CHICAGO (EGMN) Multidetector computed tomography can identify the site and etiology of gastrointestinal perforations correctly in a high percentage of patients with acute abdominal pain who present to an emergency department, according to a prospective study.

This imaging technique can help surgeons make crucial and timely decisions about surgery or other therapeutic options in these acute patients, Dr. Leopoldo D. Salvatierra Arrieta said during the annual clinical congress of the American College of Surgeons.

To assess the accuracy of multidetector computed tomography (MDCT) in this setting, Dr. Arrieta and his colleagues prospectively studied 121 patients presenting with acute abdominal pain between April 2007 and January 2009 at La Paz University Hospital in Madrid. The research was designated a Poster of Exceptional Merit at the meeting.

Two radiologists who were blinded to the subsequent surgical findings used MDCT independently of one another and reached a consensus on the perforation site in 96 of 121 cases (79%). Surgery later revealed that MCDT correctly predicted the site in 80 of these 96 cases (83%).

Of the remaining 25 patients, 12 had an indeterminate perforation site, 10 did not have a GI perforation (verified by surgery), and 3 declined surgery.

The large bowel, stomach, and small bowel were the most common sites for GI tract perforations identified with MDCT. The mean patient age was 63 years (range, 15-97 years), and the study included 58 men and 63 women.

The strongest predictors of the perforation site on MDCT were bowel wall defect, concentration of extraluminal air bubbles, and segmental bowel wall thickening, Dr. Arrieta said.

Surgeons identified more perforation sites, a total of 108, compared with the radiologists using preoperative MDCT. Surgeons found 30 perforations in the descending colon and sigmoid, 25 in the stomach or duodenum, 21 in the small bowel, 10 in the cecum or ascending colon, 5 in the rectum, and 1 transverse colon perforation; the series also included 16 patients with an acute perforated appendix.

The radiologists also evaluated MDCT scans for information on the etiology of the perforation and correctly identified the cause in 71 patients. Inflammation was the most common etiology, followed by tumor and peptic ulcer. Ischemia, foreign bodies, and trauma were other causes of the perforations.

The radiologists analyzed axial and multiplanar images. They specifically looked for contrast extravasation, bowel wall focal defects, extraluminal air-free fluid, and any inflammatory changes, including segmental bowel wall thickening, perivisceral fat stranding, or abscess. Segmental thickening of the bowel wall, fat stranding, and abscess were the most important MDCT signs in perforations associated with inflammatory causes. For patients with neoplastic perforations, segmental thickening and free air were the most frequent MDCT findings.

Dr. Arrieta and his associates chose MDCT because the modality has an overall accuracy of 82% to 90% for predicting the site of GI tract perforation in published studies (Am. J. Roentgenol. 2006;187:1179-83). With sensitivities ranging from 69% to 95% and specificities of 95% to 100% for diagnosis of bowel blunt trauma and mesenteric injuries, CT scanning and MDCT have emerged as the primary diagnostic imaging modalities for patients presenting with abdominal or pelvic pain, he added (Radiographics 2006;26:1119-31).

“We think accurate preoperative diagnosis [with MDCT] is helpful,” Dr. Arrieta said. MDCT is “the most valuable technique for identifying the presence, site, and cause of GI tract perforation.”

Dr. Arrieta had nothing to disclose.

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芝加哥(EGMN)——根据一项前瞻性研究的结果，在较高比例的因急性腹痛就诊于急诊科的患者中，多排螺旋计算机体层扫描(MDCT)技术可准确检测出胃肠穿孔的部位和病因。

 

对于急诊患者，这种影像学技术可帮助外科医生及时做出手术或选择其他治疗方式的关键决定，Leopoldo D. Salvatierra Arrieta博士在美国外科医师学会年度临床大会上说。

 

为了评估多排螺旋计算机体层扫描技术在此种临床应用中的准确性，Arrieta博士及其同事对2007年4月至2009年1月间因急性腹痛就诊于马德里La Paz大学医院的121例患者进行了前瞻性研究。会议上，该研究被指定作为杰出贡献张贴发表。

 

两位对随后手术结果不知情的放射科医生各自独立使用MDCT对患者进行检查，结果对121例患者中的96例(79%)达成穿孔部位的共识。后来的手术发现显示，在96例患者中，MCDT准确预测了80例患者(83%)的穿孔部位。

 

剩余25例患者中，12例穿孔部位不确定，10例未发生胃肠穿孔(经手术确认)，3例拒绝手术。

 

大肠、胃和小肠是MDCT确定的最常见的胃肠穿孔部位。研究共纳入58例男性和63例女性患者，平均年龄为63岁(范围 15~97岁)。

 

MDCT检查中穿孔部位最强的预测因子为肠壁缺损、肠腔外气泡浓度和节段性肠壁增厚，Arrieta博士说。

 

与放射科医生术前使用MDCT的检查结果相比，外科医生发现了更多的穿孔部位，共计108处。外科医生发现30处穿孔位于降结肠和乙状结肠，25处位于胃或十二指肠，21处位于小肠，10处位于盲肠或升结肠，5处位于直肠，还有1处为横结肠穿孔；这一系列中还包括16例急性阑尾穿孔患者。

 

放射科医生还评估了用于提供穿孔病因信息的MDCT扫描结果，在71例患者中准确识别出穿孔原因。炎症为最常见的病因，其次为肿瘤和消化性溃疡，其他穿孔原因为缺血、异物和外伤。

 

放射科医生分析了轴向和多平面影像。他们对造影剂外溢、肠壁局灶性缺损、肠腔外气体-游离液体和任何炎症变化(包括节段性肠壁增厚、内脏周围脂肪条纹征或脓肿)进行了特别关注。与炎症病因相关的最重要的MDCT穿孔征象为肠壁节段性增厚、脂肪条纹征和脓肿。对于肿瘤原因导致穿孔的患者，节段性增厚和游离气体是最常见的MDCT发现。

 

Arrieta博士及其同事之所以选择MDCT，是因为已发表的研究表明这种检查方式预测胃肠穿孔部位的总体准确度可达82%~90%(Am. J. Roentgenol. 2006;187:1179-83)。他补充道，CT扫描和MDCT对肠钝挫伤和肠系膜损伤诊断的灵敏度为69%~95%，特异性为95%~100%，已成为因腹部或盆腔疼痛就诊患者的主要影像学诊断方式(Radiographics 2006;26:1119-31)。

 

“我们认为准确的术前诊断(使用MDCT)是有益的，” Arrieta博士说，MDCT是“确定有无胃肠穿孔以及穿孔部位和原因的最有价值的技术。”

 

Arrieta博士声明无任何利益冲突。

 

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