摘要

三隻小型臘腸犬出現慢性胃腸不適，包括嘔吐和腹瀉。在這些患者中，腹部觸診可發現腹部腫塊。計算機斷層掃描顯示2例和1例患者分別有多個和單獨的腹部腫塊形成，表現如下:(1)腫塊邊緣不規則(2)腫塊所有區域增強均勻;(3)即使被腫塊嵌套，小腸管腔也能得到維護。所有3例患者均經剖腹手術切除，病理診斷為肉芽腫。這些腹部肉芽腫ct圖像的特殊表現將有助於診斷。

關鍵字

腹部;計算機斷層掃描;肉芽腫;迷你臘腸犬;小腸

簡介

腹部肉芽腫是由各種異物[1]引起的損傷、感染、腸穿孔、炎症反應繼發的增生性疾病。最常報道的異物包括術後殘留的縫合線(尤其是不可吸收的縫合線)和紗布海綿，分別稱為縫線肉芽腫或縫合線肉芽腫和棉皮腫[1-4]。在小動物實踐中，由異物殘留引起的腹部肉芽腫病例越來越多[1,4- 6]。最近縫線肉芽腫發病率的增加可能是由於日本報道的大量受影響的小型臘腸[7]。在小動物中也有此類病變的相關x線和超聲表現研究[1,4-6]。在x線圖像上，棉狀瘤的特征是團塊內的旋渦狀氣體模式，在超聲圖像上是具有高度回聲和陰影成分的低回聲團塊[1,6]。縫線肉芽腫可通過x線攝影診斷為均勻的軟組織混濁，並可通過多種超聲表現觀察到，如囊狀腫塊伴輕微聲影，以及無聲影的高回聲腫塊[4,6]。然而，計算機斷層掃描(CT)在小動物腹部肉芽腫的臨床應用尚未得到很好的討論。

案例展示

病例1是一隻3歲的絕育迷你臘腸犬，出現慢性嘔吐3個月。除卵巢子宮切除術外，無腹部內手術史。在顱骨和腹部中部觸診到一個腫塊。紅細胞計數從894 × 10下降⁴到535 × 10⁴細胞/μl從第一次臨床1周間隔。白細胞持續增加(白細胞計數為26800 ~ 57200個/μl)。射線照相的使用(Regius 110型;柯尼卡美能達公司(Konica Minolta Inc.， Tokyo, Japan)在胸部圖像上顯示左側和右側肺尾葉內多發軟組織混濁腫塊。腹部x線片上，在充滿氣體的胃的尾側發現一個大腫塊(由於肝腫大，胃軸尾側脫位)，並到達顱骨到膀胱的區域。小腸腔內可見少量氣體。超聲檢查的應用(HI VISION Preirus;HitachiAloka Medical, Ltd.， Tokyo, Japan)顯示膽囊嚴重擴張，膽管輕微延伸。腫塊被認為是由腹部左側和中部低回聲和高回聲結構組成的馬賽克(圖1A)。腹部腫塊深部可見輕微聲影。 The animal was examined using an examined by a single-slice, slip-ring CT scanner (Pronto SE; Hitachi medical Co, Tokyo, Japan) under deep anesthesia. On the abdominal CT, the abdominal mass appeared to be derived from gastric wall, because the border between the gastric structure and the mass was unclear (Figure 1B). The margin of the mass was irregular. The mass had a length of 56.0 mm, width of 56.4 mm, and height of 87.5 mm (the sizes were shown in that order on subsequent images). Intravenous injection of contrast agent revealed heterogeneous contrast enhancement of the mass; the Hounsfield units (HUs) increased from 42 to 105. There were 6 pulmonary masses, ranging in size from 6.0 mm to 16.0 mm in the longest diameter, within both the right and left caudal lobes. Examination of cytologic specimens obtained from the mass itself via ultrasonography-guided fine-needle aspiration revealed monometric accumulations of round nuclear cells, sometimes characterized as giant cells, together with cellular components consisting of neutrophils and fibrous cells (Figure 1C). Multiple formations of the masses into the thoracic and abdominal cavity on CT and accumulation of tumor-like giant cells in the cytology led to difficulty in the differential diagnosis between the abdominal granuloma and tumor before surgery. On laparotomy, the spongiform mass appeared to be derived from the caudal margin of the stomach, with the pylorus being most severely affected. The mass extended to the ventral region of both kidneys, and there were adhesions between the spleen and the caudal edge of the mass. A part of the small intestine was completely covered inside the mass. There were also adhesions between the mass and the hepatic lobes and the bile duct, resulting in bile thrombus. Gastrectomy was performed to include a large area of the caudal gastric wall near the pylorus. Blunt dissection of the mass from the liver, spleen, and small intestine was easily performed. However, the embedded small intestine developed a large discolored change, despite no destruction of the lumen. Therefore, the discolored region was completely removed and followed by an end-to-end anastomosis. Cholangioenterostomy was performed for the bile thrombus. However, the dog died by sudden cardiac arrest during surgery, possibly due to severe surgical invasiveness and the extended surgical time. A postmortem examination was declined by the owners. In the histopathology of the removed mass including a part of the gastric wall, the inflammatory cells (such as neutrophils and macrophages) were mainly accumulated within overall of the mass. The gastric wall included slight degrees of infiltrations of inflammatory cells. Mitotic figure was not evident.

圖1:狗1腹部肉芽腫的超聲(A)、CT圖像(B)和細胞學檢查(C)。(A)在6.5 mhz線性探頭的矢狀位超聲圖像上，腫塊呈馬賽克回聲結構(星號)和輕微聲影。脾髒。(B)腹部橫斷麵CT圖像(窗高40，窗寬300)顯示腫塊呈非均勻增強結構(星號)，起源於胃壁，幾乎覆蓋整個胃。GC:更大的胃彎曲。李:肝髒。P:幽門。脾髒。(C)細胞學檢查顯示圓形核細胞與中性粒細胞和纖維細胞組成的細胞成分單倍累積。

病例2是一隻8歲的小型臘腸犬，出現慢性嘔吐。2歲時行卵巢子宮切除術。在腹部中央可觸診到一個腫塊。無血液學異常;白細胞計數為12400個/μl。C反應蛋白(CRP)水平為>20 mg/dl(測量上界)(截斷值為1.0 mg/dl)。腹部x線片顯示胃脹氣。在充滿氣體的胃尾部可見軟組織混濁腫塊。超聲檢查顯示腫大的脾髒附近有不均勻的回聲腫塊。腫塊沒有陰影。 The CT examination revealed 4 masses in the abdominal cavity: one was close to the gastric cardia and was 15.0 mm × 17.6 mm × 14.3 mm in size; another mass close to the duodenum was 21.0 mm × 18.2 mm × 21.6 mm in size; the third mass was located within the space between the stomach and the spleen, and was 27.6 mm × 30.3 mm × 23.9 mm in size; and the fourth mass was located on the right side of the enlarged spleen and close to the right abdominal wall, and was 31.8 mm × 33.9 mm × 33.9 mm in size (Figure 2A). Within this mass, the small intestine was embedded. The embedded region of the small intestine running through the mass maintained a lumen structure. All margins of the four masses were irregular. With contrast, the HUs increased over all areas of the four masses from the pre-contrast levels of 37.8 to 57.0 to post-contrast levels of 113.9 to 126.7. Cytologic specimens obtained from the third mass via CT-guided fine-needle aspiration revealed accumulations of inflammatory cells composed predominantly of neutrophils and macrophages (Figure 2B). Based on the CT findings showing embedding of the small intestine within the mass, abdominal granuloma could be suspected before surgery. On laparotomy, the four masses were bound to the adjacent organs due to accumulation of fibrous structures within each region of the abdominal cavity. However, the attachments were easily released with blunt dissection. The mass on the right side of the spleen was removed with the embedded region of the small intestine, and an end-to-end anastomosis was performed. The section of the removed mass appeared spongiform, with the included small intestine maintaining its lumen (Figure 2C). Although intact removal of the masses within the space between the stomach and spleen and close to the duodenum was easy, intact removal of the mass close to the gastric cardia was impossible because of difficulty in the surgical approach. Long-term administration of prednisolone and antibiotics was performed postoperatively. The dog died 1 month after surgery from mechanical obstruction due to enlargement of the mass close to the gastric cardia. The histopathological finding of the removed mass included severe accumulations of inflammatory cells (such as neutrophils and macrophages). Lumen structures of the embedded intestine were maintained, and had slight degrees of infiltrations of inflammatory cells.

圖2:狗2腹部肉芽腫的CT圖像(A)、細胞學檢查結果(B)和大體外觀(C)。(A)腹部CT橫切麵(窗高40，窗寬300)顯示腹部腫塊位於腫大脾髒(S)右側，並包埋小腸(箭頭)。(B)細胞學檢查顯示由中性粒細胞和巨噬細胞組成的炎性細胞主要聚集。(C)切除腫塊的大體切麵，其外觀與圖2A中腫塊的CT表現相同。注意嵌有小腸，保持其管腔(箭頭)。

病例3是一隻5歲的小型臘腸犬，有1年的慢性腹瀉史。這隻狗在1歲時接受了腹部手術，切除了腹部睾丸。腹部中央至右側可觸診腫塊。無血液學異常;白細胞計數為12000個/μl。CRP為>20 mg/dl。腹部側位片顯示圓形腫塊位於脾髒附近，靠近腹壁。氣體充滿了小腸腔。右側超聲示十二指腸側部腫塊回聲均勻，無聲影。它與鄰近的器官分離，包括肝髒和胰腺。 On transverse CT images at the kidney level, the mass occupied largely the right-side and was located in the ventral region of the right kidney (Figure 3A). Its dimensions were 35.6 mm × 29.5 mm × 34.3 mm. Ball-like accumulation of the small intestine was recognized surrounding the mass acting as a core. The small intestine meandered along the mass, and a part was embedded by the mass. The embedded region of the small intestine maintained the lumen without infiltration and destruction by the mass. The entire margin of the mass was irregular. Contrast enhancement was seen uniformly within all areas of the mass; the HUs increased from 53.9 before administration of the contrast agent to 160.2 after contrast medium injection. Based on the CT findings showing ball-like accumulation of the small intestine within the mass, abdominal granuloma could be suspected before surgery. On laparotomy, a fibrous structure allowing a constricting band into the space between the small intestine and the spongiform mass was seen (Figure 3B). The adhesion was easily broken down by blunt removal and dissection, and the small intestine could be separated from the mass. The embedded structure of the small intestine showed severe discolored change. Therefore, the abnormal region was removed, and an end-to-end anastomosis was performed. Prednisolone continued to be administrated over 2 months postoperatively. This dog was alive without recurrence after surgery. The histopathological finding of the removed mass included severe accumulations of inflammatory cells. Lumen structures of the embedded intestine were maintained, and had slight degrees of infiltrations of inflammatory cells.

圖3:犬3腹部肉芽腫的CT圖像(A)和術中視圖(B)。(A)腹部CT橫切麵(窗高:60，窗寬:300)顯示腫塊周圍有小球樣小腸堆積。部分小腸被腫塊嵌入(箭頭所示)。(B)術中視圖顯示，由於纖維結構增生到小腸袢之間的間隙，小腸呈線圈狀粘連。

討論

腹部肉芽腫一般繼發於損傷、感染、腸穿孔和各種異物引起的炎症反應，包括縫合線(稱為縫合肉芽腫或縫合肉芽腫)和手術海綿(稱為棉皮腫)[1]。最初可能的原因是病例1為胃穿孔，病例2和病例3為保留縫線繼發的炎症反應。幾乎所有的外科手術都需要使用縫合材料進行結紮。保留縫線是延遲手術並發症的一個眾所周知的原因[6,8,9]。這些並發症通常是由於手術中或術後結紮和汙染周圍的慢性炎症反應引起的，膿腫或肉芽腫通常發生。大多數臨床症狀出現在術後幾個月，有時長達2年[1,5,8]。局部肉芽腫(如子宮或卵巢殘端肉芽腫)或術後較短時間(如數月)形成的肉芽腫似乎與感染性生物浸潤粘膜有關[1,6,10]。另一方麵，在出現臨床症狀之前的多年時間間隔表明，這種病變的主要原因可能不是感染[8]，而是對惰性外來物質的緩慢免疫反應[5,9]。這一過程解釋了病例1和病例2中所見的多發病變。在目前的病例係列中，所有受感染的動物都是小型臘腸犬。 The miniature dachshund has been frequently listed as affected in Japan, despite the fact that less breed specificity for the occurrence of such lesions has been reported worldwide [1,5,9]. Miniature dachshunds are known to be predisposed to pyogranulomatous inflammation in any adipose tissue [7,11]. Such lesions are considered to be part of an immunemediated disorder, because they have a good to excellent response to glucocorticoids and other immunomodulating drugs [5,11].

與我們的病例不同，在此類病變中，腹痛並不是常見的臨床症狀[1,2]。許多狗有可觸及的腹部腫塊[1,6]。在血液檢查中，白細胞計數增加和中性粒細胞增多並不總是常見的血液學發現[1,2,6,7]。CRP水平升高可能有助於肉芽腫病變的檢測，因為CRP可能是全身炎症的高度敏感指標，可導致小型臘腸發生腹部肉芽腫[5,7,11]。在本報告中，細針抽吸肉芽腫的細胞學診斷可以顯示特征性巨細胞和炎症細胞。嚴重的炎症反應可能導致臨床上難以區分肉芽腫與腫瘤，因為病變內積聚的巨細胞往往與腫瘤細胞相似[2,6,12]。基於特定的特征，診斷成像提供了最有用的信息。棉皮瘤引起的腹部肉芽腫的潛在影像學表現為螺旋樣氣體、局灶性鈣化和腸梗阻[1,6]。腹部肉芽腫因留線所致，影像學上均質性軟組織不透明可診斷[4,5]。這些先前報道的與縫合肉芽腫相關的影像學表現與本文所述的三例相同。 The ultrasonographic characteristics of abdominal masses in the three cases presented in this report were a hyperechoic mass with no or slight acoustic shadowing. On ultrasonography, gossypibomas typically have as well-demarcated hypoechoic masses with highly echogenic, shadowing components [1,6]. Suture granulomas appear as variety of ultrasound findings such as a capsule-like mass with slight acoustic shadowing and a hyperechoic mass without acoustic shadowing [4,5]. No acoustic shadows may be seen in ultrasonographic images of pure abdominal granulomas without abscess formation, mineralization, or infection [6]. In addition, acoustic shadows may disappear as the lesion progresses based on diachronic changes on ultrasonographic views in human patients with retained surgical sponges [3]. The possible developmental process was shown by the initial formation of a capsule structure filled with purulent fluid surrounding the foreign material, and the following replacement of the granulomatous tissue that infiltrated into the foreign material [3]. The variability of the ultrasound findings may contribute to difficulty in diagnosis of abdominal granulomas.

在人類患者中，典型的CT表現還包括如x線片[1]所示的漩渦狀氣體。其他CT表現包括靜脈注射造影劑[1]後腫塊邊緣強化。在獸醫領域，據我們所知，還沒有關於這種病變的CT表現的報道。目前的病例有統一的對比增強在所有區域的群眾;對比後檢查，3例6個腹部腫塊的平均Hus從47.3增加到123.7。這種差異可以解釋為單純肉芽腫而不形成膿腫或肉芽腫[6]的曆時性發展。在本報告中，腹部肉芽腫的CT表現如下:(1)腫塊[12]邊緣不規則;(2)腫塊所有區域對比度增強均勻性;(3)即使被腫塊包埋，小腸腔的維護。對於多發性腫塊的動物，可以根據準確的鑒別診斷來選擇臨床治療，如我們的兩個病例，這可以通過CT與x線、超聲、血液檢查和其他必要的檢查相結合來實現。

結論

腹部肉芽腫的CT表現為1)腫塊邊緣不規則，2)腫塊所有區域增強均勻;3)維護腫塊所包埋的小腸腔。這有助於狗腹部肉芽腫的診斷。

利益衝突

作者宣稱他們沒有利益衝突。

參考文獻

1. Merlo M, Lamb CR(2000) 8隻狗保留手術海綿的x線和超聲特征。獸醫放射超聲41:279 -283。［Ref。］
2. 普吐溫，阿徹J(2009)你的診斷是什麼?從腹部疼痛的絕育狗身上抽取腹腔內腫塊。獸醫病理學38:253-256。［Ref。］
3. Matsumoto S, Aikawa H, Miyake H, Mori H, Maeda T等(1990)手術海綿殘留的CT與超聲診斷。日本院係學社社50:1350-1358。［Ref。］
4. Boza S, Lucas X, Zarelli M, Soler M, Belda E，等(2010)母狗子宮切除術後絲線縫合引起的晚期膿腫形成。重現家養動物45:934-936。［Ref。］
5. Yuki M, Hirano T(2010)使用強尼鬆龍和瑞舒伐他汀聯合治療犬化膿性肉芽腫。美國獸醫協會236:767-769。［Ref。］
6. Maï W, Ledieu D, Venturini L, Fournel C, Fau D，等(2001)手術海綿殘留繼發於腹腔內肉芽腫的超聲表現。獸醫放射超聲42:157-160。［Ref。］
7. 山岸C，桃井Y，小林T, Ide K，大野K，等。(2007)犬無菌性脂膜炎的回顧性研究及基因分析。中華獸醫雜誌69:915-924。［Ref。］
8. Pearson H(1973)母狗卵巢子宮切除術的並發症。動物科學學報，14:257-266。［Ref。］
9. Werner RE, Straughan AJ, Vezin D(1992)去卵巢子宮母狗的尼龍索帶反應。美國獸醫醫學雜誌200:64-66。［Ref。］
10. Spackman CJA, Caywood DD, Johnston GR, Feeney DA(1984)子宮和卵巢殘肢肉芽腫:一例報告。J Am Anim Hosp雜誌20:449-453。
11. Aikawa T, Yoshigae Y, Kanazono S(2008) 5隻小型臘腸犬硬膜外特發性無菌性膿性肉芽腫性炎症引起脊髓壓縮損傷。獸醫外科37:594-601。［Ref。］
12. 金俊華，李俊華，尚玉凱，洪世傑，高淑娟等。(2009)甲狀腺乳頭狀癌甲狀腺切除術後甲狀腺床縫合線肉芽腫的超聲特征，重點探討其與局部複發性甲狀腺癌的鑒別。超聲醫學雜誌35:1452-1457。［Ref。］

下載臨時PDF

條信息

文章類型:病例報告

引用:Tsuka T, Okamoto Y, Osaki T, Morita T, Sunden Y，等(2019)3隻小型臘腸犬腹部肉芽腫的計算機斷層掃描結果。動物科學研究3(1):doi dx.doi.org/10.16966/2576-6457.122

版權:©2019 Tsuka T等。這是一篇開放獲取的文章，根據創作共用署名許可的條款發布，允許在任何媒介上不受限製地使用、分發和複製，前提是要注明原作者和來源。

出版的曆史:

收到日期:2018年12月28日

接受日期:2019年1月30日

發表日期:2019年2月6日