多层螺旋CT口服低张小肠造影的临床应用研究

发布时间：2018-08-17 09:03

【摘要】：第一部分三种不同中性对比剂MSCTE小肠扩张效果的对比研究目的:分析比较临床怀疑小肠疾病患者口服三种不同中性对比剂小肠扩张程度的差异性,为临床口服低张小肠造影选择合适的对比剂提供依据。方法:收集我院2014年1月至3月期间临床怀疑小肠疾病且无明确肠梗阻患者共60例,随机分为三组并口服三种不同的中性对比剂,即2.5%等渗甘露醇组、纯牛奶组、纯净水组各20例。60例患者均行CT增强双期扫描,所有数据建薄后导入后台独立工作站进行图像三维后重组,然后采用盲法原则经过两位具有丰富经验的放射科医生分析重组图像,判断全组小肠及各段小肠扩张程度,最后对所测量数据进行统计学分析。结果:全组小肠整体扩张程度比较:三组差异有统计学意义,等渗甘露醇组扩张程度最好,与纯牛奶组及纯水组比较差异均有统计学意义(P0.05),纯牛奶组与纯净水组比较差异无统计学意义(P0.05);组内各段小肠比较:回肠扩张效果最好,空肠其次,十二指肠扩张效果稍差。结论:2.5%等渗甘露醇扩张小肠肠管效果最好,更利于发现小肠病变,可推荐临床对怀疑小肠疾病患者口服2.5%等渗甘露醇行多层螺旋CT检查。第二部分MSCTE对小肠疾病的诊断价值研究目的:探讨多层螺旋CT口服低张小肠造影(MSCTE)对小肠疾病的临床诊断价值。方法:收集我院2014年4月至2015年2月期间消化内科及胃肠外科临床诊断怀疑小肠疾病并符合本研究纳入条件的患者共98例,CT扫描前按要求口服2.5%等渗甘露醇溶液1000～1500ml,所有患者均行多层螺旋CT轴位连续增强双期扫描,通过横断位、冠矢状位重建及曲面重组、血管成像技术观察是否有小肠病变,若有小肠病变应进一步观察病变部位、大小、形态、强化特点、与周围组织关系及远处转移情况,最后将MSCTE诊断结果与最终临床诊断作对照分析。结果:本研究98例患者中,53例患者MSCTE诊断发现有小肠疾病,没有发现小肠病变者共45例,而最终临床诊断共58例有小肠病变,40例无小肠病变。MSCTE诊断共漏诊5例,其中包括空肠腺癌1例、腹型过敏性紫癜1例、肠结石1例、小肠血管畸形2例,误诊2例,包括空肠腺癌误诊为淋巴瘤1例、腹型过敏性紫癜误诊为肠结核1例。本研究中MSCTE诊断小肠疾病的灵敏度为91.38%(53/58),特异度为100%(40/40),阳性预测值为100%(53/53),阴性预测值为88.89%(40/45),诊断正确率为92.86%((51+40)/98)。58例小肠病变中,肿瘤性病变共26例,其中腺癌13例,发生于十二指肠3例,2例表现为十二指肠降段及水平段起始部管壁环形增厚,增强轻中度强化,肠腔轻度狭窄,1例表现为十二指肠降段突向腔内的软组织结节影,增强明显均匀强化,3例均未引起近段肠梗阻征象;发生于空肠5例,位于空肠近端2例,1例表现为腔内类圆形软组织肿块影,增强明显均匀强化,1例表现为肠壁明显增厚伴异常强化,2例均引起十二指肠梗阻扩张,位于空肠中远段2例,1例为绒毛状腺瘤恶变为粘液腺癌,表现为空肠远段腔内较大分叶状肿块影,同时可见近段肠管内胶囊内镜滞留,1例表现为空肠壁不规则增厚伴肠腔扩张,MSCTE误诊为小肠淋巴瘤,1例MSCTE漏诊;发生于回肠(包括回盲部)共5例,2例表现为回肠壁局限性环形增厚,3例为回盲部肿块影,其中1例侵犯升结肠并引起低位小肠梗阻。小肠淋巴瘤4例,均表现为较长范围的肠壁环形增厚、肠腔不狭窄,2例可见腹腔腹膜后多发淋巴结增大。小肠间质瘤6例,其中3例表现为腔内均匀明显强化的软组织肿块影(最大径5cm),边界较清晰,动脉期病灶内可见多发血管影,3例表现为较大囊实性肿块影,其内见较多液化坏死及气体影。小肠脂肪瘤3例,均表现为小肠内多发结节状脂肪密度影。小肠炎症性病变共24例,其中克罗恩病4例,均表现为空回肠多节段性肠壁增厚伴肠壁强化,一例伴有腹腔脓肿形成并侵犯右腹直肌,一例伴有肠系膜多发小脓肿及肛周脓肿形成;溃疡性结肠炎3例,2例表现为降结肠、乙状结肠及直肠黏膜异常强化,肌层水肿,浆膜层模糊不清,1例表现为全结肠连续性肠壁增厚并异常强化,肠系膜增厚且明显强化;肠结核7例,3例表现为广泛腹膜、系膜增厚呈"腹茧症",小肠被聚集且肠壁弥漫性增厚,腹腔多发淋巴结增大,环形强化,4例表现为回肠末端、回盲部肠壁增厚、异常强化,腹腔积液,腹膜增厚;腹型过敏性紫癜5例,3例表现为小肠节段性肠粘膜增粗、明显强化,肠腔未见狭窄,其中1例合并盆腔积液,1例表现为回盲部及回肠末端肠壁增厚,腹腔腹膜后多发淋巴结增大,腹膜增厚,MSCTE误诊为肠结核,1例MSCTE漏诊。一般炎症性疾病5例。肠结石1例,MSCTE漏诊。肠系膜血管病变7例,包括肠系膜扭转2例,均不伴有肠壁缺血坏死,肠系膜上静脉及门静脉血栓2例,较长范围小肠壁缺血坏死,肠系膜上动脉栓塞1例,节段性小肠壁水肿增厚,小肠血管畸形2例,MSCTE漏诊。结论:小肠肿瘤性病变、炎症性病变及血管性病变等在MSCTE上具有相对特征性的表现,MSCTE能全面展示小肠腔内外病变、肠系膜、系膜血管及其他脏器情况,对小肠疾病的诊断具有重要价值。
[Abstract]:Objective: To compare the effects of three different neutral contrast agents (MSCTE) on small intestinal dilatation in patients with suspected small intestinal diseases, and to provide evidence for the selection of suitable contrast agents for oral hypotonic enterography. Sixty patients with suspected small intestinal disease and no definite intestinal obstruction were randomly divided into three groups and treated with three different neutral contrast agents, namely, 2.5% isotonic mannitol group, pure milk group and pure water group, 20 patients in each group. Then the reconstructed images were analyzed by two experienced radiologists to judge the degree of dilatation of the whole small intestine and each segment of the small intestine. There was no significant difference between pure milk group and pure water group (P 0.05). Compared with pure water group, ileal dilatation was the best, jejunum was the second, and duodenal dilatation was slightly worse. Multislice spiral CT examination of 2.5% isotonic mannitol is recommended for patients suspected of small intestinal diseases. Part 2: The diagnostic value of MSCTE in small intestinal diseases. Objective: To investigate the clinical diagnostic value of MSCTE in small intestinal diseases. A total of 98 patients with suspected small intestinal diseases and eligible for inclusion in this study were diagnosed by gastrointestinal surgery and gastrointestinal surgery. Before CT scan, 2.5% isotonic mannitol solution was taken orally for 1000-1500 ml. All patients underwent axial continuous enhanced dual-phase multi-slice spiral CT scanning. Through transection, coronary-sagittal reconstruction and curved surface reconstruction, vascular imaging techniques were performed. If there are small intestinal lesions, we should further observe the location, size, shape, enhancement characteristics, relationship with surrounding tissues and distant metastasis. Finally, the MSCTE diagnosis results were compared with the final clinical diagnosis. Results: Among the 98 patients in this study, 53 patients were diagnosed with small intestinal diseases by MSCTE, without any occurrence. There were 45 cases of small intestinal lesions and 58 cases of small intestinal lesions and 40 cases of non-small intestinal lesions. 5 cases were missed by MSCTE, including 1 case of jejunal adenocarcinoma, 1 case of abdominal allergic purpura, 1 case of enterolithiasis, 2 cases of small intestinal vascular malformation, 2 cases of misdiagnosis, including 1 case of jejunal adenocarcinoma misdiagnosed as lymphoma, 1 case of abdominal allergic Pura misdiagnosed as intestinal nodules. The sensitivity, specificity, positive predictive value and negative predictive value of MSCTE were 91.38% (53/58), 100% (40/40), 100% (53/53), 88.89% (40/45) and 92.86% ((51+40)/98). Among 58 cases of small intestinal lesions, 26 were malignant, including 13 adenocarcinoma, 3 duodenum and 2 duodenum. The wall of the descending and horizontal segments of the duodenum was thickened circularly, slightly and moderately enhanced, and the intestinal cavity was narrowed slightly. One case showed soft tissue nodules protruding from the descending segment of the duodenum. The enhancement was uniformly enhanced. No proximal intestinal obstruction was found in 3 cases. Soft tissue mass showed marked homogeneous enhancement. One case showed marked thickening of intestinal wall with abnormal enhancement. Two cases had duodenal obstruction and dilatation. Two cases were located in the middle and distal part of the jejunum. One case was malignant transformation of villous adenoma into mucinous adenocarcinoma. Large lobular mass was seen in the distal part of the jejunum. There were 5 cases of irregular thickening of jejunal wall with dilatation of intestinal cavity, 1 case of misdiagnosis of small intestinal lymphoma by MSCTE, 1 case of missed diagnosis by MSCTE, 2 cases of localized circular thickening of ileocecal wall, 3 cases of ileocecal mass, and 1 case of ascending colon with low intestinal obstruction. There were 6 cases of small intestinal stromal tumors, 3 of which showed homogeneous and markedly enhanced soft tissue mass (maximum diameter 5 cm), clear boundary, multiple vascular shadow in arterial phase, 3 of which showed large cystic and solid mass, and more in them. Liquefied necrosis and gas shadow. 3 cases of small intestinal lipoma showed multiple nodular fat density shadows in the small intestine. 24 cases of small intestinal inflammatory lesions, including 4 cases of Crohn's disease, were manifested as multiple segmental thickening of jejuno-ileal intestinal wall with intestinal wall enhancement, one case with abdominal abscess formation and invasion of right rectus abdominis, one case with multiple mesenteric abscesses. 3 cases of ulcerative colitis, 2 cases of descending colon, abnormal enhancement of sigmoid and rectal mucosa, myoedema, vague serosa, 1 case of total colon continuous intestinal wall thickening and abnormal enhancement, mesentery thickening and obvious enhancement; 7 cases of intestinal tuberculosis, 3 cases of extensive peritoneum, mesenteric thickening was "abdominal cocoon disease" The small intestine was gathered and diffuse thickening of the intestinal wall, multiple lymph node enlargement and circular enhancement of the abdominal cavity. 4 cases showed thickening and abnormal enhancement of the ileocecal intestinal wall at the end of the ileum, peritoneal effusion, peritoneal thickening; 5 cases of abdominal allergic purpura, 3 cases showed segmental thickening of the intestinal mucosa, obvious enhancement, and no stricture of the intestine, including 1 case with pelvic effusion. One case was misdiagnosed as intestinal tuberculosis by MSCTE, and the other was misdiagnosed as intestinal tuberculosis by MSCTE. There were 5 cases of general inflammatory diseases, 1 case of intestinal calculi, 1 case of MSCTE misdiagnosis. There were 2 cases of portal vein thrombosis, 1 case of ischemic necrosis of small intestinal wall, 1 case of superior mesenteric artery embolism, 2 cases of segmental small intestinal wall edema, 2 cases of small intestinal vascular malformation, and MSCTE missed diagnosis. Mesentery, mesangial vessels and other organs are of great value in the diagnosis of small bowel diseases.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R816.5;R574

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