20210708湘雅二医院课件荟萃【1796】
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
● A 46-year-old man presents with abdominal pain and distension.
● 临床表现
● 46岁男性，腹痛并腹胀
● Further Work-up
● See Images at Left
● Imaging Findings
● Click on Annotated Thumbnail to reveal caption
● 1A - Annotated Caption
● (A) Frontal view of the abdomen shows multiple dilated small-bowel loops (arrowheads) and a nondilated, air-filled colon (small arrow), indicating a partial small-bowel obstruction (SBO). There is lytic destruction of the left pubic rami and ischial tuberosity (large arrows).
● 影像学表现
● (A)腹部正位x片示：多个扩张的小肠袢（箭头）以及一个积气但不扩张气结肠（小箭头），表示部分小肠梗阻（SBO）。左耻骨支和坐骨结节（大箭头）可见溶骨性骨质破坏。
● 2B - Annotated Caption
● (B) Coronal computed tomography (CT) shows a nondilated, contrast-filled colon (small arrow) and a large pelvic mass with associated lysis of the ischial tuberosity (large arrows).
● (B)冠状位CT显示见造影剂充填的未扩张的结肠影（小箭头），以及伴有坐骨结节（大箭头）溶骨性骨质破坏的盆腔巨大肿块影。
● 3C - Annotated Caption
● (C) More anterior image shows marked mural thickening of the ileum (arrowheads).
● (C)更多的前方图像显示回肠壁显著增厚（箭头）。
● 4D - Annotated Caption
● (D) More anterior image shows a large soft-tissue mass with central necrosis compressing the distal small bowel (arrowheads). Again seen is the pelvic mass with destruction of the left pubic rami (arrows).
● (D)更多的前方图像显示：一个巨大的中央坏死的软组织肿块压迫远端小肠（箭头）。再次看到的盆腔肿块伴左侧耻骨支（箭头）骨质破坏。
● 5E - Annotated Caption
● (E) Positron emission tomography with CT shows abnormal uptake in the thickened bowel wall (colored region).
● (E) 正电子发射计算机断层扫描（ PET-CT）显示增厚的肠壁（有色区域）有异常摄取。
● 6F - Annotated Caption
● (F) Abnormal uptake is also seen throughout the mass (colored region).
● (F)异常摄取也同样见于整个肿块（有色区域）。
● Imaging Findings
● Click on Annotated Thumbnail to reveal caption
● Differential Diagnosis
● Small-bowel lymphoma: This is the most likely diagnosis for an infiltrating mass within the ileum with an associated necrotic abdominal mass and additional lesions causing lysis of bone. Bone metastasis is more common with lymphoma than with gastrointestinal (GI) primaries.
● Metastatic disease: This is a strong possibility, given the multifocal presentation. The most common metastases to small bowel include those from melanoma, breast, and lung primaries.
● Primary adenocarcinoma: This may be infiltrative but is statistically much less likely in the small bowel.
● 鉴别诊断
● 小肠淋巴瘤：这是回肠内浸润性肿块，伴有相关的坏死腹腔肿块以及其他引起溶骨性骨质破坏的病变最可能的诊断。与其他胃肠（GI）道原发相比，淋巴瘤的骨转移更常见。
● 转移性疾病：考虑到多灶性表现，这是一个很大的可能性。小肠转移瘤最常见的原发灶包括黑色素瘤，乳腺癌以及肺癌。
● 原发腺癌：可以表现为浸润性，但在统计上发生于小肠的可能性很小。
● Essential Facts
● This case shows the most common presentation of small-bowel lymphoma: diffuse, segmental infiltration, usually occurring in the ileum.
● In this case, diffuse infiltration resulted in a stricture with SBO, indicating that the autonomic plexus is intact. In some cases, this plexus is destroyed, and there is paradoxical aneurysmal dilatation of the infiltrated segment without SBO.
● The adjacent bulky, cavitary mass may indicate confluent, necrotic lymph nodes or exophytic extension of the primary tumor, both of which are common in cases of GI lymphoma.
● Lymphoma is the most common small-bowel malignancy and usually involves other locations before affecting the small bowel. Non-Hodgkin lymphoma is much more common than Hodgkin lymphoma.
● Small-bowel lymphoma can be primary or secondary to a predisposing condition.
● Predisposing conditions include celiac disease, Crohn disease, human immunodeficiency virus infection, causes of immunocompromise, and Middle Eastern descent.
● On imaging studies, lymphoma can also occur as subtle thickening and disruption of the fold pattern, a focal polypoid mass, or an ulcerated mass.
● CT often shows large, cavitary, or confluent mesenteric lymph nodes (normal abdominal lymph nodes are ≤ 11 mm).
● 知识点
● 本病例显示了小肠淋巴瘤最常见的表现：弥漫性、节段性浸润，通常发生在回肠。
● 在这里病例中，弥漫性浸润引起肠腔狭窄并不完全性肠梗阻，这表明自主神经丛是完整的。在某些病例中，这个神经丛被破坏，使得浸润阶段肠腔瘤样扩张。
● 相邻的巨大的空洞型肿块可能提示融合、坏死的淋巴结或原发肿瘤的外生性生长，这两者在胃肠道淋巴瘤的病例中都是常见的。
● 淋巴瘤是最常见的小肠恶性肿瘤，并且在累及小肠前通常先累及其他部位。非霍奇金淋巴瘤比霍奇金淋巴瘤更常见。
● 小肠淋巴瘤可以是原发的也可以继发于诱因。
● 诱因包括乳糜泻，克罗恩病，人类免疫缺陷病毒感染，致免疫功能低下的疾病以及中东人后裔。
● 在影像学研究中，淋巴瘤也可能以微小的增厚和皱壁的破坏，局灶性息肉样肿块或溃疡肿块的形式出现。
● C T通常表现为较大的，空洞的或融合的肠系膜淋巴结（正常腹腔淋巴结≤11 mm）。
● Other Imaging Findings
● No Other Imaging Findings
● Pearls and Pitfalls
● Lymphoma may fistulize to other bowel loops.
● Intussusception is common in small-bowel lymphoma. It occurs in children but may also be seen in adults.
● Malabsorption is occasionally associated with lymphoma of the small bowel.
● Do not miss perforation, which often occurs with lymphoma that is ulcerated or being treated with chemotherapy.
● 要点与误区
● 淋巴瘤可能会形成瘘口至其他肠袢。
● 肠套叠在小肠淋巴瘤中很常见。它发生在儿童身上，但也可能在成年人身上看到。
● 吸收障碍偶尔也与小肠淋巴瘤有关。
● 不要遗漏穿孔，穿孔常发生于溃烂或正在接受化疗的淋巴瘤患者中。
● Further Readings
● Rubesin SE, Gilchrist AM, Bronner M, et al. Non-Hodgkin lymphoma of the small intestine. Radiographics. 1990;10(6):985-998.