Emergency Ultrasound (EUS)教學(13)

急診超音波在胃腸道之應用
新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
 臨床情境
• 65歲男性，右下腹痛合併發燒、嘔吐

• 請問你該怎麼辦 ?

• 急診超音波在此能提供什麼幫忙?
 腦力激盪

急診超音波能應用在那些胃腸道疾病 ??

對急診臨床工作有何助益 ??
正常的胃腸道解剖及
超音波影像認識
(GI tract images)
Normal anatomy of GI tract
 解剖學上之胃腸道部位
解剖學上固定 解剖學上非固定
• 食道胃交界 • 空腸
• 胃*
• 十二指腸
• 迴腸
• 連接十二指腸之近端空腸* • 橫結腸
• 連接迴盲部之末端迴腸* • 乙狀結腸
• 闌尾*
• 升結腸
• 降結腸
• 直腸

• *表示半固定
Normal GI tract
• 1st: hyperechoic
– Lumen & mucosa
• 2nd: hypoechoic
– Mucosa
• 3rd: hyperechoic
– Submucosa
• 4th: hypoechoic
– Muscle layer
• 5th: hyperechoic
– Serosa

J Ultrasound Med 2006;25:87-97

 Normal stomach

Normal wall: 3-5 mm

J Ultrasound Med 2006;25:87-97
Location of Stomach
Location of Duodenum
Normal small bowel

J Ultrasound Med 2006;25:87-97

Small bowel
structure
Normal large bowel

J Ultrasound Med 2006;25:87-97

Normal large bowel
Landmark of Appendix
 胃腸道掃描注意事項
• 探頭: curvelinear probe 3.5-5 MHz

• 病患姿勢: 平躺 (or 左側躺)

• 病患準備: NPO急診不適用

• 掃描技巧:
– 先從”固定處”開始掃描，然後再延伸至其他位置

• 正常胃腸壁厚度: 2-4mm
– Stomach: >7mm abnormal
– Bowel: >4mm abnormal
Graded compression technique
 GI tract lesions on sonography
1. 胃腸道壁增厚 (>4mm)
2. 胃腸道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites etc.)
胃腸道疾病之超音波影像
Appendicitis
Appendicitis

Eur Radiol. 2002;12:1748-61

 Appendicitis in a 25-year-old woman with
right lower quadrant pain

Copyright © Radiological Society of North America, 2003

O'Malley, M. E. et al. Radiographics 2003;23:59-72
Diverticulitis
 Dome sign:
acute colonic diverticulitis

J Clin Ultrasound. 2000;28:340-6.

 Right-sided diverticulitis in a 32-year-old woman
with right lower quadrant pain and fever

O'Malley, M. E. et al. Radiographics 2003;23:59-72

Copyright © Radiological Society of North America, 2003

Bowel obstruction
Bisection Approximation Method
for GI obstruction

1 2

4
3

Hepatogastroenterology. 2006;53:547-51.
 Bisection Approximation Method
Location of US examination (From 1 – 5) Possible
lesion site
1. A-C 2. D-C 3. Rectum 4. IC region 5. Gastric
outlet or
duodenum
Dilated Collapsed From 1-2

Dilated Dilated Collapsed From 2-3

Collapsed - - Dilated From 1-4

Collapsed - - Collapsed Dilated From 4-5

Collapsed - - Collapsed Collapsed Above 5

Small bowel obstruction

Fold of Kerckring
Eur Radiol. 2002;12:1748-61
Intussusception
Pseudokidney sign

Radiology. 1999;211:395-7.
 Crescent-in-doughnut sign
(Target / Bull’s-eye / Doughnut )

Radiology. 1999;211:395-7.
Intussusception

J Ultrasound Med 2006;25:87-97

Intussusception

Eur Radiol. 2001;11:1867-77

Pneumoperitoneum
Duodenal ulcer

Eur Radiol. 2001;11:1867-77

Pneumoperitoneum:
GI tract perforation

Eur Radiol. 2002;12:1748-61

Perforated duodenal ulcer

Eur Radiol. 2001;11:1867-77

Others
Infectious Colitis (A-C)
Infectious ileocolitis
Pseudomembranous colitis (D-C)
Ischemic colitis
• Elderly patients
• WT of long colon
segment, >10cm
• Mainly left side
• Rare color Doppler
signal intensity

AJR 2005; 184:777-785

Intramural hematoma
(Coumadin overdose)
Vasculitis

J Ultrasound Med 2006;25:87-97

 Systemic lupus erythematosus in a 20-year-old
woman with severe abdominal pain

O'Malley, M. E. et al. Radiographics 2003;23:59-72

Copyright © Radiological Society of North America, 2003

Aurora / Circle / Corona sign:
Gas within wall of GI tract

J Clin Ultrasound. 1999;27:409-12

 Take-Home Points
1. 胃腸道超音波掃描由解剖學上固定處開始，
然後延伸至其他部位
2. 熟悉胃腸道病變時常見的超音波異常影像
原則
3. 急診病人之胃腸道掃描不適用NPO原則
4. History & PE然後才是EUS，勿反客為主