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08.11.2008 КТ. Псевдомембранозный колит (Clostridium difficile colitis).

На днях читал статью по МДКТ кишечника и наткнулся на интересную картинку; с таким диагнозом я сталкивался пару раз за свою практику. На КТ сканах, картина данной патологии на самом деле очень типичная. Догадались о каком заболевании идет речь?

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КТ-загадка

Тазовая дистопия? почки слева. Не вижу почку справа. А можна по-больше изображений ? :)

 
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К сожалению больше снимков нет.

К сожалению больше снимков нет. Повторюсь; снимок я перекатал из книжки. На опубликованном изображении представлена патология толстого кишечника. КТ признак "аккордеона" (accordeon sign) вам ни о чем не говорит?  ;-)

 
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КТ толстый кишечник

 Упс! :) 

The Accordion Sign at CT: a Nonspecific Finding in Patients with Colonic Edema , Michael Macari, MD, Emil J. Balthazar, MD and Alec J. Megibow, MD

To determine whether the "accordion sign" is a specific computed tomographic (CT) sign of Clostridium difficile colitis

http://radiology.rsnajnls.org/cgi/content/full/211/3/743

The accordion sign at CT: report of a case of Crohn's disease with diffuse colonic involvement.
Mountanos GI, Manolakakis IS.

Diagnostic Center of Messinia, Kalamata, Greece. iamou@conxion.gr
http://www.ncbi.nlm.nih.gov/pubmed/1151955
 

 
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КТ толстый кишечник. PMC!

За ссылки спасибо! Это псевдомембранозный колит (Clostridium difficile colitis). Пару лет назад у меня было пару наблюднеий; картинка на КТ очень типичная.

 
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Псевдомембранозный колит

Сегодня в руки попала интересная статья по теме, понравилась новая трактовка этиологии данного заболевания. Публикую основные выдержки:

Antibiotic-Associated (Pseudomembranous) Colitis

Clinical
  Whether the term antibiotic-associated colitis or pseudomembranous colitis is used is a personal choice; some authors simply label this condition Clostridium difficile diarrhea. A pseudomembrane is not always identified; then again, an occasional adult develops pseudomembranous colitis, even a fulminant one, without recent antibiotic therapy. A similar condition was
already recognized in the preantibiotic era when it was encountered mostly after surgery and manifested as an enteritis. Associated malnutrition, immunodeficiency, and colonic stasis, especially in fragile elderly patients, result in high morbidity and mortality.
  Numerous antibiotics and other drugs are responsible for this condition. Antitumoral agents induce a pseudomembranous colitis,presumably due to their combination antimitotic and antibacterial activity. 5-Fluorouracil often
results in a mild, nonspecific colitis but rarely leads to florid pseudomembranous colitis. Interferon occasionally results in an acute colitis similar to inflammatory bowel disease. Toxinproducing strains of the anaerobic bacterium C. difficile are implicated in almost all instances, although rarely Staphylococcus aureus, Clostridium perfringens, Yersinia enterocolitica, and some strains of salmonella and shigella are involved. Rarely, more than one organism is involved.
 Pathogenesis consists of the replacement of normal colonic bacterial flora by C. difficile with release of mucosal toxins. Damage is secondary to at least two toxins: an enterotoxin (toxin A), which induces intestinal tissue damage and fluid response, and a cytotoxin (toxin B), which produces an in vivo additive effect. A fast and inexpensive enzyme-linked immunosorbent assay (ELISA) test for the enterotoxin is available, although it is not foolproof. Also, an antibody response to these toxins is detected in some asymptomatic carriers. Complicating the picture is a wide spectrum of clinical presentations ranging from an asymptomatic
carrier to a fulminant, life-threatening toxic megacolon-like condition. Findings are most evident in the colon, although more extensive bowel involvement develops in some patients. Clinically, colitis with fever, elevated erythrocyte sedimentation rate, and elevated white cell count are common. An experienced observer can suggest the diagnosis during sigmoidoscopy. Biopsy of characteristic plaques confirms the diagnosis. One should avoid making a diagnosis of antibiotic-associated colitis based solely on stool culture for C. difficile; asymptomatic carriers exist both in adults and neonates, especially in hospitals.
  In spite of adequate medical management, some patients progress to toxic megacolon and perforation. Occasionally a colectomy is necessary. One novel therapy is formation of a colostomy and instillation of vancomycin through the colostomy.
   Imaging
Conventional radiographs detect only more extreme bowel involvement. A toxic megacolon appearance is indistinguishable from that seen in inflammatory bowel disease. A barium enema is not necessary and is poorly tolerated by these patients. Performed early in the course of this condition it shows multiple small plaques, a shaggy bowel wall outline, thickened haustra, and bowel wall thickening. Ascites develops as the condition progresses. Ascites is also found in a number of other colitides (except ulcerative colitis), and its presence does not aid in narrowing a differential diagnosis. Once pseudomembranous colitis is well
established, CT detects nodular haustral thickening, thickened colonic wall ranging from segmental to a pancolitis, ascites, and pericolonic edema; the markedly serrated lumen identified by conventional radiography has been called the CT accordion sign. These serrations should not be confused with deep ulcers or sinus tracts. One should keep in mind, however,
that the accordion sign is not specific for pseudomembranous colitis and other causes of colonic inflammation or edema also result in this sign. Arterial phase CT reveals a target sign, consisting of a hyperdense inner and outer wall submucosa.
A number of disorders have a similar abnormal appearance. Although CT can suggest the diagnosis in the appropriate clinical setting, laboratory findings are more sensitive. At one institution, C. difficile colitis was explicitly diagnosed at CT with a 52% sensitivity and 93% specificity. Ultrasonography shows a thickened bowel wall and luminal narrowing. Some patients have
two concentric bowel wall rings: a thick heterogeneous hyperechoic inner ring composed of plaques and mucosal and submucosal edema, and a thinner hypoechoic outer ring representing muscularis propria.
Indium-111–labeled leukocyte imaging identifies bowel activity. 18F-FDG-PET in a patient with C. difficile colitis can result in
marked 18F-FDG uptake throughout the colon wall.

Jovitas Skucas
Advanced Imaging of the Abdomen

© Springer-Verlag London Limited 2006
 

 

 
 

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