摘要

三只小型腊肠犬表现为慢性胃肠道不适，包括呕吐和腹泻。在这些病人中，腹部触诊可发现腹部肿块。计算机断层扫描显示，2例和1例患者分别有多个和单独的腹部肿块形成，表现如下:(1)肿块边缘不规则(2)肿块所有区域增强均匀;(3)即使被肿块包埋，小肠管腔仍能维持。在所有三例患者中，这些腹部肿块均经剖腹手术切除，病理诊断为肉芽肿。腹部肉芽肿的ct表现对诊断有一定的帮助。

关键字

腹部;计算机断层扫描;肉芽肿;迷你腊肠犬;小肠

介绍

腹部肉芽肿是继发于损伤，感染，肠穿孔和由于各种异物引起的炎症反应的增殖性疾病[1]。最常见的外来物质包括缝合线（特别是不可吸收的缝线）和纱布海绵在手术后保留，并且分别称为针脚或缝合颗粒组织和甘蓝瘤[1-4]。在小动物实践中由保留的异物引起的腹部肉芽肿的病例数量增加[1,4-6]。这最近，缝合肉芽肿的发生率可能是由于日本报告的大量影响腊肠犬[7]。在小型动物中还研究了这种病变的相关射线照相和超声检查结果[1,4-6]。GossyPibomas的特征在于在超声图像上具有高度回声的偏离偏析的旋转的脱铬物质的旋转状气体图案，在超声波视图上[1,6]。缝合线肉芽肿可以通过使用射线照相均匀的软组织不透明性诊断，并且已被各种超声检查结果观察，例如具有微小声学阴影的胶囊状的质量，以及没有声学阴影的高拱核聚物[4,6]。然而，讨论了计算机断层扫描（CT）对小动物的临床应用尚未得到很好的讨论。

案例介绍

病例1为一只3岁的小型腊肠犬，因慢性呕吐3个月。除卵巢子宫切除术外，既往无腹腔内手术。颅部及腹部中部扪及肿块。红细胞计数从894 × 10下降^4.到535 × 10^4.从首次临床开始，每隔1周注射1 μl细胞。白细胞增多(白细胞计数范围为26800 ~ 57200个/μl)。射线照相的使用(雷吉斯模型110;柯尼卡美能达公司，东京，日本)在胸部图像上显示左、右肺尾叶内多发软组织混浊肿块。在腹部x线片上，在充气胃的尾部发现一个大肿块(胃轴尾部因肝肿大而脱位)，并到达颅至膀胱区域。小肠内可见少量气体。超声检查(HI VISION previrus;日立医疗有限公司，东京，日本)显示胆囊严重扩张，胆管轻微扩张。肿块位于腹部左侧和中部，由低回声和高回声结构组成(图1A)。腹部肿块深部可见轻微声学阴影。 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.

图1：犬1腹部肉芽肿的超声(A)、CT (B)及细胞学表现(C)。(A)在6.5 mhz线性探头矢状超声图像上，肿块呈马赛克状回声结构(星号)，有轻微声影。脾脏。(B)腹部横断面CT(窗平40，窗宽300)，肿块呈不均匀增强结构(星号)，起源于胃壁，几乎覆盖整个胃区。胃曲度增大。李:肝脏。P:幽门。脾脏。(C)细胞学检查显示圆形核细胞和由中性粒细胞和纤维细胞组成的细胞成分的单个聚集。

案例2是一只8岁的微型腊肠犬，呈现为慢性呕吐。在2年龄，进行了卵巢切除术。可以在腹部的中心触诊质量。血液学未见异常;白细胞计数为12400 /μl。C反应蛋白（CRP）水平> 20mg / dl（测量上边界）（切断值：1.0mg / d1）。在腹部射线照相上，胃与气体扩张。软组织不透明度质量被视为气体胃的尾部。在超声检查中，在扩大的脾脏附近看到异质的回声肿块。质量没有遮蔽。 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.

图2：犬2腹部肉芽肿的CT图像(A)，细胞学表现(B)和大体外观(C)。(A)腹部横切面CT(窗平40，窗宽300)示脾肿大右侧腹部肿块(S)，包埋小肠(箭头)。(B)细胞学检查显示主要由中性粒细胞和巨噬细胞组成的炎症细胞聚集。(C)切除肿块的大体切面，外观与图2A中肿块的CT表现相同。可见嵌入的小肠维持管腔(箭头)。

病例3为一只5岁小型腊肠犬，有1年慢性腹泻史。这只狗在一岁时接受了腹部手术，切除了一个腹部睾丸。在腹部正中至右侧可扪及肿块。血液学未见异常;白细胞计数为12000个/μl。CRP水平为>20 mg/dl。在腹部侧位片上，可见圆形肿块靠近脾脏，靠近腹壁。小肠腔内充满了气体。右侧超声图显示肿物位于十二指肠外侧，回声均匀，无声学阴影。它被从邻近的器官中分离出来，包括肝脏和胰腺。 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.

图3:犬3腹部肉芽肿的CT (A)和术中视图(B)。(A)腹部横切面CT(窗平60，窗宽300)示肿块周围有球状小肠堆积。部分小肠被肿块(箭头所指)所嵌。(B)术中视图显示小肠线圈样粘连，因纤维结构增生进入小肠袢间间隙。

讨论

腹部肉芽肿通常继发于外伤、感染、肠穿孔和各种异物引起的炎症反应，包括缝线(称为缝线或缝线肉芽肿)和手术海绵(称为棉状肉芽肿)[1]。可能的最初原因是病例1的胃穿孔和病例2和病例3的保留缝线继发的炎症反应。几乎所有的外科手术都需要使用缝合材料进行结扎。保留缝线是延迟手术并发症的一个众所周知的原因[6,8,9]。这些并发症通常是由于手术中或术后结扎和污染周围的慢性炎症反应，脓肿或肉芽肿通常发生在[8]。大多数临床症状出现在手术后几个月，有时长达2年[1,5,8]。局部肉芽肿的形成(如子宫或卵巢残端肉芽肿)或术后较短时间内(如数月)形成的肉芽肿似乎与粘膜感染微生物浸润有关[1,6,10]。另一方面，在临床症状出现之前的长时间间隔表明，这些病变的主要原因可能不是感染[8]，而是对惰性异物的缓慢免疫反应[5,9]。这个过程解释了病例1和病例2中所见的多个病变。在目前的病例系列中，所有受感染的动物都是小型腊肠犬。 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].

在这些病变中，腹痛并不是常见的临床症状，正如我们的病例[1,2]。许多犬有可触及的腹部肿块[1,6]。在血液检查中，白细胞计数增加和中性粒细胞增多并不总是常见的血液学表现[1,2,6,7]。CRP水平升高可能有助于肉芽肿性病变的检测，因为CRP可能是全身炎症的高度敏感指标，导致小型腊肠发生腹部肉芽肿[5,7,11]。在本报告中，从细针抽吸肉芽肿的细胞学诊断可以显示特征性的巨细胞和炎症细胞。严重的炎症反应可能会导致肉芽肿与肿瘤的临床鉴别困难，因为在肉芽肿病灶内积聚的巨细胞往往类似肿瘤细胞[2,6,12]。诊断性影像根据具体的特征提供最有用的信息。棉状纤维瘤引起的腹部肉芽肿的影像学表现为漩涡状气体、局灶性钙化和肠梗阻[1,6]。腹部留置缝线引起的肉芽肿可通过影像学上的均匀性软组织阴影诊断[4,5]。这些先前报道的与缝合肉芽肿相关的影像学表现与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.

在人类患者中，典型的CT表现也可能包括影像学[1]所见的漩涡状气体模式。其他CT表现可能包括静脉注射造影剂[1]后肿块边缘的增强。在兽医学领域，据我们所知，尚无此类病变CT表现的报道。目前的病例在所有区域的群众有统一的对比度增强;3例6个腹部肿块内Hus由47.3增加到123.7。这种差异可能是由单纯肉芽肿的发展而没有形成脓肿或肉芽肿[6]的历时性发展造成的。在本报告中，腹部肉芽肿的特征性CT表现如下:(1)肿块[12]边缘不规则;(2)肿块所有区域的对比度增强均匀性;(3)即使被肿块包埋，小肠管腔仍能维持。临床治疗可以根据对动物多发性肿块的准确鉴别诊断来选择，就像我们的两个病例一样，这是通过CT与x线摄影、超声检查、血液检查和其他必要检查相结合而实现的。

结论

腹部肉芽肿的CT表现为:(1)肿块边缘不规则，(2)肿块所有区域增强均匀;3)维持肿块所包埋的小肠管腔。这对犬腹部肉芽肿的诊断有一定的帮助。

利益冲突

作者声明他们没有利益冲突。

参考文献

1. Merlo M, Lamb CR(2000) 8只狗保留手术海绵的x线和超声特征。兽医放射超声41:279-283。[参考。]
2. Putwain S, Archer J(2009)你的诊断是什么?一例腹部疼痛的切除犬腹腔内肿块。兽医临床病理38:253-256。[参考。]
3. Matsumoto S, Aikawa H, Miyake H, Mori H, Maeda T, et .(1990)保留手术海绵的CT和超声诊断。日本Igaku hoshen Gakkai Zasshi 50: 1350-1358。[参考。]
4. Boza S，Lucas X，Zarelli M，Soler M，Belda E等人。（2010）母狗子宫切除术后丝缝合造成的晚期脓肿形成。SOT MODEST ANV 45：934-936。[参考。]
5. 强的松龙和瑞舒伐他汀联合治疗狗的化脓性肉芽肿。美国兽医医学协会236:767-769。[参考。]
6. Maï W, Ledieu D, Venturini L, Fournel C, Fau D，等(2001)保留手术海绵术后腹腔内肉芽肿的超声表现。兽医放射超声42:157-160。[参考。]
7. Yamagishi C, Momoi Y, Kobayashi T, Ide K, Ohno K, et al.(2007)犬无菌性脂膜炎回顾性研究和基因分析。中国兽医科学(英文版)[参考。]
8. Pearson H（1973）卵巢中的卵巢中肿瘤切除术的并发症。J Small Anim实践14：257-266。[参考。]
9. Werner Re，Straughan Aj，Vezin d（1992）卵巢中间母母母狗中的尼龙电缆带反应。J AM VET MED Acadio 200：64-66。[参考。]
10. Spackman CJA，Caywood DD，Johnston GR，Feeney Da（1984）子宫和卵巢树桩的肉芽肿：案例报告。J AM Anim Hosp Assoc 20：449-453。
11. Aikawa T, Yoshigae Y, Kanazono S(2008) 5只微型腊肠犬的硬膜外特发性无菌性化脓性肉芽肿性炎症导致脊髓压缩损伤。兽医外科37:594-601。[参考。]
12. Kim Jh，Lee Jh，庄Yk，Hong SJ，Ko Ms等。（2009）乳头切除术后乳腺切除术后乳腺切除术治疗乳头状甲状腺癌后的超声特征，重点是它们与局部复发性甲状腺癌的分化。超声医生BIOL 35：1452-1457。[参考。]

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条信息

文章类型:病例报告

引用:Tsuka T, Okamoto Y, Osaki T, Morita T, Sunden Y，等(2019)三只微型腊肠犬腹部肉芽肿的ct表现。动物科学研究3(1):doi: dx.doi.org/10.16966/2576-6457.122

版权:©2019 Tsuka T，等。这是一篇开放获取的文章，在知识共享署名许可协议的条款下发布，该协议允许在任何媒体上无限制地使用、发布和复制，前提是注明原作者和来源。

出版历史：

收到日期:2018年12月28日

接受日期:2019年1月30日

发表日期:06年2月,2019年