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1、十二指肠解剖特点n n十二指肠分为四部分，即十二指肠上部、十二指肠降十二指肠分为四部分，即十二指肠上部、十二指肠降部、十二指肠水平部及十二指肠升部。其中十二指肠降部、部、十二指肠水平部及十二指肠升部。其中十二指肠降部、十二指肠水平部位于腹膜后，为腹腹外位器官，余为腹膜十二指肠水平部位于腹膜后，为腹腹外位器官，余为腹膜内位器官。内位器官。腹膜后间隙解剖n n腹膜后间隙是以腹后壁壁层腹膜为前界，腹横筋膜为后界，上起横膈，下达盆腔的立体间隙。腹膜后间隙划分n n关于腹膜后间隙的划分，普遍接受的观点是Meyers于20世纪60年代末70年代初在Congdon解剖工作研究的基础上提出的，即以肾筋膜为主要
2、标志，将腹膜后间隙分为肾旁前间隙APS，位于后腹膜与肾前筋膜侧锥筋膜之间。肾周间隙PS位于肾前后筋膜之间，呈倒置的锥形。肾旁后间隙PPS，位于肾后筋膜侧锥筋膜和腹横筋膜之间。n nDrawingillustratestheDrawingillustratesthetraditionaltraditionaltricompartmentmodeltricompartmentmodeloftheretroperitoneum,oftheretroperitoneum,whichisaccordinglywhichisaccordinglydividedintothedividedintothean
3、teriorpararenalanteriorpararenalspacespace(APS)(APS),perirenal,perirenalspacespace(PS)(PS),and,andposteriorpararenalposteriorpararenalspacespace(PPS)(PPS).The.Theanteriorrenalfasciaanteriorrenalfascia(ARF)(ARF),posteriorrenal,posteriorrenalfasciafascia(PRF)(PRF),and,andlateroconalfascialateroconalfa
4、scia(LCF)(LCF) dividethespaces.dividethespaces.n nDrawingillustratestheDrawingillustratestherecentlymodifiedrecentlymodifiedtricompartmentmodel,whichtricompartmentmodel,whichreflectstheunderstandingreflectstheunderstandingthattheperirenalfasciaisthattheperirenalfasciaislaminarandvariablyfusedlaminar
5、andvariablyfusedandthereareinterfascialandthereareinterfascialconnectionsbetweentheconnectionsbetweenthespaces.Theretromesentericspaces.Theretromesentericplaneplane(RMP)(RMP),retrorenalspace,retrorenalspace(RRS)(RRS),andlateroconalspace,andlateroconalspacearepotentialinterfascialarepotentialinterfas
6、cialcommunications.Perinephriccommunications.Perinephricseptarunbetweentherenalseptarunbetweentherenalcapsuleandtheperinephriccapsuleandtheperinephricfascia,allowingsubcapsularfascia,allowingsubcapsularfluidtocommunicatewithfluidtocommunicatewiththeretrorenalspaceortheretrorenalspaceorretromesenteri
7、cplane.retromesentericplane.APSAPS=anteriorpararenalspace,anteriorpararenalspace,PPSPPS =posteriorpararenalspace,=posteriorpararenalspace,PSPS=perirenalspace(,).=perirenalspace(,).腹膜后两侧同名间隙经内侧的通连n n肾旁前间隙：Meyers通过临床放射学观察到，肾旁前间隙内的积液或积气一般是局限于其来源一侧的。同时，他又指出由于胰腺特殊位置本身就是潜在的通道，可以说肾旁前间隙左右侧是相互通连的；间隙内注入对比剂后CT
8、扫描也说明两侧是相通的。n n肾周间隙：Tobin等用胚胎解剖学方法证实了1895年Cerota最早关于肾前，后筋膜的描述。并进一步指出，肾前，后筋膜绕主动脉和腔静腔与对侧同名筋膜相连续。推侧两侧肾周间隙经内侧相通。n nMitchell和Meyers在胰腺和十二指肠后方，与围绕肠系膜根部血管的致密结缔组织融合，并不与对侧同名筋膜相续，这意味着两侧肾周间隙并不通连。n n而Kneeland的尸体间隙灌注却发现两侧肾周间隙在L3-L5间任何平面以下越过下腔静脉和腹主动脉前方相通。n nMindell的注射实验研究不仅证实Kneeland的结论，还进一步观察到造影剂并未环绕血管，仅在大血管前壁组成
9、前述通道的后界，因而提出主动脉和下腔静脉并不在肾周间隙内，而在其后方。n n临床CT观察表明，两侧肾周间隙内侧并没有明显的筋膜分隔，肾周间隙的血肿和气体在肾下极或更低的平面相通。肾旁后间隙n n无论是从临床表现，CT观察还是注射实验研究，尚无任何证据证明双侧肾旁后间隙经内侧直接相通。腹膜后间隙向上通连n n以往以往MeyersMeyers认为肾前后筋膜向上融合并续接认为肾前后筋膜向上融合并续接于膈筋膜，因而肾旁前间隙向上与肝裸区相通，于膈筋膜，因而肾旁前间隙向上与肝裸区相通，肾旁后间隙向上续于薄层的膈下筋膜，至于其向肾旁后间隙向上续于薄层的膈下筋膜，至于其向前和整个膈下关系并不明确。前和整个膈
10、下关系并不明确。n n而而LimLim等用等用CTCT扫描发现在新鲜尸体上经右肾扫描发现在新鲜尸体上经右肾周间隙注入对比剂直接进入肝裸区，以充分的依周间隙注入对比剂直接进入肝裸区，以充分的依据证明与肝裸区相通的是肾周间隙而不是肾旁前据证明与肝裸区相通的是肾周间隙而不是肾旁前间隙。肾前后筋膜分别向上融合于后腹膜和膈下间隙。肾前后筋膜分别向上融合于后腹膜和膈下筋膜，因此理论上推测肾旁前后间隙不向上开放。筋膜，因此理论上推测肾旁前后间隙不向上开放。n n临床发现位于肝裸区的病变向下可直接进入右肾周间隙，反之，积于右肾周间隙的气体向上也可达肝裸区，一些位于右肾周的尿性囊肿甚至可延伸至纵隔和胸腔，这些均
11、提示肾周间隙向上不仅能与膈下间隙相通，还可能通过膈肌裂孔或膈脚与纵隔相通。腹膜后间隙向下通连n n以Rapropoulos为代表的学者认为肾筋膜锥在髂窝封闭成单一的多层筋膜，下方闭合。n n现在的学者多认为肾筋膜锥向下开放，锥口下三个间隙相互通连。n nMindell等在注射实验研究中发现，肾旁前间隙大剂量注入对比剂240-1000ml，CT观察锥下、膀胱前、膀胱旁、骶前各间隙均充盈。十二指肠损伤机制n n十二指肠损伤少见，多为上腹穿透伤引起。闭合伤引起者，或由于暴力直接作用（如车祸时方向盘将十二指肠水平段碾轧于脊柱上），或由于暴力引起处于紧闭的幽门和Treitz韧带之间的闭襻内压力骤升引起胀
12、裂。损伤部位多在23部（3/4以上）。可见于座椅安全带损伤、减速伤、方向盘或把手损伤，部分见于运动伤、跌伤及打击上腹部所致。n n十二指肠损伤在腹部损伤中，低于2%，可同时合并胰腺、肝、脾、肾、胃及小肠系膜的损伤。可造成十二指肠挫伤、十二指肠壁内血肿、十二指肠穿孔或破裂，后者是外科治疗的适应症。临床特征n n临床特征包括白细胞增多，血清淀粉酶升高和上腹痛。然而，临床征象常常是模糊的，且是非特异性的。X线平片n n平片可见右肾或腰大肌异常清楚或模糊，有时腹膜后呈“花斑状”改变（积气）并逐渐扩展，胃管内注入水溶性碘剂可见外溢。一般不采用钡餐检查诊断十二指肠破裂。CT表现n nCTCT是诊断十二指肠
13、损伤的主要手段。是诊断十二指肠损伤的主要手段。n n非穿透性损伤常常被忽略。非穿透性损伤常常被忽略。n n十二指肠水肿、壁内血肿和肠壁积气可提示十二十二指肠水肿、壁内血肿和肠壁积气可提示十二指肠挫伤。局部肠壁厚度大于指肠挫伤。局部肠壁厚度大于3mm3mm（部分学者（部分学者认为大于认为大于4mm4mm）为十二指肠壁增厚。十二指肠）为十二指肠壁增厚。十二指肠挫伤可保守治疗。挫伤可保守治疗。n n腹膜后口服造影剂溢出、肠外游离气体和肠壁不腹膜后口服造影剂溢出、肠外游离气体和肠壁不连续可提示十二指肠穿孔或破裂。当穿孔位于连续可提示十二指肠穿孔或破裂。当穿孔位于TreitzTreitz韧带时，气体或外
14、溢对比剂可进入腹膜腔韧带时，气体或外溢对比剂可进入腹膜腔内。内。n n因十二指肠与胰腺关系密切，十二指肠损伤常伴因十二指肠与胰腺关系密切，十二指肠损伤常伴胰腺损伤存在，胰腺损伤存在，CTCT检查时应注意观察。检查时应注意观察。n n十二指肠损伤的一个特殊类型是十二指肠壁内血肿，由上腹挫伤引起，大多发生在儿童，病程进展缓慢，除上腹不适隐痛外，主要表现为高位肠梗阻，有时伴有胆管及胰管的梗阻导致黄疸和淀粉酶升高，右上腹多能摸到肿块。钡餐造影可见典型的螺旋簧征。n n若保守治疗两周梗阻仍不能解除，需手术治疗。十二指肠壁内血肿n nTraumaticduodenalTraumaticduodenalin
15、tramuralhematomaintramuralhematomaina26-year-oldmanina26-year-oldmanwhohadsustainedawhohadsustainedaseatbeltinjuryinaseatbeltinjuryinahigh-speedmotorhigh-speedmotorvehiclecollision.vehiclecollision.AbdominalCTscanAbdominalCTscanobtainedwithoralandobtainedwithoralandintravenouscontrastintravenouscont
16、rastmaterialshowswallmaterialshowswallthickeningofthethirdthickeningofthethirdandfourthportionsofandfourthportionsoftheduodenumtheduodenum(arrows).No(arrows).Noextraluminalair(aextraluminalair(afindingthatwouldfindingthatwouldhavesuggestedhavesuggestedperforation)wasseen.perforation)wasseen.Thepatie
17、ntwasThepatientwastreatedconservativelytreatedconservativelyandrecoveredandrecoveredwithoutinterventionwithoutintervention十二指肠血肿十二指肠血肿n nLargetraumaticduodenalhematomaina49-year-oldmanLargetraumaticduodenalhematomaina49-year-oldmanwhowasinvolvedinamotorvehiclecollision.Thepatientwhowasinvolvedinamot
18、orvehiclecollision.Thepatientwasalsotakinganticoagulants.wasalsotakinganticoagulants.(a)(a)AbdominalCTscanAbdominalCTscanobtainedwithoralandintravenouscontrastmaterialshowsobtainedwithoralandintravenouscontrastmaterialshowsalargehematoma(arrowheads)displacingthesecondalargehematoma(arrowheads)displa
19、cingthesecondportionoftheduodenum(arrow)anteromediallyandportionoftheduodenum(arrow)anteromediallyandnarrowingtheduodenallumen.narrowingtheduodenallumen.(b)(b)CoronalreformattedCTCoronalreformattedCTimagedepictsthefullextentoftheduodenalhematomaimagedepictsthefullextentoftheduodenalhematoma(arrowhea
20、ds).(arrowheads).十二指肠降部挫伤n nGradeIGradeIduodenalduodenalinjury.AxialCTinjury.AxialCTimageshowsimageshowsthickeningofthickeningoftheduodenaltheduodenalwall(arrow)inwall(arrow)inthedescendingthedescendingpartwithoutpartwithoutevidenceofevidenceoffreeair.Therefreeair.Thereisstrandingofisstrandingofthet
21、heperipancreaticperipancreaticfat.fat.十二指肠水肿n nDuodenalhematomainDuodenalhematomainan11-year-oldboywhoan11-year-oldboywhohadsustainedabicyclehadsustainedabicyclehandlebarinjury.Onanhandlebarinjury.OnanabdominalCTscanabdominalCTscanobtainedwithoralandobtainedwithoralandintravenouscontrastintravenousc
22、ontrastmaterial,thethirdmaterial,thethirdportionoftheportionoftheduodenumisthickenedduodenumisthickenedandedematousandedematous(arrowheads).No(arrowheads).Noextraluminalaircouldextraluminalaircouldbeidentifiedtosuggestbeidentifiedtosuggestperforation.Thepatientperforation.Thepatientwastreatedwastrea
23、tedconservativelyandconservativelyandrecoveredcompletely.recoveredcompletely.十二指肠降部破裂n nGradeIIduodenalinjury.GradeIIduodenalinjury.(a)(a)AxialCTimageshowsanenlargedAxialCTimageshowsanenlargedpancreaticheadwithmildedema(arrow)(gradeIlesion).pancreaticheadwithmildedema(arrow)(gradeIlesion).(b)(b)CTCT
24、imageobtainedatalowerlevelshowsthickeningoftheduodenalimageobtainedatalowerlevelshowsthickeningoftheduodenalwallinthedescendingpart(blackarrow).Adjacenttothewallinthedescendingpart(blackarrow).Adjacenttotheduodenumisasmallcollectionofextraluminalair(whitearrow),duodenumisasmallcollectionofextralumin
25、alair(whitearrow),whichindicatesasmallgradeIIlacerationofthewall.whichindicatesasmallgradeIIlacerationofthewall.十二指肠穿孔n nDuodenalperforationina28-year-oldmanwhosustainedblunttraumainDuodenalperforationina28-year-oldmanwhosustainedblunttraumainamotorvehiclecollision.amotorvehiclecollision.(a)(a)Abdom
26、inalCTscanobtainedwithintravenousAbdominalCTscanobtainedwithintravenousandoralcontrastmaterialshowsextraluminalair(arrows)adjacenttotheandoralcontrastmaterialshowsextraluminalair(arrows)adjacenttotheduodenumduodenum(D)(D).Cholecystectomyclipsarealsopresent.Cholecystectomyclipsarealsopresent.(b)(b)Co
27、ronalCoronalreformattedCTimageshowsalargeamountoffluidintherightanteriorreformattedCTimageshowsalargeamountoffluidintherightanteriorpararenalspacewithasmallfocusofextraluminalair(arrow),findingspararenalspacewithasmallfocusofextraluminalair(arrow),findingsthatareconsistentwithaduodenalperforation.Th
28、eperforationwasthatareconsistentwithaduodenalperforation.Theperforationwasconfirmedandrepairedatsurgery.confirmedandrepairedatsurgery.DD=duodenum.=duodenum.十二指肠水平部破裂n nGradeIIGradeIIduodenalinjury.duodenalinjury.AxialCTimageAxialCTimageshowsagradeIIshowsagradeIIinjuryoftheinjuryofthehorizontalpartof
29、horizontalpartoftheduodenumtheduodenumwithsmallwithsmallcollectionsofcollectionsofextraluminalairextraluminalair(arrows).A(arrows).Asubcapsularsubcapsularhematomaishematomaispresentatthepresentatthelowerpoleofthelowerpoleoftherightliverloberightliverlobe(arrowhead).(arrowhead).十二指肠破裂n nGradeIIIduode
30、nalinjury.GradeIIIduodenalinjury.(a)(a)AxialCTimageshowsthickeningoftheAxialCTimageshowsthickeningoftheduodenalwallinthedescendingpart(blackarrow).Atthetransitionzonetoduodenalwallinthedescendingpart(blackarrow).Atthetransitionzonetothehorizontalpart,thereisdisruptionofthewall(whitearrow).Additional
31、thehorizontalpart,thereisdisruptionofthewall(whitearrow).Additionalfindingsincludearetroperitonealhematomaandhypoperfusionoftherightfindingsincludearetroperitonealhematomaandhypoperfusionoftherightkidneyduetorightrenalarteryocclusion.kidneyduetorightrenalarteryocclusion.(b)(b)CTimageobtainedatalower
32、CTimageobtainedatalowerlevelshowsthedisruption(blackarrow)withalargesurroundinglevelshowsthedisruption(blackarrow)withalargesurroundingextraluminalhematoma(whitearrow).extraluminalhematoma(whitearrow).n nRupturedRupturedduodenuminaduodenumina27-year-old27-year-oldfemalevictimoffemalevictimofamotorve
33、hicleamotorvehicleaccident.CTaccident.CTscanshowsscanshowsfluidinthefluidintheduodenumandduodenumandleakageoffluidleakageoffluidintotherightintotherightanterioranteriorpararenalspacepararenalspace(arrow).(arrow).消化内镜胃窦及胰头活检术后n nAxialCTimagesinpatientwithperforationofthesecondportionoftheduodenum1day
34、afterAxialCTimagesinpatientwithperforationofthesecondportionoftheduodenum1dayaftergastroduodenoscopywithendoscopicpancreaticfine-needleaspirationbiopsyandgastricbiopsy.gastroduodenoscopywithendoscopicpancreaticfine-needleaspirationbiopsyandgastricbiopsy.(a)(a)UnenhancedCTimageshowsairinanteriorparar
35、enalspace(whitearrow)andrightperirenalUnenhancedCTimageshowsairinanteriorpararenalspace(whitearrow)andrightperirenalspace(blackarrow).space(blackarrow).(b)(b)Amorecaudalimageshowsafocusofdiscontinuity(shortblackarrow)inAmorecaudalimageshowsafocusofdiscontinuity(shortblackarrow)inthewallofthesecondpo
36、rtionoftheduodenum,withextraluminalextravasationoforalcontrastthewallofthesecondportionoftheduodenum,withextraluminalextravasationoforalcontrastmaterial(longblackarrow).Airisalsodemonstratedintherightposteriorpararenalspace(longmaterial(longblackarrow).Airisalsodemonstratedintherightposteriorpararen
37、alspace(longwhitearrow),rightproperitonealcompartment(shortwhitearrow),andperitonealcavitywhitearrow),rightproperitonealcompartment(shortwhitearrow),andperitonealcavity(arrowhead).(arrowhead).(c)(c)Contrast-enhancedCTimageobtained2yearslatershowstherightanteriorrenalContrast-enhancedCTimageobtained2
38、yearslatershowstherightanteriorrenalfascia(whitearrow)toextendtothesecondportionoftheduodenum(arrowhead).Thecysticfascia(whitearrow)toextendtothesecondportionoftheduodenum(arrowhead).Thecysticlesioninthepancreaticheadisanintraductalpapillarymucinousneoplasm(blackarrow).lesioninthepancreaticheadisani
39、ntraductalpapillarymucinousneoplasm(blackarrow).消化内镜胰头活检术后n nContrast-enhancedaxialCTContrast-enhancedaxialCTimagesinpatientwithimagesinpatientwithperforationofthesecondperforationofthesecondportionoftheduodenumafterportionoftheduodenumafterendoscopicpancreaticfine-endoscopicpancreaticfine-needleasp
40、irationbiopsy1needleaspirationbiopsy1weekearlier.Theamountofweekearlier.Theamountofairintherightperirenalspaceairintherightperirenalspaceexceedsthatintherightexceedsthatintherightanteriorpararenalspace.anteriorpararenalspace.内镜检查后n nDuodenalDuodenalperforationperforationafterafterendoscopyinendoscop
41、yina51-year-a51-year-oldman.CToldman.CTscanshowsascanshowsathick-walled,thick-walled,contractedcontractedduodenumduodenumwithairinwithairintheadjacenttheadjacentretroperitoneretroperitoneum(arrow).um(arrow).鉴别诊断n n腹膜间位器官破裂，如升降结肠破裂。n n腹膜内位器官破裂，特别是注意Morrison窝积气与腹膜后间隙积气的鉴别，右肝上间隙与肝裸区积气的鉴别。n n膀胱破裂。n n腹后壁
42、穿通伤。空肠破裂n nJejunalperforationinJejunalperforationina66-year-oldwomana66-year-oldwomanafteramotorvehicleafteramotorvehicleaccident.AxialCTaccident.AxialCTimageshowsimageshowshypervascularhypervascularthickenedjejunumthickenedjejunumwithasuspiciouswithasuspiciousdefect(curvedarrow)defect(curvedarrow)a
43、ndwithfocalfluid,andwithfocalfluid,fatstranding,andfatstranding,andextraluminalairextraluminalair(straightarrow)(straightarrow)adjacenttojejunaladjacenttojejunalloops.Thepatientloops.Thepatientlaterunderwentlaterunderwentresectionofa20-cmresectionofa20-cmsegmentofthesmallsegmentofthesmallbowel.Nomes
44、entericbowel.Nomesentericinjurywasfoundatinjurywasfoundatsurgery.surgery.十二指肠溃疡穿孔n nAbdominalpainandAbdominalpainandaperforatedaperforatedduodenalulcerinaduodenalulcerina79-year-oldman.79-year-oldman.CTscanobtainedCTscanobtainedwithoralcontrastwithoralcontrastmaterialshowsmaterialshowsintraperitonea
45、lintraperitonealextravasationofextravasationofcontrastmaterialcontrastmaterialfromthelateralfromthelateralportionoftheportionoftheduodenum(whiteduodenum(whitearrow)andleakagearrow)andleakageofcontrastmaterialofcontrastmaterialaroundtheliveraroundtheliver(blackarrow).(blackarrow).膀胱破裂n nRupturedbladd
46、erina43-year-oldfemalepedestrianwhowasRupturedbladderina43-year-oldfemalepedestrianwhowasstruckbyacar.struckbyacar.(a)(a)AxialabdominalCTimageshowsAxialabdominalCTimageshowsintraperitonealareasoffreecontrastmaterial(straightarrows)intraperitonealareasoffreecontrastmaterial(straightarrows)andfreeair(
47、curvedarrow).andfreeair(curvedarrow).(b)(b)AxialCTimageshowsaAxialCTimageshowsaretroperitonealareaofextraluminalcontrastenhancementretroperitonealareaofextraluminalcontrastenhancement(arrow).Thesefeaturesmimicthosefoundinbowelinjurybut,(arrow).Thesefeaturesmimicthosefoundinbowelinjurybut,instead,are
48、secondarytoabladderrupture,whichwasfoundatinstead,aresecondarytoabladderrupture,whichwasfoundatsurgery.surgery.胰腺炎血肿进入十二指壁n nAcutepancreatitisandAcutepancreatitisandhemorrhageintothelateralhemorrhageintothelateralduodenalwall,whichduodenalwall,whichcausedmasseffectandcausedmasseffectandnarrowingofth
49、eduodenalnarrowingoftheduodenallumen,ina46-year-oldlumen,ina46-year-oldman.CTscanshowsman.CTscanshowsextensivestrandingoftheextensivestrandingoftheperipancreaticfatperipancreaticfatsecondarytopancreatitis.secondarytopancreatitis.MassiveenlargementofMassiveenlargementofthelateralwallofthethelateralwa
50、lloftheduodenumisaccompaniedduodenumisaccompaniedbyafocalareaofbyafocalareaofincreasedattenuationatincreasedattenuationatthesiteofthebleedingthesiteofthebleeding(blackarrow).The(blackarrow).Theduodenallumen,whichduodenallumen,whichcontainslow-attenuationcontainslow-attenuationfluid,isnarrowedandfluid,isnarrowedanddisplacedmedially(whitedisplacedmedially(whitearrow).arrow).
