tuberculousperitonitis結(jié)核性腹膜炎課件

AbdominalTuberculosis

腹部結(jié)核病ZhouLiuCancerHospitalChineseAcademyofMedicalSciences,ShenzhencenterGeneralconsiderationCanaffectanyorganintheabdomenImportanceofclinicalcontextindiagnosisHigh-riskpopulation：immunocompromisedpatients,especiallyAIDS〔免疫抑制的病人〕Typicalsymptoms:suchasdiarrhea,feveretc〔腹瀉、發(fā)熱等〕Laboratoryfindings〔實(shí)驗(yàn)室檢查〕：serumandculture〔血清和培養(yǎng)〕Histologicanalysis〔組織學(xué)檢查〕RadiologicalfindingsmightmimicmanydifferentdiseaseInflammatorydisease：Crohn'sdiseaseNeoplasticdisease:Lymphomatosis,PeritonealcarcinomatosisClassificationGastrointestinaltuberculosis〔胃腸道結(jié)核〕Tuberculouslymphadenopathy〔結(jié)核性淋巴結(jié)炎〕Tuberculousperitonitis〔結(jié)核性腹膜炎〕Solidorganinvolvement〔實(shí)性器官累及〕HepaticandsplenicTBPancreaticTBDifferentpathwaysModesofinvolvementinabdominaltuberculosisByingestion（吞咽）Infectedfoodormilk-Primaryintestinaltuberculosis（原發(fā)性腸結(jié)核）Infectedsputum（痰）-Secondaryintestinaltuberculosis（繼發(fā)性腸結(jié)核）Hematogenousspreadfromdistanttubercularfocus（血性播散）Contagiousspreadfrominfectedadjacentfoci（鄰近累及）Throughlymphaticchannel（淋巴擴(kuò)散）PathophysiologyofGastrointestinalTB

〔胃腸道TB的病理生理學(xué)〕BacteriaMucosa粘膜Submucosa粘膜下層Epithelioidtubercles表皮樣結(jié)節(jié)Ulceration潰瘍Granulomaformation肉芽腫形成Caseousnecrosis干酪性壞死Cicatrization瘢痕形成Sloughing脫落Surroundingmucosathickening鄰近粘膜增厚Lymphnodes淋巴結(jié)Peritoneum腹膜Circulationliver肝pancreas胰spleen脾SpreadingComplicationsofintestinaltuberculosisBowelobstruction〔腸梗阻〕Perforation〔穿孔〕Abscessformation〔膿腫形成〕Fistula〔瘺道形成〕Intussusception〔腸套疊〕Bowelwallischemia〔腸壁缺血〕1ileocecaljunction(90%)23456Fixedandnarrowedileum〔回腸固定及變窄〕;

Conicalandshrunkencecum〔錐形和萎縮的盲腸〕mimicCrohn'sdiseaseUniformandconcentricthickeningofterminalileumwall〔回腸末端腸壁向心性均勻增厚〕ileocecaltuberculosis回盲部結(jié)核

Mildwallthickeningofthececum〔盲腸壁輕度增厚〕

Pericecallymphnodes〔盲腸周圍淋巴結(jié)〕ileocecaltuberculosis回盲部結(jié)核

Circumferentialthickeningofthececumandterminalileum〔盲腸和末端回腸壁環(huán)形增厚〕

Adjacentlymphnodes〔鄰近淋巴結(jié)〕ProgressingDifferentiatingimagingfeaturesTuberculosisCrohn'sdiseaseAsymmetric,irregularwallthickeningCircumferentialbowelwallthickeningFleischnersignonbariumstudiesCobblestoneappearanceonbariumNocreepingfatCreepingfat(abnormalquantityofmesentericfatPositivechestfilm(50%)NegativechestfilmOmentalandperitonealthickeningNormalomentumandperitoneumEnlargedlymphnodeswithlow-denstitycentersEnlargedsoft-tissuedensitylymphnodesColonictuberculosis

(A)Twostricturesindescendingandtransversecolon

(B)MarkedinfiltrationandasymmetricalthickeningoftheascendingcolonandmesentericenlargedlymphnodeTuberculosisoftheileum

Symmetricmuralthickningileum(arrows)andadjacentenlargedlymphnodeTuberculouslymphadenopathyMultipleenlargedlymphnodesHypodensecentersandperipheralenhancement低密度中心伴有周圍強(qiáng)化Conglomeratelymphnodes淋巴結(jié)融合Caseationandliquefactionsubstancesatthecenter〔中心干酪樣和液化壞死〕Peripheralinflammatorylymphatictissue〔周圍炎性組織〕Multipleenlargedlymphnodes

RimenhancementandNecrossinside〔環(huán)形強(qiáng)化和內(nèi)部壞死〕

Calcification〔鈣化〕

Largepsoasabscess〔腰大肌膿腫〕Tuberculousperitonitis結(jié)核性腹膜炎Wettype90%Fibrotic-fixedtype7%HighdensityLargevolumeofascitesProteinandcellularcontentSmallvolumeofascitesFixedbowelloopsOmentalmassesDrytype3%DenseperitonealadhesionsFibrousperitonealreactionCaseousnodulesThickening,enhancement,andnodularityofperitoneum腹膜增厚、強(qiáng)化、結(jié)節(jié)狀

ileocolicadenopathy回盲部淋巴結(jié)Mesenteryinvolvement:mostcommonOmentalinvolvement:nodular,smudgedPeritonealinvolvement:smooth,tinynodulesAscites:30-100%ofcases&multiplestandsoffibrinanddebris〔纖維素或碎片〕&septa〔分隔〕Wettype濕型

Ascites:septa〔分隔〕

Peritoneum:smooththickening&enhancement〔光滑增厚&強(qiáng)化〕Fibroustype纖維型

Omentum&peritoneum:thickening〔增厚〕

Bowelloops:conglomerate〔聚攏〕Drytype干型Sclerosingencapsulatingperitonitis(abdominalcocoon)“繭〞Clusteringofsmallbowelloopsinthecenterofabdomen腹部中央腸袢聚攏SignsassistinginguidingdiagnosisoftuberculousperitonitisPresenceofmesentericmacronodulesEnhancementandregularthickeningoftheparietalperitoneumSplenomegalyandcalcificationofthespleenInvolvementoftheileocecalwallRetroperitonealandperi-pancreaticlymphadenopathywithahypodensecenterandring-enhancementAscites

lymphnodes:mesenteric&retroperitoneal

Necrosisinsideandring-likeenhancement

Omentum:Thickening

Peritoneum:Enhancement&RegularthickeningHepatic,SplenicandpancreaticTB肝、脾、胰腺結(jié)核Usuallyinafinemiliarypattern〔粟粒樣〕,belowtheresolvingcapacityofCTMostcommonpresentation:non-specifichepatosplenomegaly〔肝脾腫大〕Occasionally,tinyscatteringlow-densityfoci〔微小低密度灶〕Rarely,macronodularform〔大結(jié)節(jié)〕：pseudotumorortuberculoma〔假瘤或結(jié)核球〕1-3cmorasingletumor-likemassMiliaryhepaticTB粟粒型Enlargedliver肝大Heterogeneousparenchyma密度不均Multiplehypoenhancingnodulesinthespleen伴有脾臟多發(fā)小結(jié)節(jié)，低強(qiáng)化Tinyhypovascularnodulesscatteringintheliverandspleen低血供結(jié)節(jié)

Enlargedliverandspleen肝脾大

slightlyrimenhancement輕度環(huán)形強(qiáng)化Micronodulartuberculosis微小結(jié)節(jié)型Macronodular大結(jié)節(jié)

Hypovascular低血供Macronodularhepatic&splenictuberculosis大結(jié)節(jié)型Pancreatictuberculosis胰腺結(jié)核Slightincreaseinthedimensionofpancreas體積稍增大Lossoflobulatedcontour邊緣變光滑

AssociatedFindingsThoracicfindings:15%合并胸部結(jié)核Genitourinarytuberculosis泌尿生殖道結(jié)核Musculoskeletaltuberculosis骨骼肌肉結(jié)核CentralnervoussystemtuberculousisCNSTB中