门静脉高压(PHT)是肝硬化患者病程进展中的重要病理生理机制,其中严重的胃食管静脉曲张破裂出血是肝硬化最常见的致死性并发症,PHT的严重程度及胃食管静脉曲张与并发症的发生率相关,故及时对肝硬化患者的门静脉压力和出血风险进行评估尤为重要.本文主要讨论了目前诊断和评估PHT严重程度及预测出血风险的无创影像学检查方法.

1 临床资料 患者男,59岁.因1 d前无明显诱因出现咯血症状入院.既往无高血压、糖尿病、冠心病、外伤、输血等病史,否认肝炎、结核等传染性疾病史,有吸烟史.入院时偶有咳嗽,无咳 痰、发热、胸闷、气促、胸痛、盗汗、纳差、消瘦等表现,无血尿、黑便等病史.

患者女，80岁，于2022年2月13日因"乏力、纳差4天，黑便1天"入院。入院后患者乏力、纳差进一步加重，精神较差，查体胸腹部皮肤可见大片淤斑，腹部可触及多个皮下包块，明显压痛，包块质韧，边界尚清，拒按。血常规提示HGB 37 g/L，凝血功能提示PT 21.7 s、APTT 46.9 s、INR 1.88。床旁彩超检查提示腹壁及腹腔内多发不均质包块，考虑血肿可能。追问病史，患者曾于当地医院腹部皮下注射肝素。进一步行CT检查示前腹壁及盆腔多发软组织包块影，考虑血肿，CT值约60 HU，较大者位于前腹壁，最大截面积约8.4×4.8 cm（图1A），CTA示腹壁右侧血肿形成并活动性出血，出血血管考虑为腹壁上动脉及下动脉（图1B）。给予补充维生素K、输注血浆治疗后效果不佳，遂进一步行动脉栓塞止血术。

异位静脉曲张是肝硬化的少见并发症,在肝硬化患者中其发生率仅约为1％～5％, 发生在回肠造瘘口处的异位静脉曲张罕见[1].本文报道一例肝硬化门脉高压静脉曲张病例,因膀胱癌行回肠代膀胱术后回肠造口反复出血的诊治经验.

BACKGROUND:Calcification of abdominal lymph node is a common clinical phenomenon, but it is extremely rare to cause serious adverse clinical outcomes. In the present case, the ruptured hemorrhage of the oesophagogastric fundic varices occurred as a result of portal hypertension due to compression of the portal vein by calcified lymph nodes. The patient was treated with medication, interventional therapy, endoscopic therapy, and surgery, respectively and the four different treatment options for the bleeding are worth summarizing. The etiology of this case is extremely rare and is the first to be reported in the world.CASE PRESENTATION:A 32-year-old male patient with no apparent causes of sudden onset of vomiting of blood, the patient underwent four different treatment methods to stop the hemorrhage. The combined diagnosis of whole abdomen enhanced CT and angiography was calcified abdominal lymph nodes compressing the portal vein, leading to portal hypertension and resulting in esophageal and gastric variceal bleeding. Postoperatively, a biopsy of the caseous tubercular tissue of the abdominal wall observed intraoperatively was performed and the biopsy did not show a tubercular component. Therefore, the extensive intra-abdominal lymph node calcification was not associated with tuberculosis. The patient's bleeding ceased after surgery.CONCLUSION:This case has improved the clinician's understanding of the etiology of non-cirrhotic portal hypertension. Based on this, and with this case, the differences between various hemostatic measures were studied in depth.

目的:探讨锥形束CT(cone beam CT,CBCT)相关技术在原发性肝癌患者肝动脉灌注化疗栓塞术(tran?scatheter arterial chemoembolization,TACE)治疗中的应用价值.方法:收集我院2018-2019年经TACE治疗的原发性肝癌患者120例,其中观察组62例患者TACE术中使用CBCT扫描技术行肝脏双期扫描,对肝脏动脉进行三维重建明确肿瘤供血动脉,并实时引导插管及精准栓塞,并对栓塞效果进行评价;对照组58例患者行传统的数字减影血管造影(digital subtraction angiography,DSA)引导栓塞.对比两组患者术中肿瘤的检出率、肿瘤供血动脉的完全识别率、超选择插管成功率、手术时间、累计辐射剂量、术后并发症及术后1月肿瘤缓解率.结果:观察组与对照组肿瘤检出率分别为100％、91.9％,P=0.006;观察组与对照组肿瘤供血动脉识别率分别为95.2％、81.0％,P=0016;观察组与对照组超选择插管成功率分别为96.8％、84.5％,P=0.02;观察组与对照组术后1月肿瘤缓解率分别为88.7％、70.7％,P=0.014;观察组与对照组手术时间分别为(40.29±7.10)min、(35.17±6.04)min,P=0.000;观察组与对照组累计辐射剂量分别为(196.55±11.62)mGy、(157.00±11.12)mGy,P=0.000;观察组与对照组术后并发症差异无统计学意义.结论:CBCT技术会相对延长TACE手术时间,增加辐射剂量,但在肿瘤的检出率、肿瘤供血动脉识别率及肿瘤近期缓解率方面均优于传统DSA造影,值得临床采用.

目的:利用人工智能(artificial intelligence,AI)技术对COVID-19患者的胸部影像学资料进行数字化分析,并总结其特点及分析AI技术的优势.方法:应用依图肺部智能AI辅助系统对十堰市人民医院核酸检测阳性且经临床多学科会诊确诊的66例COVID-19患者的CT影像学资料及临床资料进行回顾性分析.利用GE Light?Speed16MSCT进行胸部扫描,将影像学资料导入AI系统进行量化.总结新冠肺炎患者的CT征象,包括磨玻璃影、实变影等,并对AI系统构筑的密度直方图等进行分析.采用SPSS 23.0软件进行数据分析,对左右肺的磨玻璃、实变及总病灶体积进行对比分析.结果:COVID-19患者主要的影像学表现为双肺散在分布磨玻璃密度影伴部分肺组织实变;AI辅助诊断系统较人工阅片具有优势,可以定量病灶体积并能更好地识别病灶累计的肺叶.COVID-19患者右肺病灶体积、磨玻璃影病灶体积及实变病灶体积均大于左肺,差异有统计学意义(P<0.05);并且AI辅助系统构建的密度直方图可统计区间内各种类型病灶的像素数量,对监测病情发展起到了一定作用.结论:AI技术的检测效率、能力及准确率均优于人工识别,AI技术可以通过量化病灶以及构建直方图等形式,更加直观地总结病灶的分布特点并分析病情的进展情况,因此AI技术对COVID-19的诊断具有重要的临床价值.

急性CO中毒(ACOP)的临床表现多样,多导致神经系统病症.本文报道1例ACOP继发横纹肌溶解、下肢动静脉瘘的罕见病例,以提高临床医生对ACOP并发症的认识.

目的 探讨下消化道出血患者栓塞治疗的难点及改善方法.方法 回顾性分析我院2014年1月～2017年12月收治的21例下消化道出血的患者,就其出血病因及栓塞治疗方法进行总结,分析其改善方法.结果 造影明确出血病灶的有13例,阳性率为61.9％,8例下消化道出血患者造影未见确切出血征象.15例患者经栓塞血治疗后效果明显,术后继续内科保守治疗,未再出血;有4例经介入治疗后效果不佳,术后仍有出血,最终行剖腹探查,切除部分病变肠管;2例患者出现严重并发症,其中1例出现肠坏死穿孔,感染性休克死亡,另1例术后出血性休克,家属放弃治疗.结论 介入栓塞治疗下消化道出血时应尽量进行超选择性栓塞,选择合适的栓塞材料,可取得良好的临床效果.

Our study aimed to establish and validate a multi-class scoring system for preoperative gastric gastrointestinal stromal tumors (GISTs) risk stratifications based on CT features. 150 gastric GIST patients who underwent contrast-enhanced CT examination and surgical resection from hospital 1 were retrospectively analyzed as the training cohort, and 61 patients from hospitals 2 and 3 were included as the validation cohort. A model was established by logistic regression analysis and weighted to be a scoring model. A calibration test, area under the receiver operating characteristic (ROC) curve (AUC), and cutoff points were determined for the score model. The model was also divided into three score ranges for convenient clinical evaluation. Five CT features were included in the score model, including tumor size (4 points), ill-defined margin (6 points), intratumoral enlarged vessels (5 points), heterogeneous enhancement pattern (4 points), and exophytic or mixed growth pattern (2 points). Then, based on the calibration results, performance was merely assessed as very low and high* risk. The AUCs of the score model for very low risk and high* risk were 0.973 and 0.977, and the cutoff points were 3 points (97.30%, 93.81%) and 7 points (92.19%, 94.19%), respectively. In the validation cohort, the AUCs were 0.912 and 0.972, and the cutoff values were 3 points (92.31%, 85.42%) and 5 points (100%, 87.88%), respectively. The model was stratified into 3 ranges: 0-3 points for very low risk, 4-8 points for low risk, and 9-21 points for high* risk. A concise and practical score system for gastric GISTs risk stratification was proposed.

目的:探究表阿霉素-明胶海绵微粒(Epirubici-Gelatin sponge particulate,EPI-GSP)栓塞治疗大肝癌的近期疗效.方法:收集我院2017年12月至2018年12月确诊大肝癌的52例患者,均行TACE治疗,其中观察组27例患者采用表阿霉素-明胶海绵微粒(EPI-GSP)混悬液进行栓塞,对照组25例患者采用表阿霉素及空白明胶海绵微粒序贯栓塞,对比两组患者术后不良反应及术后6个月肿瘤反应情况.结果:两组患者在随访过程中均未出现严重的不良反应,不良反应发生率差异无统计学意义(P>0.05);观察组的肿瘤部分缓解(PR)率及总缓解率(ORR)高于对照组,差异有统计学意义(P<0.05).结论:表阿霉素-明胶海绵微粒(EPI-GSP)混悬液栓塞治疗大肝癌较序贯栓塞具有更好的近期疗效,具有一定的药物缓释作用,可供临床采用.

孤立性纤维瘤(solitary fibrous tumor,SFT)是一种少见的软组织肿瘤,大部分发生在脏层胸膜,在身体其他器官也可以发生,但是发生在子宫阔韧带十分罕见.子宫阔韧带是维持子宫位置相对固定的韧带之一,位于子宫两侧,是由两层腹膜组成,内有含脂肪的疏松结缔组织,是肌瘤的好发部位之一,但是较少有文献报道关于子宫阔韧带孤立性纤维瘤,现对此病例做如下报道.

Objective: To investigate and analyze the distribution of main pathogenic bacteria in bile of patients with postoperative biliary infection after liver puncture percutaneous biliary drainage (PTCD) treatment and their sensitivity to different antibiotics. Methods: The patients (219 cases) with biliary tract infection after PTCD treatment were collected in June 2014-June 2016, the bile samples were gathered, and bacteria+fungus culture and drug sensitive test were performed and analyzed. Results: (1) The 219 bile samples were collected, a total of 253 strains were obtained, containing 20 kinds and including 194 strains of G- bacteria (76.7%) , 53 strains of G+ bacteria (20.9%) and 6 strains of fungus (2.4%) ; The top three G- bacteria were Escherichia coli (93 strains, 36.7%) , Klebsiella pneumoniae (39 strains, 15.4%) and Pseudomonas aeruginosa (18 strains, 7.1%) . The top two G+ bacteria were Enterococcus faecium (17 strains, 6.7%) and Enterococcus faecalis (14 strains, 5.5%) ; The fungi were mainly Candida albicans (3 strains, 1.2%) . (2) Antibacterial drugs with high sensitivity to G- bacteria included carbapenems, aminoglycosides and cephalosporins; Antibacterial drugs with high sensitivity to G+ bacteria included quinolones, oxazolanone and glycoside antibiotics. Fungi were sensitive to triazole antifungal drugs. Conclusions: G- bacteria are the main pathogenic bacteria in the bile of patients with biliary tract infection after PTCD treatment, followed by G+ bacteria and fungi, and some cases are mixed infection. Key words: Percutaneous biliary drainage; Biliary infection; Bacterial spectrum; Drug resistance; Antibiotic

黄疸是一种临床常见的疾病症状,病因主要包括肝细胞性、胆汁淤积性、溶血性以及原发非溶血性4种[1].其中胆汁淤积性黄疸即梗阻性黄疽,如在治疗中解除不及时,可能导致患者发生化脓性胆管炎以及肝脏功能衰竭等不良后果,严重威胁患者生命健康[2-3].其中恶性病变包括胆管与胆囊癌、原发性肝癌、壶腹癌、胰头癌、肝门区与胰腺区的转移癌等,造成阻塞性远端胆管扩张.目前临床上行经皮肝穿胆道引流术是缓解梗阻性黄疸最有效的方法之一.[4]外科手术治疗恶性梗阻性黄疸的预后差、成功率低、及病死率高,不但破坏胆道的完整性,还不同程度的改变胆汁的引流方式,使胆道感染风险显著升高,而行经皮肝穿胆道引流术安全性高、创伤小及操作简单,所以现在已经取代了部分外科手术.PTCD术后胆道感染是最主要的并发症,近年来的临床研究也发现PTCD后胆道感染的发生率在14％ ～ 47％之间,并且胆道感染会导致病情进一步恶化,甚至会引起死亡[5-6].