【www.zhangdahai.com--专题心得体会】
【摘要】目的:探讨酷似纵隔肿块的食道周围型静脉曲张的影像诊断。方法:自2005-2007年我院18例酷似纵隔肿块的食道静脉曲张在CT或MRI检查中诊断为食道静脉曲张,其中11例最终经手术或DSA证实为食道静脉曲张。回顾性分析此18例患者的影像学表现。结果:18例患者DR检查均见大小不等的后下纵隔肿块,增强CT或MRI检查中表现为静脉期食管壁及食管周围显著强化的迂曲血管团。11例患者中病变的CT或MRI表现与DSA或纵隔手术表现完全相符合,并可清楚显示流入和流出血管。结论:CT及MRI检查可正确诊断酷似纵隔肿块的食道静脉曲张,避免盲目活检造成的致命性出血。�
【关键词】门静脉;食道;静脉曲张;肿块;CT;MRI;DR�
doi:10.3969/j.issn.1006-1959.2010.09.426文章编号:1006-1959(2010)-09-2646-02�
Dentification of Esophageal Varices Similar to Mediastinal mass: imaging diagnosisDONG Yun-xu,QIN Jie,MENG Xiao-chun,ZHANG Jian-shenDepartment of Radiology,the Third Affiliated Hospital,Sun Yat-sen University,Guangzhou 510630,China�
【Abstract】Objective:To analyze the imaging diagnosis of esophageal varices similar to mediastinal mass.Methods:From 2005 to 2007,high-density mass-like shadow in mediastinal space,which was detected in DR examinations,was diagnosed as esophageal varices by CT or MRI examinations in 18 patients.Among them,11 patients were finally confirmed by DSA or mediastinal operation.The imaging features of these 18 patients were retrospectively analyzed.Results:All patients presented high-density mass-like shadow in posterior inferior mediastinum in DR images with different sizes.In contrast-enhanced CT or MRI examinations,all these lesions appeared as remarkably dilated tortuous blood vessels in or around esophageal wall with significant enhancement in portal venous phase,which connected with the portal venous branches.In CT or MRI examinations,the flow-in and flow-out vessels were clearly depicted in all of them.The manifestations of the varices presented in CT or MRI examinations were finally confirmed in DSA or mediastinal operations in 11 patients.Conclusion:Esophageal varices similar to mediastinal mass can be correctly identified by un-invasive CT or MRI examination and avoided fetal bleeding due to blinded biopsy.�
【Key words】Esophageal varices;Mediastinal mass;Computed tomography;Magnatic Resonance Imaging;CT;MRI;DR
食道胃底静脉曲张作为门静脉高压的表现之一,诊断并不困难,上消化道内镜或钡餐可直接或间接的观察到粘膜面扩张迂曲的血管,这已有众多的文献描述并为人们所熟知,本文不再赘述,而表现为酷似纵隔肿块的食道周围型静脉曲张的影像诊断文献报告基少,偶可引起误诊(迷惑),本文重点探讨这一较少见的静脉曲张类型。�
1.资料与方法�
1.1一般资料:本组18例,男12例,女6例,年龄25-72岁,平均48岁。所有病例均有慢性乙肝病史,病程15-30年,18均有肝硬化,有5例合并有原发性肝癌,11例有反复上消化道出血。本组病例均无明显的吞咽困难。�
1.2检查方法:常规照片采用GEDR设备,常规摄后前位及左侧位片;本组病例在明确诊断之前均行胸部螺旋CT(GElightspeedCT/i)或MRI(GEsigna/I1.5T)超导型磁共振成像仪,CT扫描,层厚5mm,螺距2,所有病例均行三期扫描。�
2.结果�
2.1胸片:所有病例均表现为后下纵隔大小不等的不规则软组织肿块。正位片病灶常向一侧(左侧)或两侧突出,向左侧突出更为显著,其外界光滑、锐利。降主动脉下段边缘分辨不清,左侧膈肌内缘模糊,肿块可达15cm(附图1、2)。�
�
图 1图 2�
(图1、2)示后下纵隔大小不等的软组织肿块。正位片病灶常向一侧(左两侧突出,向左侧突出更为显著,其外界光滑、锐利。降主动脉下段边缘分辨不清,左侧膈肌内缘模糊。�
�
图 3 图 4���
�
图 5�
2.2CT或MRI:平扫食道及周围巨大不规则软组织肿块;增强扫描动脉期无明显强化,静脉期可见�绕成团的扩张、迂曲的血管团,外缘清楚,可包绕或部分包绕降动脉下段,(图3、4、5)。�
(图3、4、5)示平扫食道及周围巨大不规则软组织肿块;增强扫描动脉期无明显强化,静脉期可见�绕成团的扩张、迂曲的血管团,外缘清楚,包绕降动脉下段。�
3.讨论�
门静脉高压症偶可在多个部位形成假瘤样肿块��[1-4]�。常规X线摄片及CT、MRI平扫常可带来诊断上的疑惑,通过CT或MR扫描通明确诊断,文献��[1-3,5]�报告的病告的常见部位有脾门区,双侧肾上腺、肠道、肝脏内、肛门区,一些病例合并门静脉癌栓、门静脉海绵样变、脾静脉及肠系膜上静脉癌(血)栓、或肿瘤直接侵犯。在门静脉脉压力降低后肿块可消失��[3]�,降主降动脉下段边缘分辨不清及膈肌内缘模糊是由于肿块包绕隆主动脉下段,导致间肪间隙消失及失空气软组织的天然对比(边缘掩盖征)。动脉期不强化是与纵隔真性肿瘤不同的特点之一,有作者��[3,4]�详细探讨了膈下静脉了解剖及在门静脉高压情况下的曲张情况及引流情,认为右心膈角区是团块状静脉曲张最好发的部位,这与本文的好发部分不同,另作者亦观察到很多中重度食道静脉曲张的患者不伴有食道周围的团块状静脉曲张,其具体原因还有待进一步研究。本组18例均在MR、CT增强扫描后得出正确诊断。根据本组18例的诊断经验,我们可以得出如下的诊依据:�
3.1胸片示后下纵隔大小不等的软组织肿块。正位片病灶常向一侧(左侧)或两侧突出,向左侧突出更为显著,其外界光滑、锐利。降主动脉下段边缘分辨不清,左侧膈肌内缘模糊。�
3.2平扫食道及周围巨大不规则软组织肿块;增强扫描动脉期无明显强化,静脉期可见�绕成团的扩张、迂曲粗大的血管团,同时可见到粘膜面曲张的静脉,外缘清楚,可包绕或部分包绕降动脉下段。�
3.3有肝硬化、门脉高压背境,伴或不伴门静脉脉阻塞或狭窄。本病影像表现具有特征性,可做出明确诊断,本文的意议在于提示了酷似纵隔肿块的食道周围型静脉曲张的好发部分及影像表现,避免了临床以原因不明肿块行穿刺,引起可能是致命性的出血,也提示了部分食道静脉曲张的病人有特殊的引流方式,在行介入治疗时应引起足够的重视,以达到最好的治疗效果。
参考文献�
[1]Paramesh AS,Meiners R.Fairchild RBRetroperitoneal varices presenting as an adrenal pseudotumor in a cirrhotic patient.WMJ,2006 Jun,105(4):44-6.�
[2]Ito K,Higuchi M,Kada T.CT of acquired abnormalities of the portal venous system,1997 Jul-Aug,17(4):897-917.�
[3]V??ctor Pineda,MD Jordi Andreu,MD Jose? Ca?ceres,et al.Lesions of the CardiophrenicSpace:Findingsat Cross-sectional Imaging RadioGraphics,2007,27:19-32.�
[4]Marios Loukas Robert G.Louis Jr Joel Hullett,et al.An anatomical classification of the variations of the inferior phrenic vein Surg Radiol Anat,2005,27:566-574.�
[5]T GOKAN,MD,Y OHGIYA,MD,H NOBUSAWA,et al.Commonly encountered adrenal pseudotumours on CT The British Journal of Radiology,2005,78:170-174.�
