图2 示意图（上面观）显示女性患者盆腔腹内疝、隐窝和陷凹的部位。H，膀胱上疝；I，阔韧带疝；1，膀胱子宫陷凹；2，子宫直肠陷凹；3，直肠旁窝。
In this article, we describe our clinical experience with internal hernias, the imaging technique, and diagnosis with computed tomography (CT), including the CT findings and their clinical relevance as well as the important role of multi–detector row CT. We then discuss the locations and relative frequencies of internal hernias, which include foramen of Winslow, paraduodenal, transmesenteric, transomental, pericecal, sigmoid mesocolon, and supravesical and pelvic hernias.
我们本文中描述了腹内疝及其显像技术和CT诊断，包括CT表现和临床相关性及其多层螺旋CT的重要性的临床经验，然后讨论了腹内疝的部位和相关频率，包括Winslow孔疝、十二指肠旁疝、肠系膜疝、网膜疝、盲肠旁疝、乙状结肠系膜疝和膀胱上疝及盆腔疝。
In the sections on internal hernias, we describe the anatomic locations and embryologic features of potential hernial orifices (foramina, fossae, recesses, defects of the mesentery and visceral peritoneum) and the clinical, surgical, and radiologic findings, including the characteristic CT appearances. We also present CT images, some surgical results, and some intraoperative photographs. Finally, we briefly describe the management of internal hernias.
在腹内疝章节，我们描述了潜在疝孔（肠系膜和脏层腹膜的裂孔、陷凹、隐窝和缺损）的解剖部位和胚胎学特征和临床、手术、影像学表现包括CT的特征性表现，我们也列举了一些CT图像、手术结果和术中照片，最后我们简要的描述了腹内疝的治疗。
临床经验
From November 1995 to February 2004, a retrospective review of medical records and radiologic images revealed 13 patients (eight male, five female) with surgically proved internal hernias at our institution and branch hospitals. Their age ranged from 12 to 86 years (mean age, 56.1 years) with more than half of the patients over age 50 years. All patients except one with clinical and radiologic findings suggestive of acute intestinal obstruction underwent single detector row CT of the abdomen and pelvis at the time of admission. One patient underwent CT 4 days after conservative treatment. Four patients with low-grade obstruction underwent enteroclysis, which is particularly helpful in depicting and grading the severity of partial obstruction and demonstrating sites of incomplete obstruction.
我们对1995年11月到2004年2月在我们机构和分院的医疗文件和影像学图像进行了回顾性分析，发现13例经手术证实的腹内疝，其中8例男性，5例女性，年龄从12到86岁（平均年龄56.1岁），超过一半病人大于50岁。除1例病人外所有其他临床和影像学表现怀疑急性肠梗阻的病人在住院时均进行了腹部和盆腔的单排CT扫描，一例病人在经过保守治疗4天后进行了CT扫描；4例轻度梗阻的病人进行了肠道造影，这非常有助于对部分性肠梗阻进行描述和程度分级并显示不完全梗阻的位置。
CT examinations were performed with the following imaging units: ProSeed SA (GE Healthcare Technologies, Waukesha, Wis) (n = 7); Hi-speed DXI (GE Healthcare Technologies) (n = 1); TCT-700S (Toshiba, Tokyo, Japan) (n = 1); TCT-60A (Toshiba) (n = 2); and SCT-7000 (Shimadzu, Kyoto, Japan) (n = 2).
CT检查设备包括： ProSeed SA (GE Healthcare Technologies, Waukesha, Wis) (n = 7); Hi-speed DXI (GE Healthcare Technologies) (n = 1); TCT-700S (Toshiba, Tokyo, Japan) (n = 1); TCT-60A (Toshiba) (n = 2); and SCT-7000 (Shimadzu, Kyoto, Japan) (n = 2).
The duration of symptoms before hospital admission ranged from as little as 3 hours to as long as 3 months. The interval between CT examination at the time of admission and surgery ranged from 2 hours to 20 days. Six patients underwent emergency operations within 7 hours of CT examination. Four patients were treated conservatively with insertion of a nasogastric tube or a long intestinal tube to drain the intestinal fluid, but these patients underwent operations within 12–42 hours of CT examination because of aggravated symptoms. The remaining three patients underwent operations within 4–20 days after CT examinations because at first they were making good progress with conservative treatment by means of nasogastric or long intestinal tube decompression, but their symptoms became aggravated little by little.
住院之前，病人的症状持续的时间少的3小时，多的达3个月。住院时CT检查和手术的间隔范围从2小时到20天。6例病人在CT检查的7小时内就进行了急症手术。4例病人进行了保守治疗包括经鼻胃管或肠管引流肠液，但由于病情恶化，在CT检查后的12—42小时内进行了手术。其余的3例病人在CT检查4—20天后才进行手术，是由于起初经鼻胃管或肠管减压保守治疗效果较好，但后来症状渐渐恶化。
During laparotomy in each patient, reduction of the hernia contents, resection of necrotic bowel loops, and primary anastomosis (enterostomy in one case) were performed. Gangrenous changes in the incarcerated bowel loops were present in seven patients, and six patients had viable bowel loops. Eleven patients had no history of abdominal surgery or trauma. Only two patients had a history of appendectomy.
手术中对每位病人的肠内容物进行复位，切除坏死肠管并进行基本吻合（1例进行了肠造漏术）。7例病人出现了绞窄肠管的坏疽性变，6例为存活肠管。11例病人没有先前的腹部手术或外伤史，仅有2例病人曾有过阑尾切除病史。
Nonspecific abdominal symptoms of intestinal obstruction were observed in all 13 patients. These included some degree of epigastric pain, abdominal pain, tenderness, abnormal bowel sounds, nausea, vomiting, and palpation of a mass.
所有13例病人都有非特异性的腹部症状，包括不同程度的上腹疼痛、腹痛、压痛、肠鸣音异常、恶心、呕吐和扪及团块。
显影技术
Gastrointestinal studies enhanced with intraluminal contrast material (barium-enhanced studies, enteroclysis) and abdominal CT enable accurate diagnosis of any type of internal hernia (9,10). In mechanical high-grade SBO, small bowel follow-through study has a limitation in emergency use. Enteroclysis can be performed more quickly and has been shown to have high accuracy in the evaluation of SBO, but is contraindicated in patients with high-grade closed-loop obstruction and in those with suspected hernial strangulation (11). Recently, CT has demonstrated the importance of preoperative diagnosis of early or partial obstruction and closed-loop obstruction.
胃肠造影（钡剂增强检查，肠道造影检查）和腹部CT能准确的诊断各种类型的腹内疝。急诊应用小肠通过试验对诊断重度机械性SBO病例有一定难度。肠道造影术能更迅速地评价SBO，并有高度的准确性，但在重度闭合性梗阻和怀疑绞窄疝的病人中属于禁忌。近来表明CT对术前诊断早期或部分性梗阻和闭合性梗阻具有重要的价值。
In our CT examination, intravenous administration of contrast material is essential to determine the cause of obstruction and identify any associated hernial strangulation. All patients except one underwent CT performed with 100 mL of contrast material administered intravenously at a rate of 1–2 mL/sec. The delay between the start of injection and imaging varied between 70 and 90 seconds. All images were acquired with 7–10-mm collimation and a pitch of 1.2–1.5. One patient underwent nonenhanced CT because she was allergic to the contrast material; CT images clearly demonstrated the presence of strangulating bowel loops as diffuse mesenteric fluid and haziness.
在我们的CT检查中静脉应用造影剂对于明确梗阻的病因和分辨各种有关的疝性绞窄很有必要。除1例外，所有接受CT检查的病人均静脉注射造影剂100mL，1—2mL/s。开始注射和扫描之间延迟70-90秒。图像厚7-10mm，旋距1.2-1.5。1例病人由于对造影剂过敏而进行非强化CT，CT图像清晰的显示肠管绞窄，弥漫性的肠系膜积液并分界不清。
Because of the difficulty of preoperative CT diagnosis, multi–detector row CT may play an important role. Currently, multi–detector row technology provides substantial improvements in the quality of two- and three-dimensional reformatted images, which have evolved in addition to the axial images. Many images obtained with multi–detector row CT are interpreted at workstations by manually paging up and down or reformatting by means of high-quality three-dimensional reformation techniques, such as multiplanar reformation (MPR), shaded surface display (SSD), volume rendering (VR), and maximum intensity projection (MIP).
由于术前CT诊断困难，多层螺旋CT可提供重要的作用。当前，除了轴位图像以外，多层螺旋CT技术在二维和三维图像重建中提供了实质性的改进，在多排CT扫描的图像可以在工作站一一浏览，并能以多种重建技术进行后处理，如多层面重建，表面重建，容积重建，及最大密度投影。
Multi–detector row CT with three-dimensional reformatting at a workstation provides important advantages over conventional imaging methods in evaluation of the small intestine and surrounding structures (mesentery, mesenteric vasculature, and peritoneal cavity). Multi–detector row CT can play a more active role in identification of the site, level, and cause of SBO, including internal hernias (12,13).
多排螺旋CT可以在工作站重建图像，在评价小肠及其周围结构（肠系膜，肠系膜血管，及腹膜腔）方面比传统像技术有了重大进步，在捡出SOB位置，水平及起因方面扮演可以更积极的角色。
Oral administration of contrast material and water is not necessary in view of the patients’ severe condition because intraluminal fluid collected within an SBO segment already serves as a natural contrast agent, demonstrating the bowel wall clearly (12,13). On the other hand, multi–detector row CT coupled with administration of water and oral contrast material allows the diagnosis of SBO. Some investigators advocate use of CT enteroclysis, which provides a flexible method of viewing SBO (14).
病情严重的，不需要再口服造影剂和水，因为SBO段积聚的管腔内液体足以形成天然的对比，可以清晰的显示肠壁。另一方面，多层螺旋CT和口服造影剂与水配合能诊断SBO。一些研究者主张使用CT肠造影术可以灵活的观察SBO。
