修回日期: 2012-07-08
接受日期: 2012-08-06
在线出版日期: 2012-09-08
回盲部包括回盲瓣、回肠末段、盲肠、阑尾及升结肠始段, 该部位可受到来自消化系及其以外的各种致病因素的影响, 是多种肠道疾病的好发部位, 鉴别诊断困难, 其诊断需病史、临床特征、影像学及内镜病检的综合支持. 随着各种新的影像及内镜技术的发展, 回盲部疾病的检出率在不断提高. 本文将综合对回盲部病变的内镜及影像学检查及相应的优势及劣势进行综述, 为临床医师在诊治该部位病变时提供参考.
引文著录: 孔文霞, 高青. 回盲部病变诊断的研究进展. 世界华人消化杂志 2012; 20(25): 2382-2387
Revised: July 8, 2012
Accepted: August 6, 2012
Published online: September 8, 2012
The ileocecal area includes the ileocecal valve, terminal ileum, cecum, appendix, and top ascending colon. Since this area may be affected by pathologic conditions that are either common throughout the gastrointestinal system or exclusive to this area, a great variety of intestinal diseases may arise in this region, making the diagnosis of ileocecal lesions difficult. In clinic, the diagnosis of ileocecal lesions depends on the combination of disease history, clinical features, imaging and endoscopic findings. The development of advanced imaging and endoscopy technology has greatly increased the detection rate of ileocecal lesions. In this review, we discuss the use of imaging and endoscopic examinations for evaluation of ileocecal area to help ensure accurate diagnosis and appropriate treatment.
- Citation: Kong WX, Gao Q. Progress in the diagnosis of ileocecal lesions. Shijie Huaren Xiaohua Zazhi 2012; 20(25): 2382-2387
- URL: https://www.wjgnet.com/1009-3079/full/v20/i25/2382.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v20.i25.2382
回盲部为消化系的"中间地带", 由于该区结构复杂, 淋巴组织丰富, 肠内容物在此停留时间长, 其特殊的解剖结构和生理功能, 已成为炎症、癌肿、结核等多种消化系疾病的好发部位, 但临床表现多无明显的特异性. 对回盲部病变仅凭内镜表现确定其性质常常比较困难, 即使结合病理活检, 除了排除恶性病变外, 也很难提供特异性的病理改变, 其诊断仍需依靠病史、临床特征、影像学、内镜及病检的综合支持. 随着各种影像学及内镜技术的发展, 回盲部疾病的检出率在不断提高.
回盲部位于右髂窝, 在解剖上包括回肠末段、盲肠、升结肠近端、回盲瓣和阑尾. 临床通常使用的回盲部一词, 并无特定的解剖学标界. 在X线诊断上, 一般将回肠终末15 cm左右的一段末段回肠、回盲瓣、盲肠、近侧半升结肠及阑尾作为回盲部的范围[1]. 也有研究者[2]认为回盲部区是以回盲瓣为中心, 包括盲肠、阑尾、末端回肠和升结肠起始部各10 cm的区域. 盲肠为大肠起始部, 粗而短, 几乎不参与肠内容物的排泄, 无系膜, 活动度大, 故在X线造影或CT检查中该部位息肉常因盲肠运动易被误认为粪便而造成漏诊[3]. 回盲瓣作为一个机械性屏障, 可以控制小肠内容物进入盲肠的速度, 使食糜在小肠内有足够时间的停留并得到充分消化和吸收, 避免消化吸收紊乱, 又可防止大肠内容物逆流入回肠, 因此回盲瓣在结肠细菌大量繁殖进而侵犯小肠中起一定的保护作用[4].
回盲部淋巴组织非常丰富, 作为肠黏膜的免疫屏障, 淋巴组织产生的免疫应答在抵御病原体的入侵中起重要的保护作用, 同时导致了易侵犯淋巴系统的疾病在此部位多发生, 如肠结核、淋巴瘤等, 此处肠腔宽, 食糜停留时间长, 为细菌繁殖提供了条件, 故回盲区炎症性病变的发生率高. 回盲部粪便多保持稀糊状, 对病灶刺激微弱, 加之肠壁薄易扩张, 故早期病变容易被忽略, 特别是回盲部癌肿, 位置隐蔽, 且较少引起肠梗阻, 肿块不易被摩擦引起出血, 易造成患者就诊延迟.
回盲部病变以一般炎性病变占首位, 回盲部恶性肿瘤次之, 息肉第三, 肠结核、淋巴瘤、溃疡性结肠炎及克罗恩病等少见, 我国多项大型临床研究报道结果均较一致[5]. 炎性病变中以阑尾炎最多见.
回盲部病变的诊断, 影像学检查尤为重要, 消化系钡餐能显示肠黏膜及其功能改变, 超声检查显示肠壁增厚、包块囊实性及血流变化情况, CT具有敏锐的密度分辨率, 能较好地显示病变, 尤其能准确评估肠壁、肠系膜和肠腔外组织的受侵范围, 日益受到临床重视.
采用气钡双重造影法, 能明显扩张并清楚显示回盲部解剖关系, 并可纵向了解整个消化系病变分布情况, 但不能提供回盲部病变的肠腔外表现[6]. X线造影对于阑尾炎诊断价值小, 表现为阑尾呈分节状, 腔内的钡剂排空时间延长及阑尾未显影等, 但Schisgall[7]报道钡灌肠有58%的正常阑尾不显影; 息肉显示为圆形或椭圆形的充盈缺损, 轮廓光滑整齐, 肠壁柔软; 癌肿的充盈缺损大, 轮廓有分叶征及僵硬感, 伴黏膜破坏, 龛影位于腔内的充盈缺损中, 周围伴有指压迹及裂隙征, 病变范围相对局限[8]; 溃疡性结肠炎表现为多发小龛影突出肠腔外而使管壁边缘毛糙呈毛刺状及锯齿状, 溃疡之间黏膜增生形成多个假性息肉, 充盈像上表现为小圆形充盈缺损[9]; 肠结核病变呈连续性, 早期有"跳跃征", 随着病变发展肠壁出现环形龛影, 病变后期, 由于疤痕挛缩使受累回肠末端、盲肠及回盲瓣变窄、缩短, 呈现 "一字征", 较具特征性[10]; 克罗恩病病变为节段性、边界清楚, 纵行裂隙样溃疡及黏膜改变形成"鹅卵石征"具有特异性, 且容易形成肠瘘、腹腔脓肿, 同时发现病变累及小肠时应高度怀疑[11].
超声检查方便、价格低廉, 可多次重复有利于病变的动态观察, 无禁忌症, 能提示肿块大小及囊实性的鉴别, 腹腔有无积液、脓肿、转移灶等并发症, 运用彩色多普勒超声可了解病变血供情况, 同时对炎性水肿或纤维增生所致的肠壁增厚有较好的鉴别[12], 对比增强超声(contrast-enhanced ultrasonography, CEUS)是将第2代超声对比增强剂与低机械指数的实时谐波超声结合在一起, 对于肠壁小血管的可视化有较高的分辨率.
阑尾病变可表现为阑尾肿大, 壁厚, 彩色血流信号点状或略丰富, 周围渗出明显, 并可发现是否合并有周围脓肿等[13]; 克罗恩病的超声检查对于并发症如脓肿、窦道、穿孔、肠腔狭窄等有较高的诊断准确性[14]. 克罗恩病的早期病理变化是肠壁内新生血管形成[15], 而CEUS实现了对肠壁小血管的实时可视化, 并且有与CT和磁共振成像相当的分辨率[16,17], 可用以评估克罗恩病的活动度, 有利于临床灵活制定合理的治疗方案并可对克罗恩病的治疗效果进行监测[18]. 克罗恩病具有反复发作的特点, 需长期随访监测, CT相对高昂的价格和离子辐射的危险限制了其在克罗恩病患者中的应用, 肠镜作为一种侵入性检测, 不易为患者长期接受, 故CEUS可作为理想的克罗恩病的评估及随访方法[19].
多层螺旋CT(MDCT)被认为是最好的评估回盲部病变的影像学检查, 随着MDCT后处理功能的不断发展和完善, 其在肠道病变方面的应用研究日益增多[20], 在横断位观察基础上, 通过后处理功能包括多平面重组(multiplanar reconstruction, MPR)和曲面重组(curved planar reformation, CPR)技术能够从不能角度整体观察回盲区情况, 做到观察的连续性和完整性, 尤其是CT结肠成像(CT colonography, CTC)技术, 包括多排螺旋CT仿真结肠镜技术(CT virtual colonography, CTVC)、透明显示(Ray Sum)等, 他利用计算机软件功能, 将螺旋CT容积扫描获得的图像数据进行三维后处理, 重建出类似纤维内窥镜所见的空腔脏器内表面的立体图像. 与纤维结肠镜相比, 患者不需要向体内插入任何的金属器械, 安全、舒适, 没有损伤、出血等并发症, 可以良好的展现结肠内外整体效果、三维形态和毗邻关系[21], 故CTC对回盲部病变的结构及与周围组织的关系显示有巨大优势, 不仅清楚显示病灶本身不同组织的细微特征的特点, 配合对比剂应用增强有利于良恶性鉴别, 提高了对病灶的定性诊断准确率, 而且能显示其与邻近组织结构、血管关系及腹膜后的改变, 从而全面了解病变的范围及评估病变的严重程度, 为临床确定治疗方案提供依据[22].
阑尾炎表现为平扫见阑尾增粗, 边界模糊, 周围脂肪间隙内见云雾状高密度影, 增强扫描见阑尾壁均匀强化[23]; CTC可以发现直径2-5 mm的息肉, 与肠镜相比, 其检出直径>10 mm的息肉病变的总体敏感性为94%-100%[24-26]; 癌肿表现为肠壁僵硬且增厚多>3 cm, 有不规则的肿块, 与周围正常肠壁分界清楚, 偏心性肠管狭窄, 增强扫描肿块多表现为不均匀强化、中央坏死、囊变区无强化[27]; 肠结核表现为受累肠壁及回盲瓣的不规则明显增厚, 增强扫描病段有分层显像, 当见腹腔肿大淋巴结呈环状分隔样强化及融合多环状强化时应高度怀疑结核[28]; 溃疡性结肠炎表现为连续性肠壁增厚, 病段肠壁厚度大致均匀且为对称性改变, 黏膜面出现多发小溃疡和小息肉, 可出现分层现象, 表现为"靶征"或"双晕征"; 克罗恩病表现为受累肠段沿肠轴方向较均匀一致性增厚, 病变节段跳跃性分布, 可见肠系膜增厚粘连、移位性脂肪、脂肪纤维增生, 发现瘘管、窦道、脓肿等相关并发症时更支持其诊断[29].
正电子发射断层扫描(positron emission tomography, PET)是一种进行功能代谢显像的分子影像学设备, 通过病灶部位对示踪剂的摄取了解病灶功能代谢状态, PET/CT一次显像即可获得形态和功能信息, 实现了解剖学成像和组织成像的完美融合, 不但能方便检测微小病变, 还能提供精确的解剖定位.
3.4.1 氟-18-脱氧葡萄糖: 将CT高的解剖形态分辨率和PET获取的分子水平的功能与代谢信息相结合的氟-18-脱氧葡萄糖(18F-DG PET/CT)大大提高了肿瘤的检测率. 恶性肿瘤细胞的存活数量和增殖活性决定了肿瘤组织的葡糖糖代谢水平, 18F-DG是一种天然的葡萄糖类似物, 作为肿瘤显像剂, 其摄取强度与肿瘤的恶性程度和预后相关. 故对于回盲部癌肿的诊断、分期方面18F-DG PET/CT有较高的价值[30-32], 但结核、炎症、肉芽肿以及一些良性肿瘤等也存在不同程度的FDG浓聚区, PET/CT常受其影响, 存在一定比率的假阳性和假阴性[33], 临床上尚需结合其他影像学手段进行回盲部病变的鉴别诊断.
3.4.2 99Tc-六甲基丙二胺肟标记白细胞扫描(99Tcm-HMPAO-labeled leukocyte scintigraphy, TLLS): 99Tcm-HMPAO-WBC作为一种炎症显像剂, 其中99Tcm-HMPAO为脂溶性物质, 可自由进入WBC内而变为水溶性物质, 滞留于胞浆中, WBC具有强烈的趋化性, 可向炎症部位聚集, 99Tcm释放γ射线可显示99Tcm-HMPAO-WBC的体内分布情况, 从而用于准确诊断体内炎性病灶. 故回盲部病变中, TLLS对于炎性病灶的诊断及评估炎症程度有很高的价值. 急性阑尾炎可表现为右下腹条索状浓聚, 99Tcm-HMPAO-WBC显像可快速、准确地诊断或排除急性阑尾炎, 降低阑尾炎的阴性开腹率, 值得用于阑尾炎的急诊诊断[34]. 对于炎症性肠病, 99Tcm-HMPAO-WBC显像可早期诊断、确定病变部位和范围[35,36], 观察疗效以及预后评估, 也可用于在活动性病变期或有严重并发症存在而不能行结肠镜检查者的病情评价中[37,38].
肠镜检查可在直视状态下观察肠腔, 并可对病变部位取材病理活检, 是肠道病变的首选检查, 但仅能观察到肠腔黏膜表面病变, 不能对病变厚度、肠壁外生性病变进行观察及评估肠腔外表现.
阑尾炎内镜下表现为阑尾口部黏膜不规则, 略凹陷, 边缘粗糙变形, 周围黏膜充血、水肿、脆性增加, 病理学检查为阑尾各层有中性粒细胞浸润[39]; 癌肿表现为不规则隆起伴溃疡, 呈菜花状, 病变范围局限; 溃疡性结肠炎为弥漫性改变, 溃疡呈针尖样多发性浅溃疡, 溃疡间黏膜可形成假性息肉, 病检主要为弥漫性炎性细胞浸润、隐窝上皮增生、隐窝脓肿形成; 肠结核的溃疡呈环形分布, 多数溃疡均非浅表性, 干酪样肉芽肿、肉芽肿数目增多且相互融合是其典型病理学特点[40], 但活检通常不典型, 与克罗恩病难以鉴别. Kirsch等[41]研究发现, 肉芽肿直径>0.05 mm的比率在肠结核组中较克罗恩病显著增多, 具有鉴别价值; 克罗恩病最早的损害是黏膜淋巴小结上形成的阿弗他溃疡, 呈节段性分布, 随着溃疡扩展融合, 表现为纵行裂隙状溃疡, 黏膜隆起呈鹅卵石样改变, 具有特异性, 病检为跳跃性裂隙状溃疡、结节样非干酪样肉芽肿、肠壁各层炎症细胞浸润.
随着内镜技术的发展, 目前内镜窄带成像技术(narrow-band imaging, NBI)、放大内镜(magnified endoscope, ME)、微探头超声内镜(miniprobe sonography, MPS)已在临床工作中广泛使用, 使得胃肠道病变的诊断准确率及癌肿的早期病变检出率在不断提高[42].
4.2.1 NBI结合ME技术: NBI是一种非侵入性光学增强技术, 他通过使用干扰滤光器产生窄谱红、绿和蓝光作用与靶器官, 增加上皮表面及其下方血管的对比度, 与放大内镜联合, 能对消化系病变的病灶表面腺体开口(Pit)和微血管形态显示清晰, 他的视觉效果具有获得内镜下染色同等效果的可能性[43], 与放大色素内镜相比, 无需喷洒色素, 在操作上简单易行, 只需进行模式切换, 并可行靶向活检, 对于肠道病变的肿瘤及非肿瘤性的鉴别有很好的诊断能力, 能明显提高早期癌, 特别是平坦和凹陷性病灶的诊断率[44,45]. 对于炎症性肠病, 患病时间越长, 病变癌变的可能性越高, 而这种类型早期癌的诊断困难, Danese等[46]研究报告显示: 一些在白光大肠镜下认为正常的黏膜, 应用NBI加ME有阳性发现, 其血管生成明显增加, 因此认为NBI可以提供更多的信息以诊断炎症性肠病的严重程度.
4.2.2 微探头超声内镜: 临床上消化系隆起病变靠常规内镜观察常不能明确隆起病变的性质和病变层次范围, 而超声内镜弥补了这一不足[47]. MPS是经内镜活检通道插入微探头进行扫描检查病变, 能够清楚显示肿块的边界、大小及包膜, 对了解病变的起源、性质, 正确区分消化道腔内外的病变有重要临床价值. 与常规超声内镜相比, MPS最大优点在于肠道因病变狭窄致内镜不能通过者, 微探头能够插入通过狭窄部位[48,49].
结合上述技术特点优势, 先对消化系隆起病灶表面Pit形态和微血管形态进行细致清晰的观察分析, 以明确病变的范围边界, 再予MPS了解消化系隆起性病变的来源层次和侵犯层次, 确定病变的深度. 三者联合能判断隆起病变的肿瘤性与非肿瘤性, 对消化系隆起性病变的起源具有准确的定位作用, 并能提示病变的性质, 尤其是对于早期肿瘤有极高的诊断正确性, 对于进一步治疗有明确的临床指导价值.
随着工业化进程和环境等变化, 克罗恩病在中国等发展中国家发病率呈升高趋势[50,51], 肠结核仍维持高发状态, 两者的鉴别诊断尤为困难, 相互误诊率日益增高, 有的患者甚至两种疾病重叠发生, 在多种辅助检查均无法较好鉴别的情况下须进行诊断性治疗. 随着回盲部辅助检查方法的不断改进及新的检查方法的出现, 该部位病变尤其肿瘤更容易早期诊断且准确率不断升高, MDCT结肠成像技术、NBI及MPS的前景值得临床广泛应用, 继而有利于临床工作者积极采取有效的治疗手段.
回盲部是多种肠道疾病的好发部位, 鉴别诊断困难, 其诊断需病史、临床特征、影像学及内镜病检的综合支持. 随着各种新的影像及内镜技术的发展, 回盲部疾病的检出率大大提高.
沈琳,主任医师, 北京大学临床肿瘤医院消化内科
回盲部病变的鉴别诊断困难, 目前尚无特异性的检查方法, CT结肠成像技术及新的内镜检查技术是当前研究的热点及方向.
结合多层螺旋CT表现，回盲部病变应用放大内镜联合窄带成像技术、超声内镜等新的内镜检查技术提高了病变检出率.
本文对回盲部病变的内镜、影像学检查及两者的优劣势进行综述, 对临床医生选择检查方式有指导意义.
本文综述了回盲部病变内镜及影像学的诊断进展, 内容合理、全面, 立题新颖,文章侧重临床, 对临床医生诊治回盲部病变有一定的指导意义.
编辑:张姗姗 电编:鲁亚静
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