20210816湘雅二医院课件荟萃【1801】
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● Clinical Presentation
● A 40-year-old man presents with scrotal swelling.
● 临床表现：
● 男，40岁，阴囊肿胀。
● 1A - Annotated Caption
● (A) Computed tomography (CT) with oral and intravenous contrast shows soft tissue entering the inguinal canal (arrow) lateral to the inferior epigastric vessels (arrowhead).
● 1A- 影像表现：
● (A) 增强CT示：软组织进入腹股沟管（箭头）到腹壁下血管（三角箭头）。
● 2B - Annotated Caption
● (B) Lower slice shows a soft-tissue mass expanding the inguinal canal (arrow). Enhancing mucosal rings within this mass help identify it as bowel.
● 2B- 影像表现：
● (B) 下一层面示：软组织肿块使腹股沟管扩大（箭头）。肿块内可见粘膜强化，故g该肿块为肠管。
● 3C - Annotated Caption
● (C) Lower slice shows a fluid-filled scrotum (arrow) with layering barium contrast (arrowhead) and an air-fluid level.
● 3C- 影像表现：
● (C) 下一层面示：右侧阴囊内充满液体（箭头），有造影剂液体分层（三角箭头）及气液平面。
● Further Work-up
● No Further Work-up
● 进一步处理后：
● 无进一步处理
● Differential Diagnosis
● Indirect inguinal hernia: This is indicated by the large fluid collection in the scrotum containing an air-fluid level and layering barium contrast, consistent with bowel. The point of herniation is lateral to the inferior epigastric muscles (unlike direct inguinal hernia, which is medial) and through the inguinal canal.
● 鉴别诊断：
● 腹股沟斜疝：可表现为阴囊内大量积液，包括气液平面及液体分层，与肠管内表现一致。疝点位于腹壁下肌外侧（与腹股沟直疝不同，后者位于腹股沟内侧），并通过腹股沟管。
● Essential Facts
● Indirect inguinal hernias are the most common type of inguinal hernia and commonly cause bowel obstruction. They usually occur in men and may contain peritoneal sac, bowel, and mesentery. Contents protrude down through the inguinal canal, anterior to the spermatic cord.
● Direct inguinal hernias protrude through the pelvic wall, rarely causing obstruction.
● CT clearly distinguishes direct (medial to inferior epigastric vessels) from indirect (lateral) inguinal hernia.
● Closed-loop bowel obstructions contained within hernias may be fluid-filled and aperistaltic because of distension and ischemic change, making them difficult to distinguish from abscesses on imaging studies.
● Gas-fluid collections caused by gas-forming bacteria within abscesses may mimic contents within herniated bowel.
● 知识点：
● 腹股沟斜疝是最常见的腹股沟疝，通常引起肠梗阻。它们通常发生在男性，可能包括腹膜囊、肠和肠系膜。内容通过腹股沟管向下突出，直到精索。
● 腹股沟疝直接穿过盆腔壁，很少引起梗阻。
● CT能清楚地分辨腹壁下血管与腹股沟斜疝的区别。
● 疝内肠管闭合造成梗阻可因腹胀和缺血性改变而引起液体潴留，在影像上类似脓肿，难以区分。
● 肠内含有的产气菌能模拟肠内环境产生气体导致气液平面。
● Other Imaging Findings
● Ultrasound is sometimes indicated to distinguish peristalsing bowel from fluid collections mimicking hernia, such as abscesses, seromas, lymphoceles, and hydroceles.
● 其他影像检查：
● 超声有时可以用来区分蠕动的肠管及疝内积液，如：脓肿、积液、淋巴囊肿、及鞘膜积液。
● Pearls and Pitfalls
● Pelvic external hernias are congenital, traumatic, or post-surgical herniations of pelvic contents through the pelvic wall or groin. They include inguinal, femoral, obturator, sciatic, and perineal hernias.
● Scrotal abscesses, lymphoceles, and hydroceles can sometimes mimic scrotal hernias.
● 要点及误区：
● 骨盆外疝是先天性，外伤，或手术后突出盆腔内容通过盆壁或腹股沟。包括腹股沟、股、闭孔、坐骨和会阴疝。
● 阴囊脓肿、淋巴囊肿及鞘膜积液有时类似于阴囊疝。
● 参考文献：
● Atri M, McGregor C, McInnes M, et al. Multidetector helical CT in the evaluation of acute small bowel obstruction: comparison of non-enhanced (no oral, rectal or IV contrast) and IV enhanced CT. Eur J Radiol. 2009;71(1):135-140.
● Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. 2001;176(1):167-174.。