回盲区正常结构及常见病影像研究
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摘要
目的:
1.研究正常回盲区的影像学表现,并探讨影像学检查在回盲区疾病诊断和鉴别诊断中的应用价值。
2.研究增强CT、MRI在回盲区疾病诊断和鉴别诊断中的价值。
方法:
1.对31具尸体行阑尾解剖研究,并以数码照片形式记录,观察阑尾的形态、测量长度、直径、位置、及其与回盲瓣的关系。
2.分别对134例受检者行正常阑尾Philips 1.5T磁共振成像(层厚7mm)、对108例受检者行正常阑尾TOSHIBA 16排螺旋CT扫描(层厚1mm),重点测量阑尾的位置、大小、形态、信号或密度特点。
3.分别对74例受检者行16排螺旋CT扫描(层厚1mm)、对100例受检者行正常回盲瓣Philips 1.5T磁共振成像(层厚7mm),重点为正常回盲瓣的位置、大小、形态、信号或密度特点。
4.对20例受检者行16排螺旋CT平扫、增强(3期)扫描,主要观察增强前、后盲肠、回肠末端及阑尾的密度、CT值变化和周围血管特点。
5.分别对经手术病理证实的25例回盲区恶性肿瘤及44例回盲区炎性病变影像学检查方法及表现进行分析,总结各种检查方法的价值。
结果:
1.31具标本均见阑尾,表现为短管状或蚓状盲管,18例(18/31,58%)粗细均匀,13例(13/31,42%)远段增粗。阑尾根部27例(27/31,87.1%)位于盲肠后内,4例(4/31,12.9%)位于盲肠尖端,至盲肠尖端的距离为0.1～5.9cm,距回盲瓣距离为0.7～3.5cm,17例(17/31,54.8%)阑尾位于回肠末端前,14例(14/31,45.2%)位于回肠末端后。阑尾长度、直径分别为1.5～8.9cm,为4～7mm。
2.正常阑尾常规MRI显示率为76.9%(103/134),阑尾根部距回盲瓣的距离约2cm,直径约5mm,长约1～9cm,壁厚约1～2mm,表现为:带状等T1、等T2信号影,腔内无积液。
正常阑尾CT显示率为82.4%(89/108),阑尾根部距回盲瓣的距离约2cm,直径约5mm,长约1～8cm,壁厚约1～2mm,表现为:盲肠旁圆环形或与盲肠后壁相连的盲管状等密度影。
3.CT组74例受检者回盲瓣显示率100%,其密度呈肠壁样软组织。形态可分5型,鸟嘴型、靶型、唇型、类囊肿型、混合型。69例(69/74,93.2%)回盲瓣位于盲肠内侧壁,5例(5/74,6.8%)位于后壁,回盲瓣高度1.20～2.80cm,前后径1.02～3.02cm,宽径1.00～2.64cm。
常规MRI组100例受检者回盲瓣显示率冠位、矢位、轴位分别为88%(88/100)、14%(14/100)、10%(10/100),T1WI、T2WI呈肠壁样信号影。形态分型与CT相似。约93例(93/100,93%)回盲瓣位于盲肠内侧壁,7例(7/100,7%)位于盲肠后壁。回盲瓣高度1.09～3.22cm,前后径0.74～2.67cm,宽径约0.90～2.70cm。
4.受检者CT平扫盲肠、回肠末端、阑尾、右侧髂动脉平均CT值分别为39.3HU、39HU、34.6HU、43.5HU。回盲部结构清晰,边界清楚,周围脂肪间隙无异常密度影。CT增强扫描后盲肠动脉期、静脉期、延迟期平均CT值分别为67.6HU、70.5HU、58.3HU。回肠末端动脉期、静脉期、延迟期平均CT值分别为67.4HU、79.7HU、69HU。阑尾动脉期、静脉期、延迟期平均CT值分别为60.7HU、69.8 HU、47.6HU。右侧髂动脉动脉期、静脉期、延迟期CT值分别为288.6HU、130HU、84.3HU。
5. 25例回盲区恶性肿瘤,其中腺癌22例,淋巴瘤1例,原位癌1例,恶性胃肠间质瘤1例。病变部位依次为:回盲部、右半结肠、回肠末端、盲肠。病理形态:溃疡型9例、菌伞型2例、不规则型14例。腹部超声检查示右下腹肠套叠2例、少量腹水1例,回盲区实性包块13例,回盲区囊实性包块1例,腹膜后多发淋巴结1例,小肠肠梗阻4例,未见异常2例。胃肠钡剂检查示回盲区偏侧性不规则分叶状充盈缺损、粘膜破坏,肠管不规则狭窄10例,回肠末端类圆形充盈缺损伴小肠梗阻2例,肠系膜区块状软组织1例,伴龛影2例,伴肠套叠1例,伴全结肠痉挛1例。CT回盲区肠壁高度不规则增厚块影14例,类圆形块影1例,伴小肠梗阻1例。阑尾受侵实变1例,右侧输尿管受侵2例,右侧腰大肌受侵1例,右侧附件转移性巨大块影1例,肝、肺同时转移1例,肝转移1例,胰头受侵伴坏死2例,大量腹水3例,肠管旁少量积液1例,肠壁外不规则分叶块影2例,肠系膜多发结节伴实变12例,腹膜后淋巴结增大6例,广泛腹膜转移1例。MRI高分化腺癌1例,示盲肠、回盲部肠壁明显不规则增厚,管腔狭窄,肠壁内缘呈结节状,肠壁外缘可见明显分叶块影,呈长T1长T2信号影,多发肠系膜淋巴结、右侧盆腔淋巴结、双侧腹股沟淋巴结肿大,胰头增大信号异常,肝内多发异常信号结节影。增强后回盲区及胰头病变明显不均匀强化,伴有小囊变区。
44例回盲区炎症中,急性化脓性炎14例,其中蜂窝织炎12例,伴积脓1例,伴脓肿2例。一般慢性炎症26例,伴脓肿1例。慢性肉芽肿性炎症4例,包括克隆病2例,结核1例,梅毒1例。病变部位依次为:阑尾、回盲部、盲肠、回肠末端、右半结肠、回盲瓣。腹部超声检查示右下腹肠壁局限性、节段性增厚4例,大量腹水1例,少量腹水7例,腹膜增厚5例,实性包块1例,强回声包块1例、囊性包块3例、混合性包块3例,右侧腹腔多发淋巴结肿大4例、阑尾增粗增大回声异常5例,阑尾壁轻度增厚2例,肠管粘连3例,回盲区未见异常8例。胃肠钡剂检查示肠管充盈欠佳、痉挛狭窄6例,阑尾形态异常2例,似腹膜后占位性改变2例,其中肠管边缘不规则3例,粘膜增粗、紊乱10例,气液平3例,龛影1例。CT少量腹水3例,气液平面3例,肠壁增厚2例,周围渗出改变4例,囊实性包块7例、包埋右侧输尿管1例,与周围粘连1例,盲肠积脓1例,腹腔和或盆腔积脓3例,阑尾粪石1例。
结论:
1.多数成人阑尾形态位置比较固定,其长度、管径变异小,走形方向虽存在一定的变异,但多数阑尾可通过规范的影像学检查得以显示。
2.阑尾的管径局部或全部>6mm,管壁厚>2mm是CT诊断阑尾炎的可靠征象。MRI可作为检查阑尾方法的一种补充。
3.16排螺旋CT能获得高质量正常回盲瓣图像,能对回盲瓣是否正常提供重要帮助。MRI无X线辐射,可作为孕妇、儿童回盲瓣检查的补充方法。
4.正常回盲部平扫、增强CT扫描均为边界清楚,边缘光滑的结构,缓慢轻—中度强化,这些征象有助于此区域疾病的诊断和鉴别诊断。
5.影像学检查对回盲区炎症、恶性肿瘤的诊断有较大的价值,尤其是CT可准确定位病变及累及的范围,直接显示病变处肠壁增厚、管腔狭窄,特别是判断淋巴结是否肿大、周围肠系膜、血管、输尿管受侵情况,及远隔脏器转移的情况。
Objectives:
1. To investigate the appearance of normal ileocecal region, and research the diagnosis and differential diagnosis value of imageology examination in ileocecal region diseases.
2. To investigate the diagnositic and differential diagnositic values of CE CT and DCE MRI in ileocecal region diseases.
Methods:
1. To study the anatomy of appendix in 31corpses, recorded by the digital photo, to observe the shape of the appendix,to measure the length,the diameter,the position,and the relationship between the ileoceal vavle and the appendix.
2. The Philips 1.5T MRI(thickness 7mm) and TOSHIBA 16 rows spiral CT(thickness 1mm) images of normal appendix were obtained in 134 subjects and 108 subjects, respectively, with emphasis on its position, size, shape and intensity or density.
3. The TOSHIBA 16 rows spiral CT(thickness 1mm) and Philips 1.5T MRI(thickness 7mm) images of normal ileoceal valve were obtained in 74 subjects and 100 subjects, respectively, with emphasis on its position,size, shape and intensity or density.
4. A study of 20 subjects who underwent TOSHIBA 16 rows spiral CT plain scaning and three stage enhancement scaning for other diseases, emphasized on the manifestation of the change of the mean ,CT value,vessel of the cecum,terminal ileum,appendix.
5. The imaging appearances of 25 cases of the malignant tumor and 44 cases of the inflammation of the ileocecal region confirmed by operation and pathology were analysised retrospectively, to summarize the valve of various kinds’examination.
Results:
1. The appendix were present in all 31 corpses, it was a short or a earthworm-like caecus, There were uniform diameter in 18 (18/31,58%)corpses, and the distal segment were hypertrophied in 13(13/31,42%)corpses. The root of the appendix located at the posterior wall of the caecum in 27(27/31,87.1%) corpses, at the top of the caecum in 4 (4/31,12.9%)corpses. The distance between the appendix and the top of caecum was 0.1～5.9cm, between the appendix and ileoceal valve was 0.7～3.5cm. The direction variation of appendix were ante-terminal ileum in 17(17/31,54.8%)corpses, poster- terminal ileum in 14(14/31,45.2%)corpses. The length and diameter of the appendix were 1.5～8.9cm, 4～7mm ,retrospectively.
2. The visibility of a normal appendix on routine MR imaging was 76.9 % (103/134). Its distance from ileal valve was 2 cm, it,s diameter was 5 mm ,it,s length was 1～9cm,it,s wall thickness was 1～2mm. It appeared as a cord-like structure of mediumT1, T2 intensity without fluid collection in the lumen. The visibility of a normal appendix on CT imaging was 82.4 % (89/108). It,s distance from ileal valve was 2 cm, it,s diameter was 5 mm ,it,s length was 1～8cm,it,s wall thickness was 1～2mm. It appeared as a para-caecum ring-shaped structure of isodensity or a caecus conjointed to posterior paries of caecum.
3. The ileocecal valve was visible 100% (74/74) in CT group. The density of the valve was similar to the bowel wall. It,s morphology was divided into 5 types, bill, target,lip ,round cyst,mixed type. 69 cases(69/74,93.2%)valve located on the medial wall of the cecum,5 cases (5/74,6.8%)located on the posterior wall. The average valve height was1.20～2.80cm, average anteroposterior diameter was 1.02～3.02cm,and average width was 1.00～2.64cm.
The ileocecal valve were visible 88%(88/100),14%(14/100),10%(10/100)on coronal,sagital,traverse,respectively in MRI group. The density of the valve was similar to the bowel wall tissue in T1WI, T2WI. The morphology were similar to CT imaging. 93 case(s93/100,93%)valve located on the medial wall of the cecum,7 cases (7/100,7%)located on the posterior wall. The average valve height was1.09～3.22cm, average anteroposterior diameter was 0.74～2.67cm,and average width was 0.90～2.70cm.
4. The average CT valve of the cecum, terminal ileum,appendix respectively are 39.3HU,39HU,34.6HU,43.5HU in plain scan, ileocecal region has distinct structure,clear boundary,negative surrounding fat interspace. The average CT valve of the cecum at arterial phase, venous phase, delay period respectively are 67.6HU, 70.5HU, 58.3HU. The average CT valve of terminal ileum at arterial phase, venous phase, delay period differentially are67.4HU,79.7HU,69HU,The average CT valve of the appendix at arterial phase, venous phase, delay period respectively are 60.7HU,69.8 HU、47.6HU. The average CT valve of the right arteria iliaca at arterial phase, venous phase, delay period respectively are 288.6HU, 130HU, 84.3HU.
5. In 25 cancers,there were 22 adenocarcinoma,1 lymphoma,1 tumor in situ,1 malignant interstitialoma.The location of lesions were in ileoceal junction, in right hemicolon, in terminal ileum, in caecue, by turn. The tumor pathology shape were anabrotic form in 9 cases, hut form in 2 cases, irregular form in 14 cases.On ultrasound examination, 2 cases intussusception on right lower quadrant, 1 case small quantity ascites, 13 cases solid mass on ileocecal region, 1 case sack-solid mass on ileocecal region,1 case post-peritoneum multi- lymphadenectasis, 4 cases small intestine obstruction could be seen,2 ceses no abnormality seen. On barium meal, 10 cases lobulated, lateralization, irregular filling defection, mucosa destruction, and irregular intestinal stenosis could be seen. 2 cases round, filling defect on terminal ileum and small intestine obstruction,1 case lump, soft tissue on mesangial region, 2 cases niche sign, 1 case intussusception, 1 case whole colonospasm could be seen. On CT, 14 cases obviously irregular wall thickening, lump on ileocecal region,1 case round lump, 1 case small intestine obstruction,1 case invaded consol appendix, 2 cases right ureter invaded,1 case right psoas muscles invaded,1 case metastatic macrosis lump on right ovaries, 1 case liver and lung metastasis meanwhile,1 case liver metastasis,2 cases invaded necrosis on head of pancreas,3 cases a great quantity ascites,1 case small quantity hydrops para-intestine,2 cases irregular lobulated lump on para-wall,12 cases multi-node,consol on mesentery, 6 case post-peritoneum multi-lymphoid node, 1 case widespread peritoneum metastasis.
1 case well-differentiated adenocarcinoma on MRI, obviously irregular wall thickening ,lumina narrowed on caecum and ileocecal junction, inner margin nodosity, outer margin lobulated,long T1,long T2 singal, multi mesenteric lymphadenectasis,right pelvic cavity lymphadenectasis, bilateralis inguinal lymphadenectasis,head of pancreas swelling and abnormity singal, liver abnormity singal multi-nodus,above-mentioned pathological changes obviously uneven intensification after enhancement,accompanying microcyst.
In 44 inflammations, there were 14 acute purulent inflammations, which including 12 cellularis phlegmasia, 1 empyema, 2 abscess. There were 26 common chronic inflammations, 1 accompany abscess. There were 4 chronic granulomatous inflammation,which including 2 crohn disease, 1 tuberculosis, 1 syphilis.The location of lesions were in appendix,in ileoceal junction,in caecue,in terminal ileum,in right hemicolon,in ileoceal valve by turn. On ultrasound examination, 4 cases limitations, segment,wall thickening in right lower quadrant,1 case a great quantity ascites,7 cases a small quantity ascites,5 cases peritoneum thickening,1 case solid lump, 1 case strong echo lump,3 cases sack lump,3 cases mixed lump, 4 cases multi-lymphadenectasis in right abdominal cavity,5 cases appendix thickening, swelling, echo abnormity,2 cases appendix mild wall thicking,3 cases intestinal canal conglutination could be seen,8 cases no abnormality seen.On barium meal,6 cases bowel underfilling and quick peristalsis,2 cases appendix paramorphia, 2 cases post-peritoneum-liked lump, among these 3 cases intestinal canal borderline irregular, 10 cases mucous membrane thickening, mucous membrane derangement, 3 cases air-fluid level,1 case niche sign could be seen.On CT scan, 3 cases a small quantity ascites,3 cases air-fluid level,2 cases wall thicking,4 cases surrounding exudation,7 cases sack-solid lump,1 case embedding right ureter, 1 case surrounding conglutination,1 case caecum empyema,3 cases abdominal cavity or pelvic cavity empyema, 1 case appendix stercorolith could be seen.
Conclusion:
1. Most of appendix has invariable morphous and fixed location, mild diversitary length and diameter, although has some extent direction variation, but the majority appendix could be present clearly by normative imageology examination.
2. The diameter of the appendix partly or entirely exceeded 6 mm; its wall thickness exceeded 2 mm, and accompanied phlegmona or abscess, were reliable signs to diagnose the appendicitis in CT. MRI is a supplementary method for examining appendix.
3. 16-slices spiral CT is a pratical method for acquision of high-quality imaging of the ileocecal valve, allowing differentiating if the ileoceal vavle be involved in diseases. MRI is no X ray, it could be a supplementary method for examining ileoceal vavle for pregnant women and children.
4. The normal ileocecal region has distinct structure, clear boundary in both plain and enhancement CT scanning, from light to moderate enhancement slowly, these signs is helpful to diagnose and differentially diagnose for ileocecal region diseases.
5. The imaging examination has important value in diagnosis of the malignant tumor and the inflammation of the ileoceal region, especially CT could definitely localize and make sure the extent of diseases,directly show the thickness wall and the narrow lumens, extraordinarily swell lymphade and invaded surrounding mesentery,blood vessel,ureter,and remoteness organ metastasis.
1.研究正常回盲区的影像学表现,并探讨影像学检查在回盲区疾病诊断和鉴别诊断中的应用价值。
2.研究增强CT、MRI在回盲区疾病诊断和鉴别诊断中的价值。
方法:
1.对31具尸体行阑尾解剖研究,并以数码照片形式记录,观察阑尾的形态、测量长度、直径、位置、及其与回盲瓣的关系。
2.分别对134例受检者行正常阑尾Philips 1.5T磁共振成像(层厚7mm)、对108例受检者行正常阑尾TOSHIBA 16排螺旋CT扫描(层厚1mm),重点测量阑尾的位置、大小、形态、信号或密度特点。
3.分别对74例受检者行16排螺旋CT扫描(层厚1mm)、对100例受检者行正常回盲瓣Philips 1.5T磁共振成像(层厚7mm),重点为正常回盲瓣的位置、大小、形态、信号或密度特点。
4.对20例受检者行16排螺旋CT平扫、增强(3期)扫描,主要观察增强前、后盲肠、回肠末端及阑尾的密度、CT值变化和周围血管特点。
5.分别对经手术病理证实的25例回盲区恶性肿瘤及44例回盲区炎性病变影像学检查方法及表现进行分析,总结各种检查方法的价值。
结果:
1.31具标本均见阑尾,表现为短管状或蚓状盲管,18例(18/31,58%)粗细均匀,13例(13/31,42%)远段增粗。阑尾根部27例(27/31,87.1%)位于盲肠后内,4例(4/31,12.9%)位于盲肠尖端,至盲肠尖端的距离为0.1～5.9cm,距回盲瓣距离为0.7～3.5cm,17例(17/31,54.8%)阑尾位于回肠末端前,14例(14/31,45.2%)位于回肠末端后。阑尾长度、直径分别为1.5～8.9cm,为4～7mm。
2.正常阑尾常规MRI显示率为76.9%(103/134),阑尾根部距回盲瓣的距离约2cm,直径约5mm,长约1～9cm,壁厚约1～2mm,表现为:带状等T1、等T2信号影,腔内无积液。
正常阑尾CT显示率为82.4%(89/108),阑尾根部距回盲瓣的距离约2cm,直径约5mm,长约1～8cm,壁厚约1～2mm,表现为:盲肠旁圆环形或与盲肠后壁相连的盲管状等密度影。
3.CT组74例受检者回盲瓣显示率100%,其密度呈肠壁样软组织。形态可分5型,鸟嘴型、靶型、唇型、类囊肿型、混合型。69例(69/74,93.2%)回盲瓣位于盲肠内侧壁,5例(5/74,6.8%)位于后壁,回盲瓣高度1.20～2.80cm,前后径1.02～3.02cm,宽径1.00～2.64cm。
常规MRI组100例受检者回盲瓣显示率冠位、矢位、轴位分别为88%(88/100)、14%(14/100)、10%(10/100),T1WI、T2WI呈肠壁样信号影。形态分型与CT相似。约93例(93/100,93%)回盲瓣位于盲肠内侧壁,7例(7/100,7%)位于盲肠后壁。回盲瓣高度1.09～3.22cm,前后径0.74～2.67cm,宽径约0.90～2.70cm。
4.受检者CT平扫盲肠、回肠末端、阑尾、右侧髂动脉平均CT值分别为39.3HU、39HU、34.6HU、43.5HU。回盲部结构清晰,边界清楚,周围脂肪间隙无异常密度影。CT增强扫描后盲肠动脉期、静脉期、延迟期平均CT值分别为67.6HU、70.5HU、58.3HU。回肠末端动脉期、静脉期、延迟期平均CT值分别为67.4HU、79.7HU、69HU。阑尾动脉期、静脉期、延迟期平均CT值分别为60.7HU、69.8 HU、47.6HU。右侧髂动脉动脉期、静脉期、延迟期CT值分别为288.6HU、130HU、84.3HU。
5. 25例回盲区恶性肿瘤,其中腺癌22例,淋巴瘤1例,原位癌1例,恶性胃肠间质瘤1例。病变部位依次为:回盲部、右半结肠、回肠末端、盲肠。病理形态:溃疡型9例、菌伞型2例、不规则型14例。腹部超声检查示右下腹肠套叠2例、少量腹水1例,回盲区实性包块13例,回盲区囊实性包块1例,腹膜后多发淋巴结1例,小肠肠梗阻4例,未见异常2例。胃肠钡剂检查示回盲区偏侧性不规则分叶状充盈缺损、粘膜破坏,肠管不规则狭窄10例,回肠末端类圆形充盈缺损伴小肠梗阻2例,肠系膜区块状软组织1例,伴龛影2例,伴肠套叠1例,伴全结肠痉挛1例。CT回盲区肠壁高度不规则增厚块影14例,类圆形块影1例,伴小肠梗阻1例。阑尾受侵实变1例,右侧输尿管受侵2例,右侧腰大肌受侵1例,右侧附件转移性巨大块影1例,肝、肺同时转移1例,肝转移1例,胰头受侵伴坏死2例,大量腹水3例,肠管旁少量积液1例,肠壁外不规则分叶块影2例,肠系膜多发结节伴实变12例,腹膜后淋巴结增大6例,广泛腹膜转移1例。MRI高分化腺癌1例,示盲肠、回盲部肠壁明显不规则增厚,管腔狭窄,肠壁内缘呈结节状,肠壁外缘可见明显分叶块影,呈长T1长T2信号影,多发肠系膜淋巴结、右侧盆腔淋巴结、双侧腹股沟淋巴结肿大,胰头增大信号异常,肝内多发异常信号结节影。增强后回盲区及胰头病变明显不均匀强化,伴有小囊变区。
44例回盲区炎症中,急性化脓性炎14例,其中蜂窝织炎12例,伴积脓1例,伴脓肿2例。一般慢性炎症26例,伴脓肿1例。慢性肉芽肿性炎症4例,包括克隆病2例,结核1例,梅毒1例。病变部位依次为:阑尾、回盲部、盲肠、回肠末端、右半结肠、回盲瓣。腹部超声检查示右下腹肠壁局限性、节段性增厚4例,大量腹水1例,少量腹水7例,腹膜增厚5例,实性包块1例,强回声包块1例、囊性包块3例、混合性包块3例,右侧腹腔多发淋巴结肿大4例、阑尾增粗增大回声异常5例,阑尾壁轻度增厚2例,肠管粘连3例,回盲区未见异常8例。胃肠钡剂检查示肠管充盈欠佳、痉挛狭窄6例,阑尾形态异常2例,似腹膜后占位性改变2例,其中肠管边缘不规则3例,粘膜增粗、紊乱10例,气液平3例,龛影1例。CT少量腹水3例,气液平面3例,肠壁增厚2例,周围渗出改变4例,囊实性包块7例、包埋右侧输尿管1例,与周围粘连1例,盲肠积脓1例,腹腔和或盆腔积脓3例,阑尾粪石1例。
结论:
1.多数成人阑尾形态位置比较固定,其长度、管径变异小,走形方向虽存在一定的变异,但多数阑尾可通过规范的影像学检查得以显示。
2.阑尾的管径局部或全部>6mm,管壁厚>2mm是CT诊断阑尾炎的可靠征象。MRI可作为检查阑尾方法的一种补充。
3.16排螺旋CT能获得高质量正常回盲瓣图像,能对回盲瓣是否正常提供重要帮助。MRI无X线辐射,可作为孕妇、儿童回盲瓣检查的补充方法。
4.正常回盲部平扫、增强CT扫描均为边界清楚,边缘光滑的结构,缓慢轻—中度强化,这些征象有助于此区域疾病的诊断和鉴别诊断。
5.影像学检查对回盲区炎症、恶性肿瘤的诊断有较大的价值,尤其是CT可准确定位病变及累及的范围,直接显示病变处肠壁增厚、管腔狭窄,特别是判断淋巴结是否肿大、周围肠系膜、血管、输尿管受侵情况,及远隔脏器转移的情况。
Objectives:
1. To investigate the appearance of normal ileocecal region, and research the diagnosis and differential diagnosis value of imageology examination in ileocecal region diseases.
2. To investigate the diagnositic and differential diagnositic values of CE CT and DCE MRI in ileocecal region diseases.
Methods:
1. To study the anatomy of appendix in 31corpses, recorded by the digital photo, to observe the shape of the appendix,to measure the length,the diameter,the position,and the relationship between the ileoceal vavle and the appendix.
2. The Philips 1.5T MRI(thickness 7mm) and TOSHIBA 16 rows spiral CT(thickness 1mm) images of normal appendix were obtained in 134 subjects and 108 subjects, respectively, with emphasis on its position, size, shape and intensity or density.
3. The TOSHIBA 16 rows spiral CT(thickness 1mm) and Philips 1.5T MRI(thickness 7mm) images of normal ileoceal valve were obtained in 74 subjects and 100 subjects, respectively, with emphasis on its position,size, shape and intensity or density.
4. A study of 20 subjects who underwent TOSHIBA 16 rows spiral CT plain scaning and three stage enhancement scaning for other diseases, emphasized on the manifestation of the change of the mean ,CT value,vessel of the cecum,terminal ileum,appendix.
5. The imaging appearances of 25 cases of the malignant tumor and 44 cases of the inflammation of the ileocecal region confirmed by operation and pathology were analysised retrospectively, to summarize the valve of various kinds’examination.
Results:
1. The appendix were present in all 31 corpses, it was a short or a earthworm-like caecus, There were uniform diameter in 18 (18/31,58%)corpses, and the distal segment were hypertrophied in 13(13/31,42%)corpses. The root of the appendix located at the posterior wall of the caecum in 27(27/31,87.1%) corpses, at the top of the caecum in 4 (4/31,12.9%)corpses. The distance between the appendix and the top of caecum was 0.1～5.9cm, between the appendix and ileoceal valve was 0.7～3.5cm. The direction variation of appendix were ante-terminal ileum in 17(17/31,54.8%)corpses, poster- terminal ileum in 14(14/31,45.2%)corpses. The length and diameter of the appendix were 1.5～8.9cm, 4～7mm ,retrospectively.
2. The visibility of a normal appendix on routine MR imaging was 76.9 % (103/134). Its distance from ileal valve was 2 cm, it,s diameter was 5 mm ,it,s length was 1～9cm,it,s wall thickness was 1～2mm. It appeared as a cord-like structure of mediumT1, T2 intensity without fluid collection in the lumen. The visibility of a normal appendix on CT imaging was 82.4 % (89/108). It,s distance from ileal valve was 2 cm, it,s diameter was 5 mm ,it,s length was 1～8cm,it,s wall thickness was 1～2mm. It appeared as a para-caecum ring-shaped structure of isodensity or a caecus conjointed to posterior paries of caecum.
3. The ileocecal valve was visible 100% (74/74) in CT group. The density of the valve was similar to the bowel wall. It,s morphology was divided into 5 types, bill, target,lip ,round cyst,mixed type. 69 cases(69/74,93.2%)valve located on the medial wall of the cecum,5 cases (5/74,6.8%)located on the posterior wall. The average valve height was1.20～2.80cm, average anteroposterior diameter was 1.02～3.02cm,and average width was 1.00～2.64cm.
The ileocecal valve were visible 88%(88/100),14%(14/100),10%(10/100)on coronal,sagital,traverse,respectively in MRI group. The density of the valve was similar to the bowel wall tissue in T1WI, T2WI. The morphology were similar to CT imaging. 93 case(s93/100,93%)valve located on the medial wall of the cecum,7 cases (7/100,7%)located on the posterior wall. The average valve height was1.09～3.22cm, average anteroposterior diameter was 0.74～2.67cm,and average width was 0.90～2.70cm.
4. The average CT valve of the cecum, terminal ileum,appendix respectively are 39.3HU,39HU,34.6HU,43.5HU in plain scan, ileocecal region has distinct structure,clear boundary,negative surrounding fat interspace. The average CT valve of the cecum at arterial phase, venous phase, delay period respectively are 67.6HU, 70.5HU, 58.3HU. The average CT valve of terminal ileum at arterial phase, venous phase, delay period differentially are67.4HU,79.7HU,69HU,The average CT valve of the appendix at arterial phase, venous phase, delay period respectively are 60.7HU,69.8 HU、47.6HU. The average CT valve of the right arteria iliaca at arterial phase, venous phase, delay period respectively are 288.6HU, 130HU, 84.3HU.
5. In 25 cancers,there were 22 adenocarcinoma,1 lymphoma,1 tumor in situ,1 malignant interstitialoma.The location of lesions were in ileoceal junction, in right hemicolon, in terminal ileum, in caecue, by turn. The tumor pathology shape were anabrotic form in 9 cases, hut form in 2 cases, irregular form in 14 cases.On ultrasound examination, 2 cases intussusception on right lower quadrant, 1 case small quantity ascites, 13 cases solid mass on ileocecal region, 1 case sack-solid mass on ileocecal region,1 case post-peritoneum multi- lymphadenectasis, 4 cases small intestine obstruction could be seen,2 ceses no abnormality seen. On barium meal, 10 cases lobulated, lateralization, irregular filling defection, mucosa destruction, and irregular intestinal stenosis could be seen. 2 cases round, filling defect on terminal ileum and small intestine obstruction,1 case lump, soft tissue on mesangial region, 2 cases niche sign, 1 case intussusception, 1 case whole colonospasm could be seen. On CT, 14 cases obviously irregular wall thickening, lump on ileocecal region,1 case round lump, 1 case small intestine obstruction,1 case invaded consol appendix, 2 cases right ureter invaded,1 case right psoas muscles invaded,1 case metastatic macrosis lump on right ovaries, 1 case liver and lung metastasis meanwhile,1 case liver metastasis,2 cases invaded necrosis on head of pancreas,3 cases a great quantity ascites,1 case small quantity hydrops para-intestine,2 cases irregular lobulated lump on para-wall,12 cases multi-node,consol on mesentery, 6 case post-peritoneum multi-lymphoid node, 1 case widespread peritoneum metastasis.
1 case well-differentiated adenocarcinoma on MRI, obviously irregular wall thickening ,lumina narrowed on caecum and ileocecal junction, inner margin nodosity, outer margin lobulated,long T1,long T2 singal, multi mesenteric lymphadenectasis,right pelvic cavity lymphadenectasis, bilateralis inguinal lymphadenectasis,head of pancreas swelling and abnormity singal, liver abnormity singal multi-nodus,above-mentioned pathological changes obviously uneven intensification after enhancement,accompanying microcyst.
In 44 inflammations, there were 14 acute purulent inflammations, which including 12 cellularis phlegmasia, 1 empyema, 2 abscess. There were 26 common chronic inflammations, 1 accompany abscess. There were 4 chronic granulomatous inflammation,which including 2 crohn disease, 1 tuberculosis, 1 syphilis.The location of lesions were in appendix,in ileoceal junction,in caecue,in terminal ileum,in right hemicolon,in ileoceal valve by turn. On ultrasound examination, 4 cases limitations, segment,wall thickening in right lower quadrant,1 case a great quantity ascites,7 cases a small quantity ascites,5 cases peritoneum thickening,1 case solid lump, 1 case strong echo lump,3 cases sack lump,3 cases mixed lump, 4 cases multi-lymphadenectasis in right abdominal cavity,5 cases appendix thickening, swelling, echo abnormity,2 cases appendix mild wall thicking,3 cases intestinal canal conglutination could be seen,8 cases no abnormality seen.On barium meal,6 cases bowel underfilling and quick peristalsis,2 cases appendix paramorphia, 2 cases post-peritoneum-liked lump, among these 3 cases intestinal canal borderline irregular, 10 cases mucous membrane thickening, mucous membrane derangement, 3 cases air-fluid level,1 case niche sign could be seen.On CT scan, 3 cases a small quantity ascites,3 cases air-fluid level,2 cases wall thicking,4 cases surrounding exudation,7 cases sack-solid lump,1 case embedding right ureter, 1 case surrounding conglutination,1 case caecum empyema,3 cases abdominal cavity or pelvic cavity empyema, 1 case appendix stercorolith could be seen.
Conclusion:
1. Most of appendix has invariable morphous and fixed location, mild diversitary length and diameter, although has some extent direction variation, but the majority appendix could be present clearly by normative imageology examination.
2. The diameter of the appendix partly or entirely exceeded 6 mm; its wall thickness exceeded 2 mm, and accompanied phlegmona or abscess, were reliable signs to diagnose the appendicitis in CT. MRI is a supplementary method for examining appendix.
3. 16-slices spiral CT is a pratical method for acquision of high-quality imaging of the ileocecal valve, allowing differentiating if the ileoceal vavle be involved in diseases. MRI is no X ray, it could be a supplementary method for examining ileoceal vavle for pregnant women and children.
4. The normal ileocecal region has distinct structure, clear boundary in both plain and enhancement CT scanning, from light to moderate enhancement slowly, these signs is helpful to diagnose and differentially diagnose for ileocecal region diseases.
5. The imaging examination has important value in diagnosis of the malignant tumor and the inflammation of the ileoceal region, especially CT could definitely localize and make sure the extent of diseases,directly show the thickness wall and the narrow lumens, extraordinarily swell lymphade and invaded surrounding mesentery,blood vessel,ureter,and remoteness organ metastasis.
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