肠套叠的影像学诊断

Kate Nelson, HMSIII Gillian Lieberman, MD Intussusception Intussusception in Children and Adultsin Children and Adults Kate Nelson, Harvard Medical School, Year IIIKate Nelson, Harvard Medical School, Year III Gillian Lieberman, MDGillian Lieberman, MD January 2006January 2006 22 Kate Nelson, HMSIII Gillian Lieberman, MD „„ May be precipitated by a lead pointMay be precipitated by a lead point „„ Common cause of acute abdomen in children 3 Common cause of acute abdomen in children 3 months to 3 years old (2months to 3 years old (2ndnd only to appendicitis).only to appendicitis). „„ Classic triad: abdominal pain, palpable mass and Classic triad: abdominal pain, palpable mass and currant jelly stoolcurrant jelly stool „„ A loop of bowel A loop of bowel infoldsinfolds into the lumen immediately into the lumen immediately distal to itdistal to it The Essentials of IntussusceptionThe Essentials of Intussusception IntussusceptumIntussusceptum IntussuscipiensIntussuscipiens 33 Kate Nelson, HMSIII Gillian Lieberman, MD „„ 18 month old girl with a one day history of 18 month old girl with a one day history of intermittent abdominal pain and bloody stools.intermittent abdominal pain and bloody stools. Pediatric Patient #1Pediatric Patient #1 44 Kate Nelson, HMSIII Gillian Lieberman, MD Plain FilmPlain Film Pediatric Patient #1Pediatric Patient #1 Paucity of airPaucity of air Dilated Dilated loopsloops Open Open epiphysisepiphysis Courtesy of Dr. Geary, BIDMC ? Absent Absent liver edgeliver edge 55 Kate Nelson, HMSIII Gillian Lieberman, MD Classic signs on plain filmClassic signs on plain film „„ Bowel obstructionBowel obstruction „„ No RLQ air or stool in colonNo RLQ air or stool in colon „„ Absent liver edge Absent liver edge „„ Target sign/soft tissue massTarget sign/soft tissue mass „„ Crescent signCrescent sign „„ “Lateralization” of ileum“Lateralization” of ileum http://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.htmlhttp://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html Target Target signsign Crescent Crescent signsign No stool No stool in colonin colonNo RLQ No RLQ airair ?? Air is trapped hereAir is trapped here 66 Kate Nelson, HMSIII Gillian Lieberman, MD UltrasoundUltrasound Pediatric Patient #1Pediatric Patient #1 Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC Longitudinal U/SLongitudinal U/S Transverse U/STransverse U/S HyperechoicHyperechoic mesenteric fatmesenteric fat Doughnut sign:Doughnut sign: Concentric ringsConcentric rings IntussusceptumIntussusceptum: : internal ringinternal ring IntussuscipiensIntussuscipiens: : external ringexternal ring PseudokidneyPseudokidney sign:sign: Sandwich like thin lines with varying Sandwich like thin lines with varying echogenecityechogenecity 77 Kate Nelson, HMSIII Gillian Lieberman, MD Pediatric Treatment by Reduction Pediatric Treatment by Reduction Pediatric Patient #1Pediatric Patient #1 „„ Only 3Only 3--10% have lead points allowing non10% have lead points allowing non-- surgical reductionsurgical reduction „„ Reduction successful in 80Reduction successful in 80--90% of cases90% of cases „„ Factors decreasing the likelihood of successFactors decreasing the likelihood of success „„ Symptoms >24hSymptoms >24h „„ Rectal bleedingRectal bleeding „„ SBOSBO „„ No blood flowNo blood flow 88 Kate Nelson, HMSIII Gillian Lieberman, MD Examination of bowel viabilityExamination of bowel viability Pediatric Patient #1Pediatric Patient #1 Doppler U/SDoppler U/S Courtesy of Dr. Geary, BIDMC Areas of flow Areas of flow suggest that suggest that bowel can be bowel can be reduced by reduced by air/barium air/barium enema without enema without increase risk of increase risk of rupturerupture 99 Kate Nelson, HMSIII Gillian Lieberman, MD Method of ReductionMethod of Reduction „„ Typically air enema with a Typically air enema with a maximum air pressure of maximum air pressure of 120mmHg120mmHg „„ Complication is perforationComplication is perforation „„ Contraindications: Contraindications: pneumoperitoneum, pneumoperitoneum, peritonitisperitonitis „„ Intussusceptions may recur, Intussusceptions may recur, necessitating repetition of necessitating repetition of reductionreduction http://www.hopkinshttp://www.hopkins-- gi.org/images/shared/disease/database/shared_6784_CoCgi.org/images/shared/disease/database/shared_6784_CoC--11.jpg11.jpg SetSet--up for barium enemaup for barium enema 1010 Kate Nelson, HMSIII Gillian Lieberman, MD Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC Fluoroscopic View 1Fluoroscopic View 1 Fluoroscopic View 2Fluoroscopic View 2 Air enema under fluoroscopyAir enema under fluoroscopy Pediatric Patient #1Pediatric Patient #1 Flow defect Flow defect Defect size Defect size decreasingdecreasing Dilated loopDilated loop Less dilatationLess dilatation 1111 Kate Nelson, HMSIII Gillian Lieberman, MD Air enema continuedAir enema continued Pediatric Patient #1Pediatric Patient #1 Fluoroscopic view 3Fluoroscopic view 3 Fluoroscopic view 4Fluoroscopic view 4 Resolved flow defectResolved flow defect Regular peristalsis has returnedRegular peristalsis has returned Courtesy of Dr. Geary, BIDMC Courtesy of Dr. Geary, BIDMC 1212 Kate Nelson, HMSIII Gillian Lieberman, MD Adult Patient #1Adult Patient #1 „„ 39 year old man with a four day history of 39 year old man with a four day history of abdominal pain and progressively abdominal pain and progressively decreasing stools decreasing stools „„ On exam, abdomen is distended and On exam, abdomen is distended and diffusely tenderdiffusely tender „„ WbcWbc 12,50012,500 1313 Kate Nelson, HMSIII Gillian Lieberman, MD Intussusception in AdultsIntussusception in Adults „„ Presents in ~1% of adult patients with Presents in ~1% of adult patients with bowel obstructionbowel obstruction „„ Not part of the differential diagnosis for Not part of the differential diagnosis for adults with abdominal pain; generally adults with abdominal pain; generally found on CT workupfound on CT workup „„ 8080--90% are secondary to underlying 90% are secondary to underlying pathologypathology 1414 Kate Nelson, HMSIII Gillian Lieberman, MD Diagnosis by CTDiagnosis by CT Adult Patient #1Adult Patient #1 CrossCross--section 1section 1 CrossCross--section 2section 2 PACS, BIDMCPACS, BIDMC PACS, BIDMCPACS, BIDMC „„ PathognomonicPathognomonic RUQ target mass (blue circle)RUQ target mass (blue circle) „„ Small bowel does not appear obstructedSmall bowel does not appear obstructed——loops not dilated (yellow arrows)loops not dilated (yellow arrows) „„ Question of Question of pneumotosispneumotosis vs. vs. intralumenalintralumenal air (green arrow)air (green arrow) 1515 Kate Nelson, HMSIII Gillian Lieberman, MD Plain film proxy Plain film proxy (for comparison with pediatric case)(for comparison with pediatric case) Adult Patient #1Adult Patient #1 CT Scout filmCT Scout film PACS, BIDMCPACS, BIDMC Paucity of Paucity of gas in RUQ gas in RUQ consistent consistent with the with the RUQ massRUQ mass Otherwise, Otherwise, gas is gas is throughout throughout suggesting suggesting he is not he is not currently currently obstructedobstructed 1616 Kate Nelson, HMSIII Gillian Lieberman, MD SagittalSagittal ReconstructionReconstruction Adult Patient #1Adult Patient #1 PACS, BIDMCPACS, BIDMC TargetTarget--like like massmass 1717 Kate Nelson, HMSIII Gillian Lieberman, MD Coronal ReconstructionCoronal Reconstruction Adult Patient #1Adult Patient #1 SausageSausage--shaped shaped massmass PACS, BIDMCPACS, BIDMC Target appearance Target appearance on both axial and on both axial and sagittalsagittal cuts cuts explained by explained by oblique orientationoblique orientation 1818 Kate Nelson, HMSIII Gillian Lieberman, MD Adult Treatment by SurgeryAdult Treatment by Surgery „„ MUST consider likely pathologic lead point in MUST consider likely pathologic lead point in patients >12 yearspatients >12 years „„ AppendicealAppendiceal massmass „„ Lymphoma / other malignancyLymphoma / other malignancy „„ Meckel’s Meckel’s diverticulmdiverticulm „„ Duplication cystsDuplication cysts „„ PolypsPolyps „„ HemmorhageHemmorhage (HSP)(HSP) „„ Because of the high likelihood of pathology, the Because of the high likelihood of pathology, the treatment of treatment of intussusceptionintussusception in adults is surgery.in adults is surgery. 1919 Kate Nelson, HMSIII Gillian Lieberman, MD Operative FindingsOperative Findings Adult Patient #1Adult Patient #1 „„ IleocolicIleocolic intussusception with obstruction, intussusception with obstruction, but no necrosisbut no necrosis „„ Mass consistent with Mass consistent with appendicealappendiceal mucocelemucocele „„ Decompression of intussusception Decompression of intussusception followed by right followed by right hemicolectomyhemicolectomy 2020 Kate Nelson, HMSIII Gillian Lieberman, MD SummarySummary „„ Intussusception in children is common and Intussusception in children is common and generally idiopathic. It is diagnosed by generally idiopathic. It is diagnosed by plain film and ultrasound, and it is reduced plain film and ultrasound, and it is reduced by air enema.by air enema. „„ Intussusception in adults usually has a Intussusception in adults usually has a causative pathologic lead point. It is rare, causative pathologic lead point. It is rare, diagnosed by CT, and treated by surgery.diagnosed by CT, and treated by surgery. 2121 Kate Nelson, HMSIII Gillian Lieberman, MD AcknowledgementsAcknowledgements „„ VaiboVaibo KhasgiwalaKhasgiwala, MD, MD „„ Mike Geary, MDMike Geary, MD „„ Gillian Lieberman, MDGillian Lieberman, MD „„ Pamela LepkowskiPamela Lepkowski „„ Larry Barbaras, webmasterLarry Barbaras, webmaster 2222 Kate Nelson, HMSIII Gillian Lieberman, MD ReferencesReferences „„ Byrne, AT, et al. The imaging of intussusception. Byrne, AT, et al. The imaging of intussusception. Clinical RadiologyClinical Radiology 2005; 2005; 60: 3960: 39--46. 46. „„ Gayer, G, et al. Adult intussusceptionGayer, G, et al. Adult intussusception——a CT diagnosis. a CT diagnosis. The British Journal The British Journal of Radiology of Radiology 2002; 75:1852002; 75:185--190.190. „„ DanemanDaneman, A, Alton, DJ. Intussusception: Issues and controversies relate, A, Alton, DJ. Intussusception: Issues and controversies related to d to diagnosis and reduction. diagnosis and reduction. The Radiologic Clinics of North America The Radiologic Clinics of North America 1996; 34 1996; 34 (4): 743(4): 743--56.56. „„ Wood, BP. Intussusception, Child. Wood, BP. Intussusception, Child. http://www.emedicine.com/radio/topic366.comhttp://www.emedicine.com/radio/topic366.com.. Accessed 1/17/06.Accessed 1/17/06. „„ Yamamoto, LG. Find the Intussusception Target and Crescent SignsYamamoto, LG. Find the Intussusception Target and Crescent Signs. . Radiology Cases in Pediatric Emergency MedicineRadiology Cases in Pediatric Emergency Medicine. . http://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.htmlhttp://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html. Accessed . Accessed 1/18/06.1/18/06. Slide Number 1 The Essentials of Intussusception Plain Film�Pediatric Patient #1 Classic signs on plain film Ultrasound�Pediatric Patient #1 Pediatric Treatment by Reduction �Pediatric Patient #1 Examination of bowel viability�Pediatric Patient #1 Method of Reduction Air enema under fluoroscopy�Pediatric Patient #1 Air enema continued�Pediatric Patient #1 Adult Patient #1 Intussusception in Adults Diagnosis by CT�Adult Patient #1 Plain film proxy (for comparison with pediatric case) �Adult Patient #1 Sagittal Reconstruction�Adult Patient #1 Coronal Reconstruction�Adult Patient #1 Adult Treatment by Surgery Operative Findings�Adult Patient #1 Summary Acknowledgements References