灰阶超声造影在脾脏外伤诊断中的动物实验研究

目的 评价灰阶超声造影在脾外伤诊断中的应用价值.方法 在动物全麻开腹状态下建立脾脏钝性伤和锐性伤动物模型.所用动物为6只小型猪(体重30～40 kg),共建立脾脏外伤模型13处,其中锐性伤5处,钝性伤8处.脾脏创伤后即刻,首先应用常规超声观察脾实质损伤的部位、范围及内部回声,然后在灰阶超声造影条件下静脉团注自制造影剂1.8 ml,观察脾实质损伤的部位、范围、损伤程度及造影增强特征,并与病理组织学检查进行对照分析.结果 灰阶超声造影可清晰显示脾内损伤病灶的部位、形态、范围,其显示脾内损伤区的敏感性为100%(13/13),显著优于常规超声(30.8%,P＜0.01).脾内损伤病灶的超声造影特征为在动脉期和延迟期均无增强,呈负性显影,损伤区与周围正常实质分界清晰.在判断脾损伤的严重程度上,超声造影分级与病理学检查具有较好的一致性.结论 超声造影剂结合灰阶超声造影技术可显著提高常规超声对脾脏外伤的诊断水平,在脾脏外伤的诊断上具有潜在的应用价值.     

创伤重点超声评估法联合超声造影的临床研究

目的探讨创伤重点超声评估法(FAST)联合超声造影对肝脏、脾脏闭合性创伤早期诊断的临床应用价值。方法选择本院急诊科2016年1月至2018年5月期间收住的32例经腹部增强CT诊断肝、脾破裂患者,所有患者入院后常规治疗后予以FAST超声检查,超声介入医生随后行超声造影,待生命体征平稳后行增强CT确诊,评价FAST超声联合超声造影对创伤性肝、脾损伤患者快速诊断的有效性。结果与增强CT相比,FAST检查阳性预测值为87%,阴性预测值91%。对脾脏诊断阳性89%,肝脏诊断阳性72%。两者差异有统计学意义(P0.05)。造影检查阳性预测值为93%,阴性预测值94%。其中对脾脏诊断阳性95%,肝脏诊断阳性88%。超声造影诊断创伤性肝/脾破裂的诊断率为96%,FAST超声诊断率为88%,两种超声方法诊断率比较差异有统计学意义(P0.05)。超声造影分型准确率为92%,FAST分型准确率为65%,两种超声方法分型准确率比较,差异有统计学意义(P0.05)。结论 FAST检查法联合超声造影对创伤性肝、脾损伤患者具有快速评价诊断效能,可作为急诊医生判断腹部外伤患者是否存在腹部损伤的初步检查方法。     

肝、脾、肾外伤性破裂的急诊B超诊断

肝、脾、肾创伤是常见的急腹症之一.由于超声具有独特的影像特征,应用超声检查闭合性肝、脾、肾创伤[1],多年来在本院开展应用,经临床验证,确定为临床提供了不可否认的诊断依据.本组重点讨论肝、脾、肾创伤的超声影像特点,及诊断肝、脾、肾创伤的临床意义.     

超声造影检查在肾脏非典型占位性病变诊断中的价值

目的:探讨超声造影检查对肾脏非典型占位性病变的诊断价值。方法:回顾性分析2015年5月至2019年6月北京大学第一医院收治的44例肾脏非典型占位性病变患者的常规超声和超声造影检查资料。男26例,女18例。年龄(55.9±13.7)岁。44例共47个占位,均行常规超声检查观察肿物的位置、大小、回声、边界、彩色血流情况,做出常规超声诊断。行超声造影检查观察肿物增强时相、增强水平、增强模式、是否有环状增强,做出超声造影诊断。将超声检查诊断与最终病理或临床诊断进行比较。绘制受试者工作特征(ROC)曲线,比较常规超声和超声造影检查对肾脏非典型占位性病变的诊断效能。结果:本研究47个病灶中,诊断为恶性15个,良性32个。19个病灶经手术病理诊断,分别为肾细胞癌13个、肾淋巴瘤2个、肾囊肿3个、炎性肉芽肿1个;28个经增强CT或MRI检查诊断为良性肿瘤或假性肿瘤,且定期随访≥1年无变化,分别为血管平滑肌脂肪瘤5个、囊肿15个、肾连接部皮质缺损3个、肾柱肥大2个、未萎缩肾实质1个、驼峰肾1个、瘢痕1个。常规超声检查病灶最大径(2.5±1.3)cm。肾细胞癌常规超声检查以低回声多见(8/13);超声造影检查以快进快出为主(9/13),多为不均匀低增强(6/13),9个发现假包膜,6个发现坏死。2个肾淋巴瘤常规超声检查均为低回声;超声造影检查均为快进快出,等增强1个,低增强1个。5个肾血管平滑肌脂肪瘤常规超声检查为高回声;超声造影检查以慢进慢出为主(4/5),低增强2个,高增强2个,等增强1个。肾囊肿常规超声检查以无回声多见(16/18);超声造影检查,单纯性肾囊肿无增强,复杂性肾囊肿囊壁或分隔薄且均匀强化,呈慢进慢出、等增强或低增强。炎性肉芽肿常规超声检查呈囊实性;超声造影检查实性部分与肾实质同步强化,呈低增强。肾柱肥大、驼峰肾和局限性未萎缩肾实质常规超声检查为低回声;超声造影检查为与肾实质同进同出的均匀等增强,无明显包块轮廓出现。肾连接部皮质缺损和瘢痕常规超声检查为高回声,超声造影检查自始至终无增强。常规超声检查将1个炎性肉芽肿、1个未萎缩肾实质、2个复杂肾囊肿误诊为恶性,2个高回声肾细胞癌误诊为良性;超声造影检查仅将1个炎性肉芽肿误诊为恶性。常规超声检查对良恶性病变诊断的敏感性为86.7%,特异性为87.5%,准确性为87.2%,ROC曲线下面积0.871。超声造影检查对良恶性病变诊断的敏感性为100.0%,特异性为96.9%,准确性97.9%,ROC曲线下面积为0.984。常规超声与超声造影检查的ROC曲线下面积比较差异有统计学意义(P=0.03)。结论:超声造影检查对肾脏非典型占位性病变的诊断效能优于常规超声检查,对于常规超声检查诊断困难的肾肿瘤,以及酷似肾占位病变的良性病变和解剖异常的诊断和鉴别诊断具有优势。     

囊性肾肿物超声造影诊断分析

目的 探讨超声造影对囊性肾肿物诊断价值. 方法 按照影像诊断标准,对29例囊性肾肿物的常规超声、超声造影、增强CT诊断结果进行分级,与最终诊断结果比较,应用受试者工作特征(ROC)曲线进行分析.男15例,女14例,年龄18～63岁.肿瘤位于左肾13例,右肾16例.29例均行常规超声检查后1～3 d行超声造影及增强CT检查. 结果 29例中20例有病理结果,其中恶性18例、良性2例.其余9例中失访1例,8例随访6～12个月,经超声或增强CT检查,病灶无明显变化.常规超声、超声造影与增强CT对囊性肾肿物分级的ROC曲线下面积分别为0.721、0.997、0.997,超声造影与常规超声比较差异有统计学意义(P=0.003),与增强CT比较差异无统计学意义(P=1.000).结论 超声造影对于囊性肾肿物诊断效果优于常规超声,与增强CT相似,可以应用Bosniak诊断系统对囊性肾肿物进行评价.     

超声造影在肾细胞癌临床诊断中的应用价值

目的 通过观察肾细胞癌的超声造影表现,以探讨超声造影对肾细胞癌的临床诊断价值.方法 分析106例经手术和病理检查证实的肾细胞癌患者的常规超声及超声造影资料,比较两种方法对肾细胞癌假包膜的显示能力.结果 106例肾细胞癌中,肾透明细胞癌98例,多房性囊性肾细胞癌3例,乳头状肾细胞癌5例.超声造影显示假包膜80例(75.4％),而常规超声显示假包膜29例(27.3％),超声造影及常规超声均不显示假包膜26例,两者间差异有统计学意义(P＜0.01).结论 超声造影对肾细胞癌假包膜显示率明显高于常规超声,超声造影对诊断肾细胞癌有重要的临床价值.     

急诊超声对钝性腹部创伤内脏破裂出血的诊断分析

目的探讨急诊超声对钝性腹部创伤内脏破裂出血诊断的临床应用价值。方法回顾性分析2017年6月至2019年6月于本院急诊确诊为腹部创伤并内脏破裂出血的患者90例的影像学资料,与手术结果或随访资料进行对比分析。分析其超声显像特征;超声显像结果与手术结果诊断符合率。结果纳入患者超声显示仪上明确提示仅内脏破裂有59例,明确提示仅腹腔内积液21例,明确提示内脏破裂伴有腹腔积液6例,阳性率为95.6%。最终经手术发现共计124个脏器破裂出血,其中肝破裂33例,脾破裂64例,肾破裂15例,胰腺破裂7例,膀胱破裂5例。纳入患者经超声检查肝破裂、脾破裂、肾破裂、胰腺破裂、膀胱破裂的例数分别为24、57、10、6、3,漏诊例数分别为4、5、5、1、2,诊断符合率分别为72.7、89.1%、66.7%、85.7%、60%。结论急诊超声对钝性腹部创伤内脏破裂出血的诊断具备可行性,可作为临床钝性腹部创伤内脏破裂出血的首选检查方法。     

急诊超声用于腹部外伤合并腹腔脏器损伤诊断的符合率

目的分析腹部外伤合并腹腔脏器损伤采用超声检查与临床最终确诊的符合率,分析。方法回顾性分析本院收治的131例腹部外伤合并腹腔脏器损伤患者,所有患者给予急诊超声检查,统计其与临床最终确诊的符合率。结果肝挫裂伤急诊超声检查的临床确诊符合率最高,其次为脾挫裂伤和肾挫裂伤。膀胱破裂急诊超声检查的临床确诊符合率最低,误诊率最高。131例患者总漏诊率8.40%,漏诊率较高的有胰腺挫伤,胃肠挫伤和膀胱破裂。肝挫裂伤、肾挫裂伤和脾挫裂伤漏诊率低。急诊超声总诊断符合率较高,误诊率较低。结论腹部外伤合并腹腔脏器损伤采用超声检查的诊断符合率较高,但要特别注意空腔脏器损伤时超声检查容易漏诊的情况。     

肝移植术后脾动脉窃血综合征的超声诊断

目的探讨超声诊断肝移植术后脾动脉窃血综合征(SASS)的价值。方法通过对肝移植术后10例并发SASS患者(研究组)及术后肝功能恢复正常的8例患者(对照组)进行常规超声及超声造影检查,总结SASS的超声表现。将研究组患者的数字减影血管造影术(DSA)检查结果与超声造影进行对比。结果研究组二维超声见肝脏回声正常或肝内见多发细小坏死灶,彩色多普勒血流显像(CDFI)可见肝动脉内血流信号稀少或呈星点状,超声造影见移植肝肝动脉内造影剂增强信号微弱。肝动脉内径偏细,脾动脉内径明显增粗。超声造影与DSA的诊断结果一致。结论常规超声及超声造影应常规作为肝移植术后的可疑移植肝血管系统异常的无创检查手段,具有较高的应用价值。     

肝门部胆管癌的临床诊断与手术治疗分析

目的探讨肝门部胆管癌的临床诊断方法及两种不同手术方法的预后。方法选取2002年12月至2008年3月就诊的肝门部胆管癌患者43例作为研究对象,回顾性分析所有患者的临床表现、影像学检查结果、手术方式、生存率等临床资料,所有对象按手术方法分为根治性切除术组（22例）和姑息性切除术组（21例）,对比分析两组间患者的术后并发症发生率,1、3、5年生存率有无统计学差异。结果临床表现以黄疸最为常见,占86．0％,其次是尿黄（81．4％）和皮肤瘙痒（72．1％）;经过常规超声、CT及MRI联合检查,根治性切除术组和姑息性切除术组对肝门部胆管癌检出率分别为90．9％和95．2％;MRI诊断阳性率明显高于超声诊断阳性率（χ^2=7．379,P〈0．01）。根治性切除术组患者并发症发生率明显高于姑息性切除术组（χ^2=14．321,P〈0．01）,1、3、5年生存率也明显高于姑息性切除术组（r=6．018、χ^2=2．842、r=17．483,P〈0．05）。结论对于肝门部胆管癌患者,MRI诊断阳性率明显高于超声,采取超声联合CT或MRI可提高早期诊断率;根治性切除术治疗肝门部胆管癌,能够提高此类患者的远期存活率。     

Ultrasound detection of blunt urological trauma: a 6-year study

The objective of this study was to assess the utility of emergency ultrasonography in the detection of blunt urological injury. A retrospective review was conducted of all consecutive emergency blunt trauma ultrasonograms (US) obtained at a level I trauma centre from January 1995 to January 2001. Among the 4320 emergency ultrasonograms performed, 596 patients (14%) had intraabdominal injury and, of these, 99 patients (17%) had urological injuries. The sensitivity of ultrasound for all urological injuries was 67%, and specificity was 99.8%. For isolated urological injuries, sensitivity and specificity were 55.6 and 99.8%, respectively. Ultrasound was most accurate in the detection of grade III renal injuries, identifying 14/15 (93%), and 13 underwent laparotomy. For isolated urological injuries, 15 of 25 (60%) patients with a true-positive US underwent laparotomy compared to 3 of 20 (15%) with a false-negative US. Isolated urological injury was significantly associated with an ultrasonographic pattern of free fluid in the left upper quadrant and the left pericolic gutter (odds ratio=55.1; P<0.001), followed by isolated fluid in the left pericolic gutter (odds ratio=8.6; P=0.04). Although emergency ultrasonography is useful in the triage of patients with blunt urological trauma, it may miss significant urological injury requiring further intervention. As most renal injuries may be managed non-operatively, further studies such as contrast-enhanced CT or angiography should be obtained in the stable patient with suspected blunt urological injury.     

闭合性肾外伤合并腹腔内脏器损伤的急诊救治(附36例报告)

目的探讨闭合性肾外伤合并腹腔内脏器损伤的急诊处理措施。方法对本院最近10年收治的36例闭合性肾外伤合并腹腔内脏器损伤的救治资料进行回顾性分析。结果保守治疗3例均痊愈。施行急诊剖腹探查手术33例,其中8例同期切开后腹膜探查患肾,包括肾切除6例,肾部分切除1例,肾修补1例;25例未同期切开后腹膜探查患肾,均无因肾损伤二期手术者。手术组治愈30例,死亡3例。结论闭合性肾外伤合并腹腔内脏器损伤以剖腹探查手术治疗为主,术前CT检查可以准确进行肾外伤的分级,结合术中病情变化决定是否同期探查肾损伤。     

严重多发脏器损伤的临床特点及诊治

目的探讨严重多发脏器损伤的临床特点和诊治方法.方法对1988～1998年间收治的合并有闭合性腹内脏器损伤的严重多发伤、ISS大于16的165例患者进行回顾性分析.结果3个或3个以上部位多发伤占28.5%.63例有腹内多脏器损伤.腹腔穿刺是确诊的主要检查手段,部分病例选用了腹部B超和CT,3项诊断检查阳性率均在90%以上.全组漏诊腹内伤21例(12.7%),死亡29例(17.6%).死亡病例平均ISS41.6,明显高于非死亡病例24.8(t=15.21,P<0.01).结论严重多发伤病例应常规行诊断性腹腔穿刺,酌情选择腹部B超和CT等检查,以排除腹内脏器损伤.对全身多发伤并存腹内伤的病例,要根据伤情确定急救处理顺序.剖腹手术中要注意多脏器损伤.ISS大于40提示预后不良.     

Clinical value of bedside abdominal sonography performed by certified sonographer in emergency evaluation of blunt abdominal trauma

Purpose: To investigate the accuracy and efficiency of bedside ultrasonography application performed by certified sonographer in emergency patients with blunt abdominal trauma. Methods: The study was carried out from 2017 to 2019. Findings in operations or on computed tomography (CT) were used as references to evaluate the accuracy of bedside abdominal ultrasonography. The time needed for bedside abdominal ultrasonography or CT examination was collected separately to evaluate the efficiency of bedside abdominal ultrasonography application. Results: Bedside abdominal ultrasonography was performed in 106 patients with blunt abdominal trauma, of which 71 critical patients received surgery. The overall diagnostic accordance rate was 88.68%. The diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation, retroperitoneal hematoma and multiple abdominal organ injury were 100%, 94.73%, 94.12%, 20.00%, 100% and 81.48%, respectively. Among the 71 critical patients, the diagnostic accordance rate was 94.37%, in which the diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation and multiple abdominal organ injury were 100%, 100%, 100%, 20.00% and 100%. The mean time for imaging examination of bedside abdominal ultrasonography was longer than that for CT scan (4.45 ± 1.63 vs. 2.38 ± 1.19) min; however, the mean waiting time before examination (7.37 ± 2.01 vs. 16.42 ± 6.37) min, the time to make a diagnostic report (6.42 ± 3.35 vs. 36.26 ± 13.33) min, and the overall time (17.24 ± 2.33 vs. 55.06 ± 6.96) min were shorter for bedside abdominal ultrasonography than for CT scan. Conclusion: Bedside ultrasonography application provides both efficiency and reliability for the assessment of blunt abdominal trauma. Especially for patients with free peritoneal effusion and critical patients, bedside ultrasonography has been proved obvious advantageous. However, for negative bedside ultrasonography patients with blunt abdominal trauma, we recommend further abdominal CT scan or serial ultrasonography scans subsequently.     

Delayed presentation of blunt splenic injury

Eleven patients with delayed presentation of splenic injury after blunt abdominal trauma treated during a 10 year period have been described. They represented 24 percent of all patients treated for blunt splenic injury in our department in that time period. Ten patients required operative treatment and one was treated nonoperatively. There were no deaths. The value of computerized tomography and ultrasonography in the accurate preoperative assessment of splenic injury has been documented. In addition, the various diagnostic and therapeutic possibilities in blunt splenic trauma have been discussed.     

Role of magnetic resonance imaging in blunt renal parenchymal trauma

The accuracy of magnetic resonance imaging (MRI) in the evaluation of blunt renal parenchymal trauma was compared with that of contrast-enhanced computed tomography (CT) and ultrasonography (US) in a prospective study of 12 patients. CT was superior to other methods in identifying and characterising the renal parenchymal lesion, and both CT and US exceeded low field MRI in recognising a perirenal fluid collection. The role of high field MRI in the evaluation of blunt renal trauma requires further study.     

Clinical retrospective and comparative study on diaphragm injuries in 46 cases

ａｕｍａｔｉｃｄｉａｐｈｒａｇｍｒｕｐｔｕｒｅｉｓｎｏｔｃｏｍｍｏｎｉｎｃｌｉｎｉｃａｌｗｏｒｋ ,ａｎｄｔｈｅｉｎｊｕｒｙｉｓｖｅｒｙｓｅｒｉｏｕｓａｎｄｔｈｅｍｏｒｔａｌｉｔｙｉｓｈｉｇｈ .Ｔｈｅａｉｍｏｆｐｒｅｓｅｎｔｓｔｕｄｙｗａｓｔｏｅｌｕｃｉｄａｔｅｔｈｅｃｌｉｎｉｃａｌｃｈａｒａｃｔｅｒｉｓｔｉｃｓｏｆｂｌｕｎｔａｎｄｐｅｎｅｔｒａｔｉｎｇｄｉａｐｈｒａｇｍｉｎｊｕｒｉｅｓａｎｄｔｏｑｕａｎｔｉｔａｔｉｖｅｌｙｃｏｍｐａｒｅｔｈｅｓｅｖｅｒｉｔｙｏｆｄｉｆｆｅｒｅｎｔｄｉａｐｈｒａｇ…     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma

OBJECTIVE: To determine the accuracy of physical examination and ultrasonographic evaluation performed by emergency physicians in cases of blunt abdominal trauma for the early diagnosis of intraabdominal haemorrhage. METHODS: In this clinical prospective study, trauma patients were evaluated with four-quadrant ultrasonography by emergency physicians after initial stabilisation and physical examination. Diagnoses based on demographic data, physical examination and emergency physician's ultrasonography were compared with the subsequent clinical course. RESULTS: A total of 442 patients participated in the study. The sensitivity and specificity of emergency physician's ultrasonographic examination to detect intraabdominal haemorrhage were 86 and 99%, respectively. Pre-test sensitivity and specificity of physical examination to detect intraabdominal haemorrhage were 39 and 90%, respectively. CONCLUSIONS: Physical examination was not a reliable method to detect intraabdominal haemorrhage in cases of blunt abdominal trauma. In contrast, abdominal ultrasonography performed by emergency physicians was a reliable diagnostic tool. Emergency physicians should be familiar with abdominal ultrasonographic examination, which should be routine in cases of blunt abdominal trauma.     

Is computed tomography necessary to determine liver injury in pediatric trauma patients with negative ultrasonography?

Purpose

Abdominal trauma is the third most common cause of all trauma-related deaths in children. Liver injury is the second most common, but the most fatal injury associated with abdomen trauma. Because the liver enzymes have high sensitivity and specificity, the use of tomography has been discussed for accurate diagnosis of liver injury.

Methods

Our study was based on retrospective analyses of hemodynamically stabil patients under the age of 18 who were admitted to the emergency department with blunt abdominal trauma.

Results

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were significantly higher as a result of liver injury. In the patients whose AST and ALT levels were lower than 40 IU/L, no liver injury was observed in the contrast-enhanced computed tomography (CT). No liver injury was detected in the patients with AST levels lower than 100 IU/L. Liver injury was detected with contrast-enhanced CT in only one patient whose ALT level was lower than 100 IU/L, but ultrasonography initially detected liver injury in this patient.

Conclusions

According to our findings, abdominal CT may not be necessary to detect liver injury if the patient has ALT and AST levels below 100 IU/L with a negative abdominal USG at admission and during follow-up.