胃肠道气钡双重造影与CT检查

胃肠道气钡双重造影与CT检查 胃肠道气钡双对比造影与CT检查 在胃癌诊断中的价值 海洋石油总医院 放射科 边晓 [摘要] 目的 评价胃肠道气钡双对比造影(DC)与CT在胃癌诊断中的价值。方法 20例胃癌患者进行胃肠道气钡双对比造影和CT检查, 并经胃镜和手术病理确诊。结果 肿瘤对胃壁浸润范围及早期胃癌的诊断、肿瘤的定性、黏膜显示、表面轮廓等, DC检查比CT有明显的优势。而对于有无远处转移及术前分期, CT具有最大的优势。结论 DC对胃癌的定性、定位诊断具有重要的作用, 但有一定的漏诊率。CT对远处转移及邻近器官浸润占优势, 综合CT、DC检查技术可极大地提高胃癌的诊断率, 价值较高。 [关键词] 胃癌;胃肠道气钡双对比造影;体层摄影术,X线计算机 胃癌是指发生在胃上皮组织的恶性肿瘤,我国胃癌死亡率占所有恶性肿瘤病死率的23.02% [1]，具有发病率高、病死率高、预后较差等特点，故早发现、早诊断、早治疗是降低病死率的关键。 目前胃肠造影检查是发现、诊断胃癌的基本手段, 对于大多数向腔内生长的肿块均可做出正确诊断。但对部分向腔外生长的肿块, 以及对附近淋巴结、脏器转移病变的诊断, 这种方法有一定局限性。近年来由于CT 技术的广泛应用, CT application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 检查对胃疾病的诊断应用日益增多, 该检查已成为继胃肠道影检查后, 胃肿瘤诊断手段的又一重要补充[2]。本文的宗旨在于综合应用影像学DC、CT检查为胃癌诊断提供客观有力的条件, 收集近两年来本院就诊且经手术病理证实的胃癌病例20例,就CT、DC检查在胃癌诊断中的应用价值进行初步评价。 1 资料与方法 1.1 一般资料 收集2008年1月以来因胃癌来院就诊病例20 例, 所有病例均行胃肠道气钡双对比造影, 2 天后自愿行CT 检查, 确定瘤体及瘤周情况, 本组资料4 例为早期胃癌,16 例为中晚期胃癌。 1.2 设备 西门子R200数字胃肠X线诊断机, GE Prospeed F?螺旋CT扫描机。 1.3 检查方法 1.3.1 胃肠道造影检查 采用气钡双对比造影法。检查过程:患者空腹，先做胸腹部常规透视, 接着用5 ml 温开水冲服产气剂3g使胃充气,随即在透视下分次口服医用硫酸钡200%(w/v)混悬液,投照常规位,转动合适体位并配合钡剂灌洗技术, 以便显示黏膜相、双对比相、充盈相。发现可疑病灶时, 摄取多体位、多时相、病变显示最清楚的影像照片。 1.3.2 CT 检查 进行上腹部CT平扫加增强扫描。检查过程: 患者禁水禁食6h以上, 检查前口服温开水1000ml使胃充分application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 扩张，常规取仰卧位，先行CT平扫, 扫描参数120kv ,160mAs，准直10mm，螺距1;然后行增强扫描，对比剂选用欧乃派克(300mgI/ml) , 注射速率2.5,3.0mml/s,用量按1.5ml/kg体重计算。肘静脉注射开始后分别于25s(动脉期) 、65-70s(实质期或称门静脉期) 、2-3min(延时期)进行三期扫描，采集全胃图像。扫描参数为120kv, 140mAs，准直5-10mm，螺距1。 1.4 DC 与CT 检查腔壁线是否连续、柔软度, 胃黏膜有无中断,龛影、钡斑滞留等。CT 包括肿瘤侵及胃壁的厚度、强化的特点、淋巴转移、远处转移等。 2 结果 2.1 胃癌CT 表现 2.1.1 胃壁增厚 大多数胃壁不均匀增厚约112,114 cm, 且增厚的胃壁密度不均匀, 其内可见片状低密度影, 境界不清, 当侵及浆膜层时轮廓外缘不规整( 图1 ) 。增强扫描胃壁动脉期轻中度强化18例, 为高/中分化胃癌。不均匀强化2例, 低分化腺癌。 2.1.2 软组织块影 本组13例发现软组织块影,向腔内或腔外生长, 表面凹凸不平, 增厚软组织呈均匀强化(图2)。 2.1.3 肿瘤向周围组织直接浸润 当肿瘤破坏浆膜层及邻近组织器官时, 胃腔轮廓不, 周围脂肪层显示不清或消失, 可见条状低密度区(图3) ,手术证实当胃壁增厚> 2cm, application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 且与周围组织分界不清时,表明癌肿突破浆膜层及周围组织。 2.1.4淋巴转移 淋巴结扩散是胃癌的主要转移方式, 淋巴结增大说法不一致(8,15mm) , 根据本组经验认为, 当淋巴结>10mm, 应考虑淋巴结转移, 淋巴结呈虫蚀状、囊状、周边密度高中心密度低及花瓣状(图4)、团块状增大而压迫周围血管、神经、器官引起相应的症状。 2.1.5 胃癌的远处转移 癌肿易转移至肝脏、胰、双肾、横结肠和十二指肠, 当腹腔种植转移至大网膜、肠系膜时，CT 均能显示, 腹水和淋巴结肿大是胃癌的主要征象。 2.2 胃癌的气钡双对比造影(DC) 所见各型胃癌表现不一,其基本表现: (1)腔壁线僵直,腔壁线毛糙,双边征等。(2)充盈缺损。(3)龛影。(4)胃腔狭窄或梗阻[3]。早期胃癌: 20 例中有4 例, 占20% , 双对比造影显示胃小区、胃小沟破坏消失, 胃壁僵硬, 双边征,小龛影区有钡斑积聚, 周围黏膜纹消失, 中断或毛糙不平的突起(图5) 。中晚期胃癌: 20 例中有16 例,占80% , 胃癌侵及肌层甚至浆膜层, 故病区的胃壁蠕动消失, 胃壁僵硬(图6) 。肿块显示突出腔内的充盈缺application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 损, 轮廓不规则或分叶状, 周围黏膜消失,肿块侵及全胃或大部分溃疡性胃癌8例,表现为龛影口部指压、裂隙征,有时周围出现不规则环堤征,为其基本特征。 3 讨论及结果 3.1 胃癌影像学诊断的评价 3.1.1 胃肠道气钡双对比造影:可显示胃黏膜、胃小区的微细结构, 可发现较早期的黏膜破坏、隆起、凹陷等细微病变, 观察有无充盈缺损或龛影, 以及龛影周围黏膜的细微改变, 并可动态观察胃壁蠕动情况及柔软度改变, 对早期胃癌有特殊的诊断价值[4] 。另外, 由于可对病灶进行多方位、多时像观察, 可明确排除因痉挛引起的假阳性改变。缺点是不能准确判断病变胃壁受侵程度, 无法观察腔外病变及邻近组织器官有侵及远隔器官及淋巴结转移情况, 因此无法对癌肿做出准确分期。 3.1.2 CT 检查: 具有较高的分辨率, 与DC 相比, 对胃癌的术前分期和估价,胃癌随访术后治疗及腔内、壁内、腔外鉴别等, CT 显著优于DC检查[5]。特别是较先进的多排螺旋CT, 由于扫描时间缩短, 空间分辨率的提高, 能明确显示胃癌application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 的浸润深度和范围, 对向腔外突出的肿块、邻近组织器官的受累以及有无肝、肺、脑等远隔器官及淋巴结转移情况的观察, 是胃肠道气钡双对比造影所不能比拟的。因此, CT 检查可为胃癌的临床分期提供更科学的依据, 对临床医生确定治疗有重要参考价值[6]。另外, 对胃外肿瘤与胃源性肿瘤的鉴别诊断, 也能提供更直接、更准确的影像学资料[6]。但CT 检查因受胃蠕动、胃内气体的影响, 常常产生伪影或导致影像模糊, 检查前饮水以充盈胃腔可在很大程度上改善上述情况。另外, 不能动态观察胃壁柔软度也为其不足之处。由于空间分辨率的不足,CT 检查对于细微病变的观察还有一定局限, 早期胃癌因其局限于黏膜层和黏膜下层, 病理改变轻微, 而且与胃壁密度差别不大, 因此容易漏诊[7] 。所以CT对早期胃癌的诊断受到一定的限制。 4.小结 综上所述, 胃肠道气钡双对比造影因其相对简便易行且较为廉价, 可作为拟诊胃癌患者的基本筛查手段, CT 检查则可提供更加详细完整的资料, 对肿瘤作出较准确的分期, 使患者得到最为合理的治疗。两者在诊断胃癌中各有利弊, 必须综合分析其影像学特征, 在治疗方案的拟定, 手术清除范围选择, 患者预后优劣等方面,互相取长补短, 互为补充，有利于提高胃癌的诊断率。 [ 参考文献] application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check 1.尚克中, 陈九如.胃肠道造影原理与诊断.上海:上海科技文献出版社,2005,6. 2.周仁娣, 唐秀贞, 沈秀明.探讨X线钡餐检查和CT 检查在胃癌诊断中的价值.中华现代影像学杂志,2009,6(1):5 3.杨贤增, 魏磊.应用数字化设备普及双对比造影提高胃肠道病变的检诊.上海影像学杂志,2007,2(4):247 4.谭治林. X线双对比造影诊断早期胃癌89 例分析. 中华医学实践杂志, 2004, 3(12) : 1096 . 5.张宗鸣, 魏罡.CT与胃肠道气钡双重造影在胃癌诊断中的价值比较.2008,9(10):422 6.高剑波, 杨学华. 进展期与早期胃癌螺旋CT 三期增强的诊断价值. 中华放射学杂志, 2006.4: 254. 7.艾金中, 艾柯. 胃癌的螺旋CT诊断价值.《中外健康文摘? 临床医师》, 2007 , 4(4) : 1112112. application; infection and antibacterial drug of clinical application; transfusion refers to levy; nutrition support of adapted card and clinical application; common life support technology (as cycle breathing support, and nutrition support,) and emergency technology of application; common guardianship instrument using. Look: shock, cardiac respiratory arrest and acute organ failure, systemic inflammatory response syndrome and severe infection and multiple organ dysfunction syndrome (MODS), severe disturbance of body fluid environment such as critical theory and progress of the illness. 2. basic requirements (1) species and cases of study requirements: severe pneumonia in disease-disease myocardial infarction ... 3. high requirements (1) learning disease species: disease species disease species image radiation: rheumatic heart congenital heart intestinal Crohn's (Crohn) disease intestinal tuberculosis bile duct cancer chronic pancreatic inflammatory urinary system stone urinary system tumor adrenal disease thyroid disease cranial within infection nervous system tumor nuclear medical: Digest road bleeding explicit like brain blood flow perfusion explicit like testicular blood pool explicit like salivary glands explicit like (2) clinical knowledge, and skills requirements: understand various image check