1、急腹症CT诊断-腹部外伤,胜利油田中心医院CT检查科 宋殿行,2013-10-22,创伤是40岁以下死亡的主要原因创伤死亡中腹部外伤占 10%，致死原因主要为肝损伤分类：钝器伤（闭合性损伤,坠落、碰撞、冲击、挤压等钝性暴力引起）穿透伤（开放性损伤,刀刺、枪弹、弹片所引起）,2013-10-22,CT 初诊首选检查方案敏感性、特异性高一站式检查,2013-10-22,技术,不需口服胃肠道对比剂（不需要、不必要）体外物品，离开扫描野（监护及生命支持设备等）双臂抱头或置于胸前，或上肢紧贴身体两侧（减少伪影，上肢与身体留有间隙，伪影更明显）扫描大范围（无遗漏）、大扫描野（减少伪影）如无禁忌，建议增强（
2、发现实质脏器破裂、尿漏以及活动出血等）常规时相增强扫描（一般损伤门脉期、排泄期即可）合理应用窗技术,2013-10-22,影像诊断需提供信息,有无明确腹外伤改变若有，损伤脏器，出血、积液、积气量及部位提示损伤脏器有无其他合并伤,2013-10-22,表现,腹腔积液、游离气体增强对比剂外溢提示活动性出血裂伤：线形或斜行区血肿：椭圆形或圆形区挫伤：模糊的低密度影器官全部或部分血运中断包膜下血肿,2013-10-22,示意图,2013-10-22,腹腔积血,男，37岁，腹外伤就诊肝脾周、结肠旁沟积血手术证实脾脏中下部裂伤,2013-10-22,点评,腹外伤常见并发症发现积血，进一步查找损伤脏器出血首
3、先积聚于损伤部位，继而流向低处出血形态、密度不一（腹腔间隙特点、出血吸收不规则及间断性出血、腹腔呼吸运动）增强扫描对比剂外溢，活动性出血的特征表现,前哨血块，损伤脏器附近的高密度血凝块，为内脏损伤的敏感征象，提示出血的来源，对诊断肠管、肠系膜、脾脏损伤意义重大,2013-10-22,脾脏损伤,闭合性腹外伤中，最易损伤的器官(质地脆弱、血供丰富)CT增强扫描评价脾外伤首选检查方案,CT平扫：脾脏密度不均脾周积血前哨血块,提示脾脏损伤,2013-10-22,脾损伤分类,撕裂伤脾实质内不规则线状低密度影脾脏碎裂严重创伤，脾脏破裂成多分小碎片脾内血肿脾实质内大范围无强化区，密度均匀/不均匀包膜下血肿包
4、绕脾实质的半月形或卵圆形液体密度影梗死继发血管损伤，常为延及包膜的楔形无强化区，可累及整个脾脏,2013-10-22,损伤分级,2013-10-22,易低估损伤程度分级中未涉及：活动出血、挫伤、外伤性梗塞最重要的是：没有判断非手术治疗的标准(NOM),级为包膜下血肿，小于面积10%，实质撕裂1cm级包膜下血肿占面积10-50%，实质撕裂1-3 cm级包膜下血肿50%，撕裂大于 3 cm或累及小梁血管级撕裂累及脾段或脾门血管，导致超过25%脾体积缺血级是脾门血管中断或脾实质完全碎裂,AAST（the American Association of Surgery of Trauma)损伤分级标准
5、,2013-10-22,1.有多处大小不一的低密度区。这些低密度影不是线状的，因此不是裂伤2.伴有肋骨骨折和气胸、皮下气肿3.无对比剂外溢,2013-10-22,线形低密度裂伤圆形和椭圆形低密度区脾血肿腹腔积液,2013-10-22,2013-10-22,围绕脾和肝腹腔积液。椭圆形或圆形低密度区符合脾脏血肿。线性低密度影符合脾前部的裂伤。脾门区对比剂外溢。,对比剂外溢，提示活动出血，不宜保守治疗,2013-10-22,活动性出血,Splenic pseudoaneurysm(thick arrow)in a 22-year-old man involved in a motor vehicle
6、 accident.Blood is present in the perisplenic space and Morisons pouch(asterisk).Thin arrows point to a left pneumothorax and chest wall emphysema,外伤后假性动脉瘤,2013-10-22,Subcapsular splenic hematoma.Contrast-enhanced computed tomography image demonstrates a lenticular-shaped subcapsular hematoma(H)that
7、 indents the underlying splenic parenchyma.A higher attenuation perisplenic hematoma(arrow)is seen posteriorly.P,pancreatic tail;K,left kidney.,包膜下血肿,脾内血肿,2013-10-22,Partial transection of the splenic hilum with active bleeding and massive hemoperitoneum.A,B:Computed tomography(CT)scans through the
8、upper pole of the right kidney demonstrate a large amount of hemoperitoneum,virtually absent perfusion of the splenic parenchyma,and active bleeding(arrows)from disrupted hilar vessels.C:CT scan through the lower margin of the spleen(S)shows some preservation of splenic enhancement consistent with p
9、artial hilar transection.A small laceration is noted in the left kidney.(Case courtesy of Christine O Menias,M.D.,St.Louis,Missouri.),脾门横断,2013-10-22,Congenital splenic clefts.A:Computed tomography image demonstrates a sharply marginated cleft in the posterior tip of the spleen.The smooth,rounded co
10、ntour of the cleft as it meets the margin of the spleen,as well as the absence of perisplenic hematoma,is helpful in distinguishing a congenital cleft from a parenchymal laceration.B:Another patient with multiple splenic clefts along the lateral margin of the spleen.,先天性脾裂，需与脾裂伤鉴别,2013-10-22,男，37岁，摔
11、伤后腹痛,病例,2013-10-22,2013-10-22,2013-10-22,肝脏在后腹部实质性脏器损伤中位居第二位肝损伤是死亡的最常见原因：肝下、肝静脉、肝动脉、门静脉分支丰富肝右叶后段因体积大、位置固定为最易受伤部分。这部分还涉及裸区，伤及该区域，将会导致腹膜后出血而不是腹腔出血,肝脏损伤,表现形式,包膜下血肿实质内血肿撕裂伤肝破裂,2013-10-22,最常见，分为浅表、肝门周围、深部3类正常强化肝实质内线状、分枝状、类圆形低密度影通常平行于肝静脉或门静脉结构，延伸至肝脏周边撕裂处可见局限性高密度的新鲜血块，撕裂贯穿肝包膜，常出现腹腔积血累及胆道，形成胆脂瘤或肝外胆汁聚集（初诊难以显
12、示）熊爪征：肝表面平行的线状或从肝门向外的辐射状撕裂，由于放射状、平行的裂痕表现，形似熊爪,深部撕裂或撕裂伤连接两侧肝表面，形成肝破裂可形成部分无强化区,肝内圆形或类圆形的混杂高密度区，无强化，边界多不清，周围可有肝脏挫伤水肿区,包膜下血肿可由钝伤引起，但更常见于医源性损伤，如肝穿刺等，表现为肝周透镜形或新月形积液（密度依出血时间而异），相邻肝实质变平或凹陷,2013-10-22,级：血肿：包膜下10%表面面积；裂伤：包膜撕裂，涉及实质深度小于1cm级：血肿：包膜下涉及10%-50%表面面积，实质内直径10cm，撕裂涉及实质深度1-3cm，长度小于10cm级：血肿：包膜下大于50%表面面积，扩
13、张性；包膜下血肿破裂伴活动性出血；实质内大于10cm或扩张，裂伤深度超过3cm级：撕裂，实质破裂累及25-75%肝叶，或一个肝叶内1-3个肝段；级：裂伤：实质破裂涉及大于75%肝叶或一个肝叶内3个以上肝段。血管：近肝静脉损伤，级：血管：肝撕脱,CT分级,2013-10-22,2013-10-22,Hepatic laceration.Note irregular,low-attenuation laceration in the posterior right lobe of the liver.High-attenuation foci of clotted blood(arrows)are
14、 seen within the area of laceration,Hepatic laceration.A,B:Computed tomography images demonstrate an irregular,low-attenuation laceration(arrow)in the right hepatic lobe.Note heterogeneous early arterial phase contrast enhancement of the spleen(S).,肝裂伤,2013-10-22,Bear claw type laceration of the rig
15、ht hepatic lobe.Note roughly parallel,radiating,low-attenuation lacerations involving the dome of the liver.A small amount of perihepatic blood is present(arrow),熊爪征：肝表面平行的线状或从肝门向外的辐射状撕裂，由于放射状、平行的裂痕表现，形似熊爪,2013-10-22,Hepatic laceration and hematoma.A,B:Computed tomography images demonstrate extensiv
16、e,irregular laceration and intraparenchymal hematoma(arrows),occupying much of the right lobe of the liver.The injury extends centrally to the confluence of the hepatic veins and inferior vena cava(arrowhead).Note associated perihepatic and perisplenic hemorrhage(h).ST,stomach,Intrahepatic hematoma
17、with sterile necrosis.Contrast-enhanced computed tomography scan 3 days following blunt abdominal trauma demonstrates intraparenchymal hematoma containing several small bubbles of gas(arrows),presumably secondary to necrosis within the area of injury.The patient had no evidence of infection and reco
18、vered uneventfully.E,pleural effusion,腹部钝伤2-3天后，肝实质或包膜下撕裂伤或血肿区可出现气体。肝内气体通常提示感染，但严重钝伤而没有感染时亦可出现，气体来源可能为肝脏缺血、坏死所致,2013-10-22,Periportal low attenuation.Computed tomography image demonstrates periportal low attenuation(arrows)surrounding the portal triads.A small amount of fluid is seen adjacent to the
19、 inferior vena cava(V).,约22%的腹部钝伤病人可出现门脉分支周围低密度区，亦称门脉周围轨道征（periportal tracking），撕裂伤附近的门脉周围间隙增宽，提示可能为出血进入门脉周围结缔组织，如果弥漫性改变，可能为补液过多所致中心静脉压升高、张力性气胸、心包填塞等所引起的门脉周围淋巴管扩张。研究显示，肝外伤血肿清除后，解除了对肝淋巴引流的阻塞，该征象可消失,轨道征病理基础,各种原因所致血管周围的淋巴回流受阻或淋巴液产生过多导致肝内淋巴瘀滞，外伤后glisson鞘周围疏松的结缔组织中存留血液；其中肝淋巴动力学异常被认为是最主要和最重要的病理性基础。尚见于活动性肝
20、炎、,2013-10-22,2013-10-22,绿色箭头：椭圆状低密度区符合血肿黄色箭头：线性形低密度影区符合挫裂伤。（注意此挫裂伤与左侧的门静脉相交）蓝色箭头：密度不均的低密度区符合挫伤肝周积液液此患者肝脏损伤几乎涉及两叶，但血供正常,2013-10-22,肝右叶门静脉中断(4 级)增强显示对比剂溢出肝脏外缘腹腔积液,2013-10-22,多发撕裂伤左侧裂伤表现为星状右侧裂伤表现为树枝状,2013-10-22,男，26岁，腹部外伤后持续腹痛,病例1,病例2,男，45岁，胸腹部外伤，右腹部疼痛为著,手术所见,2013-10-22,病例3,男，46岁，高处坠落伤及胸腹,2013-10-22,病
21、例4,男，40岁，腹部外伤,2013-10-22,2013-10-22,2013-10-22,2013-10-22,损伤转归,包膜下血肿通常6-8周内吸收肝内血肿通常6月至数年完全吸收。血肿内的胆汁成分延缓了血块的吸收，还可延缓肝实质损伤的愈合肝脏挫裂伤可在2-3周内明显好转肝脏挫裂伤和肝内血肿首次复查CT（7天）常出现密度减低，范围稍有增大；随着病情恢复，病变逐渐吸收，体积缩小、边界清晰、呈圆形或卵圆形，或者以边界清晰的肝囊肿或胆脂瘤形成持续存在,2013-10-22,2013-10-22,Healing hepatic lacerations on serial computed tomo
22、graphy(CT)examinations.A:Initial scan demonstrates bear claw type laceration in the right lobe of the liver.B:Scan 4 days later shows decrease in CT attenuation value and slight increase in size of the hepatic lacerations,probably a result of osmotic absorption of fluid.C:On a scan 3 weeks later,the
23、 lacerations have assumed a more rounded configuration,and the margins of the lacerations are better defined.D:Follow-up scan 3 months after the initial injury demonstrates virtually complete resolution of the liver lacerations,肝裂伤随访,2013-10-22,肝挫裂伤,男，48岁，外伤后4小时即行CT检查,2天后复查肝脏挫裂伤更加明显，肝脾周积液，双侧胸腔积液、肺挫裂
24、伤，注意右侧肾上腺血肿,2013-10-22,11天复查，肝内出血较前吸收,2013-10-22,2013-10-22,50天复查，出血明显吸收，局部呈类圆形水样低密度灶,胰腺损伤,2013-10-22,少见，仅占腹部损伤的3-12%单独损伤少见通常是复合性损伤的一部分损伤机制：椎骨、腹壁对胰腺的挤压，如方向盘、自行车把挤压或顶伤症状隐匿，难以诊断,分类（病理）,胰腺挫伤轻度挫伤严重挫伤胰腺断裂伤部分断裂伤完全断裂伤,2013-10-22,轻度挫伤：胰腺组织水肿或（和）少量出血，或形成胰腺被膜下小血肿严重挫伤：胰腺组织失去活力，伴有比较广泛或比较粗的胰管破裂导致胰液外溢部分断裂伤：胰腺周径1/
25、3、胰腺周径2/3的裂伤；胰腺周径1/3的裂伤归为严重挫裂伤完全断裂伤：胰腺周径2/3的裂伤,2013-10-22,2013-10-22,AAST胰腺损伤分级,CT改变：挫伤，正常强化胰腺实质内的局限性低密度灶，撕裂、破裂：线状低密度影，通常垂直于胰腺长轴，多位于胰腺颈部、体部（位于脊柱前）活动性出血，少见胰腺局部肿大、胰周间隙模糊、积液可提示胰腺损伤，非特异,外伤12小时内，CT难以显示胰腺撕裂或断裂，由于撕裂实质碎片间出血或相互邻近，掩盖破裂表现；随后，外漏的胰液（消化酶）造成水肿、炎症、自身消化反应，损伤显示较为明显CT无法直接显示胰管的完整性，深的撕裂或横断提示胰管破裂ERCP/MRC
26、P显示胰管损伤，后者无创、快速、易操作,另一分类方法,2013-10-22,2013-10-22,Pseudofracture of the pancreas due to physiologic thinning of the pancreatic neck.A:Computed tomography(CT)scan at the level of the superior mesenteric vein splenic vein confluence demonstrates apparent fracture of the pancreatic neck(open arrow).B:CT
27、 scan 1 cm caudal to(A)shows fat in the region of the neck consistent with physiologic thinning.Note also the absence of peripancreatic fluid.,Pancreatic laceration.A,B:Computed tomography images through the pancreas(P)demonstrate peripancreatic fluid(arrowheads)tracking into the left anterior parar
28、enal space.Note irregular,low-attenuation laceration(arrow)extending through the body of the pancreas.Adjacent fluid surrounds the superior mesenteric vein(a).Fluid is also present in the hepatorenal fossa(asterisk),胰体断裂胰周积液,胰颈生理性狭窄导致假性胰腺撕裂，冠状位图像可鉴别,2013-10-22,Pancreatic laceration with disruption o
29、f the pancreatic duct.A:Computed tomography scan demonstrates laceration through the tail of the pancreas(open arrow).Fluid is seen about the tail of the pancreas(solid arrows)adjacent to the spleen(S).B:Endoscopic retrograde cholangiopancreatography(ERCP)demonstrates disruption of the main pancreat
30、ic duct in the tail of the pancreas with extravasation of contrast material(arrows).,胰腺裂伤胰管断裂胰液外溢,2013-10-22,车祸伤患者，生命体征稳定，下腹部轻度压痛,胰腺发现有模糊的低密度影，胰尾周围少量液体，左肾前方较明显其余腹腔器官正常，其他部位没有腹腔积液之后病人症状加重，CT复查发现胰周积液增加（未显示），提示该病人是一个独立的胰腺损伤独立的胰腺损伤极其罕见（多为复合伤的一部分），因为胰腺位置较深，受肝、脾和胸骨的保护放射学者认为需要重视可能存在的胰腺损伤,病例,男，19岁,2013-10-2
31、2,2013-10-22,2013-10-22,2013-10-22,2013-10-22,术后诊断：胰腺断裂伤,2013-10-22,肾脏损伤,单独损伤少见，通常是复合性损伤的一部分多为钝伤患病或异常的肾脏，较正常肾脏更易损伤（轻微外伤即可能积水肾盂破裂，感染脆弱肾脏碎裂，异位肾、马蹄肾碎裂；外伤较轻，损伤严重时，考虑到基础肾脏病变的可能）儿童较成人更易发生肾脏损伤（外缘分叶、肾脏相对身体体积大）CT首选检查，明确肾脏损伤的类型和范围,2013-10-22,分类,2013-10-22,Michael Federle将肾损伤分为四类：轻度损伤：（75-85%）肾挫伤肾和包膜下血肿不涉及收集系统
32、或髓质的小挫裂伤小段梗死中度损伤：（10%）涉及髓质或收集系统的挫裂伤节段性梗塞重度损伤：（5%）肾碎裂肾梗死收集系统破裂,CT改变,肾挫伤，最轻的肾损伤，平扫表现为弥漫性或局限性的肾肿胀，含有点状高密度新鲜出血，增强扫描延迟强化或强化程度降低，常伴有包膜下和肾周出血肾裂伤，正常强化实质内线状无强化区，常伴有包膜下和肾周出血肾碎裂，多发线状无强化区，分隔开强化或不强化的肾脏碎片，常撕裂肾段血管，伴有大的肾周血肿肾蒂损伤，肾梗死或肾淤血性改变（肾脏增大，皮质患者强化，肾静脉内发现血栓可确诊）集合系统损伤，含对比剂尿液外溢（延迟扫描时间足够长）,2013-10-22,2013-10-22,Rena
33、l contusion.Computed tomography image demonstrates a focal area of low attenuation in the posterior aspect of the left kidney representing renal contusion(arrows),左肾挫伤,右肾裂伤，左肾挫伤,Renal laceration.Computed tomography image at the level of the renal veins demonstrates an irregular,linear,low-attenuation renal laceration(arrow)extending from the right renal hilum to the renal capsule.A left renal cont
