双语病例丨腹盆腔多发种植脾并其一扭转（CT）

患者的生命体征正常，体格检查示盆腔疼痛、压痛、腹胀。 实验室检查示代谢性酸中毒，血清乳酸和淀粉酶升高，白细胞增多，C反应蛋白和血小板计数增加。

Subsequent plain abdominal radiographs (not shown) demonstrated no evidence of bowel obstruction or perforation. A contrast-enhanced CT scan of the abdomen and pelvis was performed. In order: a coronal 4-mm slab thickness maximum intensity projection (MIP) contrast-enhanced CT image and axial contrast-enhanced CT images.

随后的腹部平片（未示出）证明没有肠梗阻或穿孔的迹象。 行腹盆部增强CT扫描。依次为：冠状MIP（层厚4mm）增强CT图像和轴位增强CT图像。

Findings

• Image 1: MIP coronal contrast-enhanced image shows several lesions of variables size with different pattern of contrast-enhancement (arrowhead, arrow) in keeping with splenic implants.

• Image 2: Axial contrast-enhanced CT image shows poor contrast enhancement of the left splenic implant surrounded by fat stranding and a small amount of fluid in the rectouterine pouch, in keeping with torsion (arrowhead). There is a right contrast enhancing pelvic implant as well (arrow).

• Image 3: Axial CT image shows a further contrast-enhancing lesion in the liver in keeping with hepatic splenosis (arrow).

影像表现：

• 图1：冠状MIP增强：多个大小不等的病变，具有不同的增强方式（箭头，箭），提示种植脾。

• 图2：轴位增强CT：盆腔左侧种植脾的强化程度弱，其周围脂肪间隙浑浊，子宫直肠窝见少量液体，提示肿物扭转（箭头）。 右侧另见一明显强化的种植脾（箭）。

• 图3：轴位增强CT：肝脏见一持续性强化的病变，提示肝脏种植脾（箭）。

Differential diagnosis

• Endometriosis

• Pedunculated fibroid torsion

• Ovarian torsion

• Splenosis torsion.

鉴别诊断：

• 子宫内膜异位症

• 带蒂纤维瘤扭转

• 卵巢扭转

• 种植脾扭转

Diagnosis: Torsion of a splenic implant in abdominopelvic splenosis

最后诊断：腹盆腔多发种植脾并其一种植脾扭转

Torsion of a splenic implant in abdominopelvic splenosis

This case of torsion of a splenic implant in a context of abdominopelvic splenosis in a young adult female patient was managed as an acute abdomen. Clinically, the patient’s symptoms were highly suspicious for an acute bowel ischemia. Given this clinical scenario, rapid evaluation was necessary to identify any intra-abdominal pathology requiring timely surgery. Thus, contrast-enhanced dual-phase CTA was the first-line imaging modality in our case.

在年轻成年女性患者有腹盆腔种植脾的情况下，种植脾扭转的情况应作为急腹症来对待。 临床上，患者的症状与急性肠缺血非常相似， 鉴于这种情况，需要快速评估以确定是否需要及时手术。 因此，双期对比增强CTA是首先需要考虑到的成像方式。

Appearance of the splenic implants at ultrasound is nonspecific. However, similar to multiplanar reformatted (MPR) images, color Doppler ultrasound may be useful to identify the twisted pedicle when it is not extremely thin. Torsion of pedunculated fibroids is a rare complication, which is difficult to diagnose preoperatively because the twisted pedicle is often extremely thin and the absence of contrast enhancement is not pathognomonic for ischemia. In our case, the presence of multiple masses led to rule out this condition. Similarly, adnexal torsion is commonly unilateral, with a slight (3:2) right-sided predilection. CT has lesser specificity for the diagnosis of endometriomas than MRI and thus plays a limited role in the evaluation of endometriosis. However, ovarian endometriomas may be cystic and often contain blood, whereas the appearance of the endometrial implants is generally nonspecific. At contrast-enhanced CT, splenosis has comparable attenuation to that of normal splenic tissue (images 1 and 2). The intensity and enhancement of the splenic nodules on MRI are also similar to that of normal spleen. T2- and T1-weighted fat-suppressed MRI sequences play a critical role in the detection of the infarcted splenosis, showing hypointense signal on both T1- and T2-weighted sequences and no postcontrast enhancement on T1-weighted sequences.

• 超声检查种植脾的外观是非特异性的。然而对于MPR图像，彩色多普勒超声可能有助于识别扭曲的蒂部，当它不是非常薄的时候。

• 带蒂纤维瘤的扭转是一种罕见的并发症，由于扭曲的蒂部非常薄，术前通常难以诊断，强化程度低并非是缺血的特征。在上面这个病例中，多个肿物的存在导致我们排除了这种情况。

• 同样，附件扭转通常是单侧的，右侧略多见（3：2）。

• CT对子宫内膜异位症的诊断比MRI具有更低的特异性，因此在子宫内膜异位症的评估中作用有限。然而，卵巢子宫内膜异位可能是囊性的并且通常含有血液，其影像表现通常是非特异性的。

• 增强CT示种植脾的密度与正常脾脏组织相同（图像1和2）。 MRI上种植脾的信号和强化程度也与正常脾相似。T2/T1WI压脂序列在种植脾梗死的检测中发挥关键作用，T1/T2WI均呈低信号，增强后无强化。

On unenhanced MRI weighted sequences, endometriomas show very high signal intensity on T1-weighted imaging, shading on T2-weighted imaging, and poor to absent enhancement on postcontrast T1-weighted imaging.

子宫内膜异位症在T1WI上表现为高信号，T2呈低信号，增强后无明显强化。

Although MRI using superparamagnetic iron oxide (SPIO) is specific for the diagnosis of splenosis, the current diagnostic tool of choice is scintigraphy with reticuloendothelial agents such as technetium 99m (Tc-99m) sulphur colloid, Tc-99m heat-damaged erythrocytes, or indium-111-labeled platelets.

尽管使用超顺磁性氧化铁（SPIO）进行MR成像对种植脾的诊断具有特异性，但目前选择使用的诊断工具是用网状内皮药物如锝99m（Tc-99m）硫胶体，Tc-99m热损伤红细胞或铟-111标记的血小板进行闪烁显像。

The use of indocyanine green (ICG)-enhanced fluorescence agent during laparoscopy plays a confirmatory role in the diagnosis of perfusion abnormalities of solid and hollow viscous organs, and, as in our case, to confirm an ischemic process of the splenic implant.

在腹腔镜检查中使用吲哚菁绿（ICG）增强的荧光剂在诊断实心和中空粘性器官的灌注异常方面起到确定作用，并且在我们这一例确认了种植脾的缺血情况。