20210913湘雅二医院课件荟萃【1816】
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● Clinical Presentation
● 临床表现
● A 51-year-old man presents with fevers. Two computed tomography studies were performed 1 week apart.
● 男，51岁，发热，两次影像学检查前后间隔一周。
● Further Work-up
● 进一步检查
● See Images at Left
● 见左图
● 1A - Annotated Captio
● (A) Contrast-enhanced computed tomography (CT) shows a well-circumscribed focus of hypoattenuation in the body of the pancreas (large arrow), a complex peripancreatic collection (large arrowhead), and subcapsular perihepatic fluid (small arrows) suspicious for hematoma. Peripancreatic fat stranding is also seen (small arrowhead).
● 1A - 注释说明
● (A)对比增强断层扫描(CT)显示边界清楚胰腺内低信号(大箭头)、胰周聚集的复合物(大箭头)和肝周包膜下积液(小箭头)疑似血肿。胰周脂肪滞留也可见(小箭头)。
● 2B - Annotated Caption
● (B) The follow-up CT shows a growing peripancreatic fluid collection (arrowheads), suspicious for hemorrhage. The hypodense focus in the body of the pancreas (arrow) appears to be the source.
● 2B-注释说明
● 连续的下一个断层CT显示了胰周积液的增多(箭头)，怀疑出血。胰体内的低密度病灶可能是来源。
● 3C - Annotated Caption
● (C) Celiac angiogram shows opacification of the dorsal pancreatic (large arrowhead) and pancreatica magna (small arrowhead) arteries. A small pseudoaneurysm is evident in the body of the pancreas (arrow).
● 3C-注释说明
● (C)腹腔血管造影显示胰背动脉(大箭头)和胰腺magna(小箭头)动脉影。一个较小的假性动脉瘤（箭头）在胰体的内很明显。
● 4D - Annotated Caption
● (D) Injection of the main pancreatic artery again shows a pseudoaneurysm (arrowhead) supplied by a branch vessel.
● 4D-注释说明
● (D)造影剂注射入胰主动脉可再次显示由分支血管供应的假性动脉瘤(箭头)。
● Imaging Findings
● 影像学表现
● Click on Annotated Thumbnail to reveal caption
● 点击缩略图显示注释
● Differential Diagnosis
● Pancreatic necrosis with hemorrhage: This diagnosis is indicated by a focal area of nonenhancing pancreatic parenchyma and evidence of acute pancreatitis, such as fat stranding, and a phlegmonous peripancreatic fluid collection suspicious for a developing abscess or pseudocyst. Hemorrhage from pseudoaneurysm is indicated by the second CT and subsequent angiographic findings.
● Focal pancreatitis: This may appear as a focal, low-density region with peripancreatic signs such as those in this case.
● Pancreatic abscess: This may have an appearance of a well-circumscribed pancreatic collection within the parenchyma, similar to that of pancreatic necrosis. This may occur as a result of infected pancreatic necrosis.
● 鉴别诊断
● 胰腺坏死与出血:这一诊断是由非增强的胰腺实质，急性胰腺炎的证据，如脂肪滞留，蜂窝织炎导致的胰周积液，怀疑形成脓肿或假性囊肿。假性动脉瘤出血是由第二次CT和随后的血管造影结果显示的。
● 局灶性胰腺炎:局限性，低密度，如本例中表现类似的胰周征象
● 胰腺脓肿:边界清楚的胰周聚集物质可能出现在胰腺实质内，与胰腺坏死相似。这可能是由于胰腺坏死引起的。
● Essential Facts
● Acute pancreatitis can cause several complications:
● Necrosis such as that seen in this case can become infected in 50% of cases and usually requires partial pancreatectomy with debridement of necrotic tissue.
● Pseudoaneurysm formation and hemorrhage can result from pancreatic enzymes weakening an arterial wall. The splenic, gastric, gastroduodenal, and pancreatic arteries are common sites of pseudoaneurysm caused by pancreatitis. Treatment is with surgery (partial pancreatectomy) or embolization.
● Compared with adenocarcinoma, acute pancreatitis:
● More typically causes duodenal and gastric wall thickening due to inflammation.
● Is not associated with metastatic disease and prominent local lymphadenopathy. Mild adenopathy may be present.
● 要点
● 急性胰腺炎可引起多种并发症:
● 这种情况下的坏死可以发生在50%被感染的病例中，通常需要部分胰腺切除术和坏死组织的清创。
● 假性动脉瘤的形成和出血可能是由于胰酶削弱了动脉壁。脾、胃、胃十二指肠和胰动脉是由胰腺炎引起的假性动脉瘤的常见部位。治疗包括手术(部分胰腺切除术)或栓塞。
● 与腺癌相比，急性胰腺炎:
● 更典型的是由于炎症引起十二指肠和胃壁增厚。
● 与转移癌和明显的局部淋巴结病无关。轻微的腺病可能出现。
● Other Imaging Findings
● Magnetic resonance imaging can help characterize suspected focal pancreatitis. On fat-suppressed T1 images, normal pancreatic tissue has high signal, and pancreatitis causes variable loss of signal.
● On gradient-echo (GRE) gadolinium-enhanced images, mild pancreatitis may mildly enhance, similar to pancreatic adenocarcinoma. However, lack of enhancement on GRE images suggests necrosis or abscess.
● 其他影像学表现
● 磁共振成像可以帮助诊断被怀疑为局灶性胰腺炎。在脂肪抑制T1图像上，正常胰腺组织有高信号，胰腺炎引起信号的可有衰减。
● 在梯度回声(GRE)钆增强图像中，轻度胰腺炎可能轻度增强，类似于胰腺腺癌。然而，GRE图像上的未增强提示坏死或脓肿。
● Pearls and Pitfalls
● Gas within a focus of necrosis or within a fluid collection indicates either infection with gas-forming bacteria or the development of a fistulous connection to bowel.
● Focal pancreatitis most commonly involves the pancreatic head and can be difficult to distinguish from pancreatic adenocarcinoma.
● Pancreatic necrosis more commonly involves the body and tail because the head has a rich collateral vascular supply from the gastroduodenal and dorsal pancreatic arteries.
● 经验与教训
● 在坏死组织中的积气或积液，表明要么是感染了气体形成的细菌，要么是与肠道形成了瘘。
● 局灶性胰腺炎最常见的是胰头，很难与胰腺腺癌区分。
● 胰脏坏死更常见的是身体和尾部，因为头部有丰富的血管供应来自胃十二指肠和背胰动脉。
● Further Readings
● Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002;223(3):603-613.