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2022-10-301n创伤是40岁以下死亡的主要原因n创伤死亡中腹部外伤占 10%，致死原因主要为肝损伤n分类：q钝器伤（闭合性损伤,坠落、碰撞、冲击、挤压等钝性暴力引起）q穿透伤（开放性损伤,刀刺、枪弹、弹片所引起）2022-10-302nCT 初诊首选检查方案敏感性、特异性高一站式检查2022-10-303技术n不需口服胃肠道对比剂（不需要、不必要）n体外物品，离开扫描野（监护及生命支持设备等）n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）n扫描大范围（无遗漏）、大扫描野（减少伪影）n如无禁忌
2、，建议增强（发现实质脏器破裂、尿漏以及活动出血等）n常规时相增强扫描（一般损伤门脉期、排泄期即可）n合理应用窗技术2022-10-304影像诊断需提供信息n有无明确腹外伤改变n若有，损伤脏器，出血、积液、积气量及部位n提示损伤脏器n有无其他合并伤2022-10-305表现n腹腔积液、游离气体n增强对比剂外溢提示活动性出血n裂伤：线形或斜行区n血肿：椭圆形或圆形区n挫伤：模糊的低密度影n器官全部或部分血运中断n包膜下血肿2022-10-306示意图2022-10-307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2022-10-308点评n腹外伤常见并发症n发现积血，
3、进一步查找损伤脏器n出血首先积聚于损伤部位，继而流向低处n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）n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2022-10-309脾脏损伤n闭合性腹外伤中，最易损伤的器官(质地脆弱、血供丰富)nCT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2022-10-3010脾损伤分类n撕裂伤q脾实质内不规则线状低密度影n脾脏碎裂q严重创伤，脾脏破裂成多分小碎片n脾内血肿q脾实质内大范围无强
4、化区，密度均匀/不均匀n包膜下血肿q包绕脾实质的半月形或卵圆形液体密度影n梗死q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2022-10-3011损伤分级2022-10-30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
5、 of Trauma)损伤分级标准122022-10-301.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132022-10-30线形低密度裂伤圆形和椭圆形低密度区脾血肿腹腔积液142022-10-30152022-10-30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162022-10-30Active arterial hemorrhage.Contrast-enhanced multidetector computed tomo
6、graphy image demonstrates a linear focus of extravasated contrast-enhanced blood(arrow)originating from the spleen.This focus of active hemorrhage is surrounded by a large perisplenic hematoma(h)that is lower in attenuation than the extravasated contrast-enhanced blood.Perihepatic blood(arrowhead)is
7、 also evident.活动性出血Splenic pseudoaneurysm(thick arrow)in a 22-year-old man involved in a motor vehicle 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172022-10-30Subcapsular splenic hematoma.Con
8、trast-enhanced computed tomography image demonstrates a lenticular-shaped subcapsular hematoma(H)that 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182022-10-30Partial transection of the splenic
9、hilum with active bleeding and massive hemoperitoneum.A,B:Computed tomography(CT)scans through the 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 throug
10、h the lower margin of the spleen(S)shows some preservation of splenic enhancement consistent with partial hilar transection.A small laceration is noted in the left kidney.(Case courtesy of Christine O Menias,M.D.,St.Louis,Missouri.)脾门横断脾门横断192022-10-30Congenital splenic clefts.A:Computed tomography
11、image demonstrates a sharply marginated cleft in the posterior tip of the spleen.The smooth,rounded contour 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
12、 with multiple splenic clefts along the lateral margin of the spleen.先天性脾裂，需与脾裂伤鉴别202022-10-30男，37岁，摔伤后腹痛病例212022-10-30222022-10-30232022-10-30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24表现形式n包膜下血肿n实质内血肿n撕裂伤n肝破裂2022-10-30最常见，分为浅表、肝门周围、
13、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252022-10-30级：血肿：包膜下
14、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26CT分级2022-10-30272022-10-30Hepatic laceration.Note irregular,low-attenuation l
15、aceration in the posterior right lobe of the liver.High-attenuation foci of clotted blood(arrows)are seen within the area of lacerationHepatic laceration.A,B:Computed tomography images demonstrate an irregular,low-attenuation laceration(arrow)in the right hepatic lobe.Note heterogeneous early arteri
16、al phase contrast enhancement of the spleen(S).肝裂伤肝裂伤282022-10-30Bear claw type laceration of the right 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
17、，形似熊爪292022-10-30Hepatic laceration and hematoma.A,B:Computed tomography images demonstrate extensive,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(ar
18、rowhead).Note associated perihepatic and perisplenic hemorrhage(h).ST,stomachIntrahepatic hematoma with sterile necrosis.Contrast-enhanced computed tomography scan 3 days following blunt abdominal trauma demonstrates intraparenchymal hematoma containing several small bubbles of gas(arrows),presumabl
19、y secondary to necrosis within the area of injury.The patient had no evidence of infection and recovered 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302022-10-30Periportal low attenuation.Computed tomography image demonstrates periportal lo
20、w attenuation(arrows)surrounding the portal triads.A small amount of fluid is seen adjacent to the 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31轨道征病理
21、基础n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，n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。尚见于活动性肝炎、2022-10-30322022-10-30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332022-10-30u肝右叶门静脉中断(4 级)u增强显示对比剂溢出肝脏外缘u腹腔积液342022-10-30多发撕裂伤左侧裂伤表现为星状右侧裂伤表现为树枝状35
22、2022-10-30男，26岁，腹部外伤后持续腹痛病例136病例2男，45岁，胸腹部外伤，右腹部疼痛为著手术所见2022-10-3037病例3男，46岁，高处坠落伤及胸腹2022-10-3038病例4男，40岁，腹部外伤2022-10-30392022-10-30402022-10-30412022-10-3042损伤转归n包膜下血肿通常6-8周内吸收n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n肝脏挫裂伤可在2-3周内明显好转n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、
23、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2022-10-30432022-10-30Healing hepatic lacerations on serial computed tomography(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
24、the hepatic lacerations,probably a result of osmotic absorption of fluid.C:On a scan 3 weeks later,the 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 resolu
25、tion of the liver lacerations4天天3周周3月月肝裂伤随访442022-10-30肝挫裂伤男，48岁，外伤后4小时即行CT检查452天后复查肝脏挫裂伤更加明显，肝脾周积液，双侧胸腔积液、肺挫裂伤，注意右侧肾上腺血肿2022-10-304611天复查，肝内出血较前吸收2022-10-30472022-10-3050天复查，出血明显吸收，局部呈类圆形水样低密度灶48胰腺损伤2022-10-30n少见，仅占腹部损伤的3-12%n单独损伤少见n通常是复合性损伤的一部分n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n症状隐匿，难以诊断49分类（病理）n胰腺挫
26、伤q轻度挫伤q严重挫伤n胰腺断裂伤q部分断裂伤q完全断裂伤2022-10-3050n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n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n部分断裂伤：胰腺周径1/3、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n完全断裂伤：胰腺周径2/3的裂伤2022-10-30512022-10-30AAST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
27、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/MRCP显示胰管损伤，后者无创、快速、易操作52另一分类方法2022-10-30532022-10-30Pseudofracture of the pancreas due to physiologic thinning of the pancreatic neck.A:Computed tomography(CT)scan at the level of the
28、 superior mesenteric vein splenic vein confluence demonstrates apparent fracture of the pancreatic neck(open arrow).B:CT 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 tom
29、ography images through the pancreas(P)demonstrate peripancreatic fluid(arrowheads)tracking into the left anterior pararenal 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
30、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542022-10-30Pancreatic laceration with disruption of 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)adjacen
31、t to the spleen(S).B:Endoscopic retrograde cholangiopancreatography(ERCP)demonstrates disruption of the main pancreatic 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552022-10-30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
32、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56病例男，19岁2022-10-30572022-10-30582022-10-30592022-10-30602022-10-3061术后诊断：胰腺断裂伤2022-10-3062肾脏损伤n单独损伤少见，通常是复合性损伤的一部分n多为钝伤n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）n儿童较成人更
33、易发生肾脏损伤（外缘分叶、肾脏相对身体体积大）nCT首选检查，明确肾脏损伤的类型和范围2022-10-3063分类2022-10-30Michael 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64CT改变n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n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n肾碎裂，多发线状无强化区，
34、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n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）n集合系统损伤，含对比剂尿液外溢（延迟扫描时间足够长）2022-10-30652022-10-30Renal 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
35、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 contusion(arrowheads)is also present.The hemoperitoneum was related to concomitant
36、 splenic injury662022-10-30侧面刀刺穿透伤患者 小的肾包膜血肿及肾周积血左肾包膜下血肿非膨胀672022-10-30Renal fracture.A:Contrast-enhanced computed tomography scan demonstrates fractured left lower renal pole(K)with large perirenal hematoma(H).B:Delayed scan shows extravasation of opacified urine into the perirenal space(arrow).左肾破
37、裂对比剂外溢Renal laceration with perirenal hematoma.Contrast-enhanced computed tomography scan demonstrates a right renal laceration(thick arrow)with associated perirenal hematoma confined by the posterior renal(Gerotas)fascia(thin arrow).The patient also has intraperitoneal blood(H)from a ruptured splee
38、n右肾裂伤682022-10-30Shattered kidney with large perirenal hematoma.Active bleeding is noted in the left perirenal space anteriorly(straight arrows).Small liver laceration(curved arrow)and blood in the hepatorenal fossa are also evident左肾碎裂Renal pedicle injury with devascularization of the left kidney.C
39、omputed tomography scan at the level of the left renal hilum demonstrates absent perfusion of the left kidney(K).Blood tracks along an unenhanced left renal artery(thick arrow).A diminutive left renal vein(thin arrow)and a small amount of hemorrhage(H)in the left anterior pararenal space are also no
40、ted.(Case courtesy of Kevin Smith,M.D.,Birmingham,Alabama.)肾蒂损伤，左肾无血供69病例1男，46岁，外伤及右腰背部2022-10-30702022-10-3071病例2男，28岁，胸腹外伤，脾破裂，肾挫裂伤，肾周积血2022-10-3072病例3男，41岁，肾周出血，腹膜后血肿2022-10-3073病例4女，45岁，摔伤左腰部4小时就诊2022-10-30742022-10-30752022-10-30762022-10-30肾穿后包膜下出血病例5男，23岁，肾脏活检后腰痛1天77病例6男，43岁，头胸腹部外伤4小时就诊胆管结石20
41、12-06-172022-10-30右侧肾上腺血肿782013-06-19复查，肾上腺血肿密度增高，肝脾周见有积血2022-10-30792012-06-28日复查，肾上腺出血较前有所吸收2022-10-30802012-08-03复查，血肿基本吸收2022-10-3081输尿管膀胱损伤n输尿管损伤多为医源性损伤，钝伤、穿通伤少见n输尿管腹膜后器官，破裂尿液聚集于输尿管周围间隙，主要在肾周间隙内侧n膀胱损伤见于医源性损伤、钝伤、穿通伤，多有肉眼血尿n膀胱为腹膜间器官，依破裂口位置与腹膜反折关系，尿液可聚集于腹膜腔或腹膜后nCT为首选影像学检查方法2022-10-30822022-10-30Ex
42、traperitoneal bladder rupture.A:Transaxial image from a computed tomography cystogram demonstrates extravasation of iodinated contrast material(arrows)from the urinary bladder(B)into the extraperitoneal prevesical space.U,uterus.B:Coronal image demonstrates the site of bladder rupture(arrow).Multipl
43、e pelvic fractures are present.C:Sagittal image clearly shows the size and site(thick arrow)of the contrast extravasation from the urinary bladder(B)into the prevesical space(thin arrow).F,Foley balloon.膀胱前下壁破裂，尿液聚集于腹膜外间隙膀胱胃横结肠十二指肠83膀胱穿孔女，34岁酒后(大量啤酒)外伤腹痛，无法排尿4小时来诊 尿检红细胞+；HCG阴性（排除宫外孕）2022-10-30腹膜腔积液8
44、4手术：膀胱顶后壁纵行5cm裂口，诊断膀胱破裂2022-10-3085点评n少见急腹症n影像表现典型n本例的难点在于显现破口 2022-10-3086肠及肠系膜损伤n仅见于3-5%的腹部钝伤n损伤机理为挤压伤、肠内压力突然增大，剪切伤n肠管损伤，肠壁粘膜挫伤、血肿、肠管断裂n损伤部位受创伤部位的影响，总体十二指肠多见，结肠较少nCT征象q腹腔游离气体，相对特异征象，仅见于50%病例q口服对比剂外溢，目前不建议口服对比剂扫描q腹腔内游离液体，常见，不特异q肠壁增厚或不连续，肠壁明显强化提示肠壁损伤q前哨血块（受累肠附近的高密度血块）q肠系膜脂肪的条带状浸润2022-10-30872022-10-
45、30Jejunal perforation.A:Computed tomography image demonstrates a markedly thickened loop of jejunum(j),with free fluid(arrowheads)tracking along the posterior aspect of the jejunum and into the mesentery.B,C:Images at a slightly higher level demonstrate additional perijejunal fluid(arrowhead)on soft
46、 tissue window settings,and several foci of extraluminal air(arrows)on lung window settingsJejunal perforation.Computed tomography images through the lower abdomen(A,B)demonstrate thick-walled jejunum(J),soft tissue infiltration of the adjacent mesenteric fat(curved arrows),and extraluminal mesenteric air(straight arrow).肠壁增厚周围积液游离气体空肠穿孔88肠管损伤2022-10-30回肠穿孔，肠壁气泡，相邻肠袢积液，肠壁增厚，系膜密度增高892022-10-30大网膜裂伤、血肿肠系膜分支撕裂902022-10-30十二指肠降段撕裂91病例2022-10-30922022-10-30932022-10-30942022-10-30腹腔游离气体盆腔积液局部肠壁增厚952022-10-3096
