中华疝和腹壁外科杂志（电子版）2018年2月第12卷第1期Chin J Hernia Abdominal W all Surg(Electronic Edition), February 2018,V ol.12,No.1·51·
·论著·肠粘连束带腹内疝的CT诊断
阮志兵楚兰焦俊闵定玉瞿金环
【摘要】目的探讨肠粘连束带腹内疝的CT表现特点，提高术前早期诊断水平。方法回顾
性分析2001年1月至2017年3月，贵州医科大学附属医院经手术、病理证实为肠粘连束带腹内疝21例
患者的临床与CT检查资料，同时有3例行多期增强CT，15例行腹部立位平片检查。在飞利浦影像工
作站2位腹部放射高级职称医师双盲法评价图像。结果术前21例患者均有程度不等的腹胀腹痛等
肠梗阻症状，术前CT诊断小肠梗阻21例，提示肠粘连束带腹内疝3例，肠管绞窄5例，术前诊断符合
率14.29%，漏诊率为85.71%。所有患者均手术证实小肠梗阻，肠管绞窄9例，11例合并肠扭转，1例
合并腹茧症。主要影像表现包括：局部明显粘连伴束带形成21例（100%），局限性肠梗阻21例（100%），
肠管异位21例（100%），无疝囊（100%），占位征象/周围脏器移位21例（100%），鸟嘴征13例（61.90%），
缆绳征/漩涡征17例（80.95%），肠壁增厚伴肠周明显渗出15例（71.43%）。肠粘连束带腹内疝的CT
表现特征与手术结果存在相关性。结论肠粘连束带腹内疝CT表现具有一定特点，提高认识并熟知
其影像征象对早期诊断至关重要。
【关键词】肠粘连束带腹内疝；肠梗阻；体层摄影术，X线计算机；诊断
CT Diagnosis of Internal Adhesion Band Abdominal Hernia Ruan Zhibing, Chu Lan, Jiao Jun, Min
Dingyu, Qu Jinhuan. Department of Imaging, Guizhou Medcial University, Guiyang 550004, China
Corresponding Author: Jiao Jun, Email: https://www.doczj.com/doc/ef18048596.html,
【Abstract】Objective To investigate the features of imaging findings of internal adhesion band
abdominal hernia (ABAH), in order to improve the understanding and the early diagnosis efficacy of
ABAH before operation. Methods Retrospective analysis of clinical data and imaging findings were
performed among 21 patients (10 males and 11 females with the age ranging from 4 to 81 years old) with
ABAH proved by surgery from January 2001 to March 2017. All cases underwent multidetector computed
tomography (MDCT) scan, including 3 casesofmultiphase dynamic contrast-enhanced CT scan and 15
casesabdominal plain film. The images were reviewed independently by two expert radiologistswith
double-blind method.Results Intestinal obstructionoccurred in all the 21 patients with CT examination,
included strangulated intestine obstruction (n=5) and ABAH (n=3) before operation, 3 cases (14.29%) were
correctly diagnosed and 18 cases (85.71%) were misdiagnosed before operation. All of 21 cases were
confirmed ABAH and intestinal obstruction, included intestinal twist (n=11), intestinal strangulation
obstruction (n=9), and abdominal cocoon (n=1) after operation. CT findings of ABAH were significantly
characterized by obvious local adhesion band formation and were correlated with results of operation, other
imaging signs of ABAH included bowel obstruction (100%), ectopic bowel (100%), sign of space
occupying (100%), stretched, engorged, and twisted mesenteric vessels (n=17, 80.95%), beak sign of bowel
loops wereclustered and twisted (n=13,61.90%), and bowel wall thickening with obvious exudation around
in 15 cases (71.43%). Butsign of space occupying was relatively less degree than other abdominal hernia.
Conclusion Early diagnosis of ABAH is difficult before operation in clinic, but it isincreasingly
significant. CT examination with certain characteristic findings is of significant importancefor early diagnosis,
Misdiagnosis of ABAH mainly due to insufficient disease awareness and lack of relevant knowledge.
DOI:10.3877/cma.j.issn.1674-392X.2018.01.012
基金项目：贵阳市科技类计划子课题资助项目（GY2015-32）
作者单位：550004 贵阳，贵州医科大学附属医院影像科
通信作者：焦俊，Email: https://www.doczj.com/doc/ef18048596.html,
腹内疝是指腹腔内脏器或组织通过腹膜或肠系膜正常或异常的孔道、裂隙离开原有位置而进入腹腔内的某一解剖间隙，其发病率低(约0.2%~0.9%)，为小肠梗阻一少见病因（约5.8%）。然而，腹内疝易并发肠绞窄或缺血，致死率高（>75%），因此早期诊断和手术治疗至关重要，但由于缺乏特异性症状及体征，且多与性别和年龄无关，其术前诊断困难。近年来，医学影像检查技术的发展，则为腹内疝的检出、诊断和鉴别诊断提供了新的依据。 一、腹内疝的分型 （一）根据发生位置 Meyers提出的腹内疝传统分型已被广泛接受，包括十二指肠旁疝（53%）、盲肠周围疝（13%）、Winslow孔疝（8%）、经肠系膜疝（8%）、乙状结肠周围疝（6%）、吻合口后方疝（5%）[1]。此外尚有较少见的经网膜疝及发生在盆腔的膀胱上疝、经子宫阔韧带疝、Douglas疝等。 二）根据发生原因 腹内疝又可分为先天性和后天性两类。 1．先天性：是指因胚胎发育过程中肠管旋转或腹膜附着异常等先天性因素所致腹膜隐窝大而深，腹膜、网膜或肠系膜存在缺损，或Winslow孔过大，肠管可经此疝入。包括十二指肠旁疝、Winslow 孔疝、部分乙状结肠周围疝、部分盲肠周围疝、部分经肠系膜疝等。 2．后天性：是指后天因素如手术、外伤、炎症等所致腹膜或肠系膜的异常孔隙，肠管可经此疝入。包括部分经肠系膜疝、吻合口后疝、部分乙状结肠周围疝和部分盲肠周围疝等。
（三）根据疝的结构 可按有无疝囊分为真疝和假疝。脏器疝至另一个腹膜囊隐窝，具有疝囊而称真疝。若网膜或肠系膜存在裂孔，或因手术、创伤等构成一异常孔隙，肠管因此疝入，不具有疝囊而称假疝。先天性腹内假疝指肠管经大网膜、肠系膜裂孔疝入的内疝，而后天性腹内疝均为假疝。 二、不同类型腹内疝的临床和影像学表现 （一）十二指肠旁疝 据文献报道，此型为最常见类型，约占全部内疝的53%。与其他类型内疝不同，十二指肠旁疝的发生有性别倾向，男性发病率约为女性的3倍。包括左侧及右侧两种亚型，其中前者常见（约占3/4），二者临床表现相似，均为先天性疝，有疝囊，但胚胎学发育病理基础却不同。 1．左侧十二指肠旁疝：为小肠肠袢经Landzert’s陷窝向后下疝至十二指肠升段的左侧，可达左侧结肠系膜深面。Landzert’s陷窝位于十二指肠升段的左后方，前界为覆盖走行于陷窝左侧的肠系膜下静脉及左结肠动脉升支的腹膜皱襞，认为其形成与发育中降结肠系膜的先天性缺损有关，可见于约2%的人群。 临床上，病人常表现为慢性食后腹痛、恶心，症状可追溯至儿时。十二指肠旁疝易自行缓解，症状间断发作。 在消化道造影检查中，表现为左上腹十二指肠升段左侧的小肠肠袢聚集成团，可致远端横结肠、十二指肠空肠曲向下移位，压迫胃后壁使其呈锯齿状。CT可更清楚显示疝入肠袢的位置，可位于Treitz韧带左侧、胃与胰腺之间，或胰腺后方，或横结肠及左侧肾上腺之间，肠系膜血管的改变包括供应疝入肠段的肠系膜血管向疝口处拉伸、纠集、扩张充血，肠系膜下静脉及左结肠动脉升支位于疝囊颈前界并可向左侧移位。常并发肠梗阻，表现为肠管扩张，管腔内气液平面。应注意有无并发肠扭转及急性肠缺血，C形或U形肠管、鸟嘴征及漩涡征提示肠扭转，肠壁增厚、增强后无强化、肠系膜积液、肠壁积气提示肠缺血。罕见并发肠套叠，可见由软组织密度肠壁及低密度肠系膜脂肪、更低密度肠管内气体交替排列形成的靶环状肿块。由于此型疝具有较特异的发生部位及边界清晰的疝囊，较易诊断。 左侧十二指肠旁疝示意图
中华疝和腹壁外科杂志（电子版）2018年2月第12卷第1期Chin J Hernia Abdominal W all Surg(Electronic Edition), February 2018,V ol.12,No.1·51· ·论著·肠粘连束带腹内疝的CT诊断 阮志兵楚兰焦俊闵定玉瞿金环 【摘要】目的探讨肠粘连束带腹内疝的CT表现特点，提高术前早期诊断水平。方法回顾 性分析2001年1月至2017年3月，贵州医科大学附属医院经手术、病理证实为肠粘连束带腹内疝21例 患者的临床与CT检查资料，同时有3例行多期增强CT，15例行腹部立位平片检查。在飞利浦影像工 作站2位腹部放射高级职称医师双盲法评价图像。结果术前21例患者均有程度不等的腹胀腹痛等 肠梗阻症状，术前CT诊断小肠梗阻21例，提示肠粘连束带腹内疝3例，肠管绞窄5例，术前诊断符合 率14.29%，漏诊率为85.71%。所有患者均手术证实小肠梗阻，肠管绞窄9例，11例合并肠扭转，1例 合并腹茧症。主要影像表现包括：局部明显粘连伴束带形成21例（100%），局限性肠梗阻21例（100%）， 肠管异位21例（100%），无疝囊（100%），占位征象/周围脏器移位21例（100%），鸟嘴征13例（61.90%）， 缆绳征/漩涡征17例（80.95%），肠壁增厚伴肠周明显渗出15例（71.43%）。肠粘连束带腹内疝的CT 表现特征与手术结果存在相关性。结论肠粘连束带腹内疝CT表现具有一定特点，提高认识并熟知 其影像征象对早期诊断至关重要。 【关键词】肠粘连束带腹内疝；肠梗阻；体层摄影术，X线计算机；诊断 CT Diagnosis of Internal Adhesion Band Abdominal Hernia Ruan Zhibing, Chu Lan, Jiao Jun, Min Dingyu, Qu Jinhuan. Department of Imaging, Guizhou Medcial University, Guiyang 550004, China Corresponding Author: Jiao Jun, Email: https://www.doczj.com/doc/ef18048596.html, 【Abstract】Objective To investigate the features of imaging findings of internal adhesion band abdominal hernia (ABAH), in order to improve the understanding and the early diagnosis efficacy of ABAH before operation. Methods Retrospective analysis of clinical data and imaging findings were performed among 21 patients (10 males and 11 females with the age ranging from 4 to 81 years old) with ABAH proved by surgery from January 2001 to March 2017. All cases underwent multidetector computed tomography (MDCT) scan, including 3 casesofmultiphase dynamic contrast-enhanced CT scan and 15 casesabdominal plain film. The images were reviewed independently by two expert radiologistswith double-blind method.Results Intestinal obstructionoccurred in all the 21 patients with CT examination, included strangulated intestine obstruction (n=5) and ABAH (n=3) before operation, 3 cases (14.29%) were correctly diagnosed and 18 cases (85.71%) were misdiagnosed before operation. All of 21 cases were confirmed ABAH and intestinal obstruction, included intestinal twist (n=11), intestinal strangulation obstruction (n=9), and abdominal cocoon (n=1) after operation. CT findings of ABAH were significantly characterized by obvious local adhesion band formation and were correlated with results of operation, other imaging signs of ABAH included bowel obstruction (100%), ectopic bowel (100%), sign of space occupying (100%), stretched, engorged, and twisted mesenteric vessels (n=17, 80.95%), beak sign of bowel loops wereclustered and twisted (n=13,61.90%), and bowel wall thickening with obvious exudation around in 15 cases (71.43%). Butsign of space occupying was relatively less degree than other abdominal hernia. Conclusion Early diagnosis of ABAH is difficult before operation in clinic, but it isincreasingly significant. CT examination with certain characteristic findings is of significant importancefor early diagnosis, Misdiagnosis of ABAH mainly due to insufficient disease awareness and lack of relevant knowledge. DOI:10.3877/cma.j.issn.1674-392X.2018.01.012 基金项目：贵阳市科技类计划子课题资助项目（GY2015-32） 作者单位：550004 贵阳，贵州医科大学附属医院影像科 通信作者：焦俊，Email: https://www.doczj.com/doc/ef18048596.html,