounded by pancreatic tissue. The distal intestine became shrunken and the inflation was significantly reduced. The location of mesenteric vessels was not abnormal.
3. 1 cases of intussusception diagnosed by ultrasound. It is characterized by "target ring like" sign with a diameter of about 3.5cm in the right upper abdomen and abdomen. The echo of lymph nodes is seen. The long axis is "sleeve sign". It is diagnosed as intussusception. After air enema, the sign is disappeared. The symptoms disappear.
(4) ultrasonic diagnosis of 2 cases of enteric cystic duplication of the intestine. A cystic like structure was seen in the distal part of the right lower abdomen. The wall thickness was stratified, resembling the wall structure of the bowel wall. The proximal segment of intestinal obstruction was dilated, and the ultrasonic diagnosis was intracavity type cystic intestinal duplication. It was confirmed by operation.
conclusion
By changing the position between the artery and the superior mesenteric vein to observe mesenteric is an important method in diagnosis of intestinal malrotation. When intestinal malrotation with midgut volvulus after ultrasonic diagnosis can be carried out by the "whirlpool" features, and the diagnosis coincidence rate is higher. When intestinal rotation without adverse reverse, if you do not observe ultrasound easily missed, then the relationship of the mesenteric vein and superior mesenteric artery were observed on the key, when the superior mesenteric vein in superior mesenteric artery to the left, can be diagnosed with intestinal malrotation. When the superior mesenteric vein in superior mesenteric artery in front, should be careful to exclude or diagnose the disease (detection this is only 25% of the disease), when necessary, should be combined with gastrointestinal radiography comprehensive judgment. Intestinal malrotation is the most common disease of duodenal obstruction, because the disease symptoms and other intestinal stem Little difference in clinical manifestations of disease resistance, therefore in the examination should pay attention to the differential diagnosis and improve the accuracy of diagnosis. In addition, observe whether there is associated with other digestive tract malformation, so that the operation in a timely manner. Ultrasonography is quick and accurate, simple and convenient, no radiation, has important application value in the diagnosis of intestinal malrotation.

【学位授予单位】：泰山医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R725.7;R816.92

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