20201118湘雅二医院课件荟萃【1635】
本着交流学习、公益教育的愿望，我们创办了这个公众号。希望各基层医生可以积极踊跃的参与我们，共同探讨和学习。公众号内容主要包括：湘雅二医院放射科典型、疑难、罕见病例讨论；英语小讲堂；科研进展和课件荟萃等。
感谢大家的关注，欢迎留言交流。
● Clinical Presentation
● 临床表现
● A 39-year-old presents with severe cramping and watery diarrhea after treatment for acute lymphocytic leukemia.
● 39岁患者，急性淋巴细胞白血病治疗后出现严重抽搐和水样腹泻。
● 1A - Annotated Caption
● 1A - 注释说明
● Single-contrast barium study shows diffuse separation of the jejunal loops (small arrowheads) as well as the ileal loops; featureless, ribbonlike ileum (arrow) with luminal narrowing; and markedly thickened, nodular jejunal folds (large arrowhead). The sigmoid colon is also featureless.
● 单对比钡造影显示空肠袢（小箭头）以及回肠袢的扩散分离；无特征的带状回肠（箭头），管腔变窄；并空肠皱襞的明显增厚、结节（大箭头）。乙状结肠也没有特点。
● Further Work-up
● 进一步检查
● No Further Work-up
● 没有进一步检查
● Imaging Findings
● 影像表现
● Click on Annotated Thumbnail to reveal caption
● 点击缩略图显示注释
● Differential Diagnosis
● 鉴别诊断
●Graft-versus-host disease (GVHD): This diagnosis is indicated by the classic history and imaging findings of diffuse, ribbon-like bowel.
● 移植物抗宿主病（GVHD）：影像学表现为弥漫性带状肠，以及经典病史提示该诊断。
●Radiation enteritis: Radiation enteritis is usually more localized as it involves structures within the radiation port, but it may also cause ribbon-like or nodular bowel loops.
● 放射性肠炎：放射性肠炎通常更局限，因为它只累及辐射端口的结构，但也可能导致带状或结节性肠袢。
● Infection by cytomegalovirus (CMV) or Cryptosporidium: This may have a similar appearance and clinical presentation. CMV infection may occur in an immunocompromised host or be secondary to GVHD.
● 巨细胞病毒（CMV）或隐孢子虫感染：这可能具有相似的外观和临床表现。CMV感染可能发生在免疫功能低下的宿主或继发于GVHD。
● Essential Facts
● 基本事实
●GVHD is marked, multisystemic inflammation usually occurring within 100 days after bone marrow transplant (including autologous!) performed after induction radiation and/or chemotherapy. Acute and chronic forms are observed.
● GVHD是典型的多系统炎症，通常发生在骨髓移植（包括自体）后100天内，诱导放射和/或化疗后。有急性和慢性形式。
● Locations include the gastrointestinal (GI) tract, lungs, liver, and skin. GVHD of the GI tract is most pronounced in the small bowel and colon, as in this case.
● 累及部位包括胃肠（GI）道、肺、肝脏和皮肤。在这种情况下，胃肠道的GVHD以小肠和结肠最为明显。
● Pathogenesis is believed to be severe, acute enteritis caused by an immune response mounted by transplanted lymphocytes against the host tissue. This response is made possible by destruction of the host defenses by a combination of induction chemotherapy and immunosuppressive drugs.
● 发病机理被认为是由移植的淋巴细胞对宿主组织造成的免疫反应引起的严重急性肠炎。诱导化学疗法和免疫抑制药物的组合可通过破坏宿主防御产生该反应。
● Barium imaging shows the classic findings demonstrated in this case, including marked fold and mural thickening progressing to featureless, narrowed ileum (“ribbon-like” or “toothpaste-like”) and marked separation of bowel loops. The jejunum is often normal but may show involvement, as in this case, occasionally progressing to featureless bowel.
● 钡餐显示该病典型的影像包括明显的回肠皱襞和管壁肥厚，进展为无特征的狭窄（“带状”或“牙膏状”）和明显的肠袢分离。空肠往往是正常的，但可能会受累，在这种情况下，偶尔也会发展成无特征的肠管。
● Colonic involvement may show a markedly edematous wall, luminal narrowing, occasional ulcerations, and progression to featureless bowel.
● 结肠受累可能表现为明显的管壁水肿、管腔变窄，偶尔溃疡和进展为无特征肠。
● Alternative considerations:
● 备选方案：
●Radiation enteritis is the main alternative diagnostic consideration and may cause thickened, fixed, featureless, separated loops of bowel on barium studies. This entity may have an acute stage of enteritis with severe diarrhea, similar to GVHD, but often presents as subacute or chronic enteritis with bowel obstruction and ulceration causing GI bleeding.
● 放射性肠炎是主要的鉴别诊断，并且可能会导致钡餐中增厚、固定、无特征的和分开的肠袢。该病可能出现严重腹泻的急性期肠炎，与GVHD相似，但通常表现为亚急性或慢性肠炎、肠梗阻和溃疡引起胃肠道出血。
● CMV can superinfect patients with GVHD or primarily infect immunosuppressed patients. Clinical and imaging features of severe CMV enteritis are similar to those of GVHD.
● 巨细胞病毒可以重叠感染GVHD患者或原发感染免疫抑制患者。严重CMV肠炎的临床和影像特征与GVHD相似。
● Other Imaging Findings
● 其他影像表现
● Computed tomography of GVHD may show marked, diffuse small-bowel and colon wall thickening, pneumatosis, and surrounding edema, similar to radiation enteritis.
● GVHD的计算机断层扫描可能表现与放射性肠炎相似，明显的弥漫性小肠和结肠壁增厚、管腔扩张和周围水肿。
● Pearls and Pitfalls
● 经验与教训
●GVHD can be exacerbated by a host of opportunistic infections due to the causative underlying condition of immunocompromise.
● 由于免疫功能低下的原因，宿主的机会性感染会加重GVHD。
● Moulage pattern of celiac disease is mentioned here only for the characteristic imaging finding of ribbon-like jejunum occurring after long-standing disease. The clinical history should distinguish this entity from GVHD or radiation enteritis.
● 长程的乳糜泻后可能发生带状空肠的特征性影像表现。临床病史应该将此该病与GVHD或放射性肠炎区分开来。
● Ulcerative colitis can result in featureless, ahaustral colon, but the small bowel is not affected, and the clinical picture of known, long-standing disease distinguishes this entity.
● 溃疡性结肠炎可形成无特征的、囊袋状结肠，但小肠不受影响，并且已知的长期疾病的临床特点可以区分该病。
● History and disease distribution are critical in the evaluation of patients with barium findings of featureless, ribbon-like bowel.
● 病史和疾病分布对于评估无特征带状肠的钡餐结果至关重要。
● Further Readings
● Rosenberg HK, Serota FT, Koch P, Borden S IV, August CS. Radiographic features of gastrointestinal graft-vs.-host disease. Radiology. 1981;138(2):371-374.