İnce barsak duvar içi hematomu

Özet

İnce barsak duvar içi hematomu spontan olarak, özellikle antikoagülasyon zemininde, ya da künt travma sonrasında gelişebilir. İntramural hematom şüphesinde kontrastsız BT, kontrastlı BT’den önce çekilmelidir; duvar çevresel kalınlaşıp lümen daralabilir. Kontrastlı BT’de duvar kontrastlanması ve aktif kanama bulguları değerlendirilebilir; ancak kontrastlanma hematomu maskeleyebileceği için öncesinde kontrastsız BT çekilmelidir. İntramural hematom lümen daralmasıyla ince barsak obstrüksiyonuna yol açabilir; iskemi veya perforasyon eşlik ederse bunlar komplikasyon olarak değerlendirilmelidir.

Faz ve pencere

Kontrastsız tanısal

Duvar içinde spontan yüksek atenüasyonlu, çoğunlukla çevresel veya asimetrik kalınlaşma ve buna bağlı lümen daralması görülür; bu patolojinin tanısal temel fazıdır.

Portal

Kontrastlı BT’de duvar kontrastlanması ve aktif kanama bulguları değerlendirilebilir; kontrastlanma hematomu maskeleyebileceğinden kontrastsız seri önce çekilmelidir.

BT bulguları

• Jejunumda sık görülen, kısa veya uzun bir segment boyunca konsantrik duvar kalınlaşması.
• Kontrastsız seride duvar katmanları içinde kendiliğinden hiperdens kan ürünleri.
• Submukozal genişleme ve duvar kalınlaşmasına bağlı lümen daralması; proksimal anslarda sıvı-gaz dilatasyonu gelişebilir.
• Komşu mezenterik yağda infiltrasyon görülebilir.
• Travma ilişkili barsak duvarı hematomunda perforasyon eşlik edebileceğinden barsak duvarı sürekliliği de değerlendirilmelidir.
• Duvarın belirgin kontrastlanmaması, pnömatozis veya serbest hava eşlik ederse yalnızca hematomla açıklanmayan komplikasyon olasılığı artar.
• Kontrastsız BT'de intramural atenüasyon artışı görülebilir; bir olgu serisinde ortalama yaklaşık 38 HU, odaksal değerler ise 70 HU'ya kadar bildirilmiştir.

Normalde

Normal jejunum ve ileumla karşılaştırmada, hematom düşünülen anslarda duvar kalınlaşması, artmış intramural atenüasyon ve lümen daralması aranır. Şüpheli ansı aynı düzeydeki komşu barsakla karşılaştırırken duvarın kalınlığını, spontan yoğunluğunu ve lümen çapını birlikte değerlendir; obstrüksiyon varsa proksimal ansların genişliği distaldeki çökmüş lümenle zıtlık gösterir.

Ayırıcı tanı

İskemik duvar ödemi

çoğunlukla kontrastlı görüntüde azalmış duvar boyanması, mezenterik ödem veya damar tıkanıklığıyla desteklenir.

İnfeksiyöz enterit, ince barsak duvar kalınlaşmasının ayırıcı tanısında yer alabilir; bu görüntüleme bulgusu tek başına hematom tanısı koydurmaz.

İnce barsak lenfoması tümöral ayırıcı tanıdadır; ince barsak tümörlerinde duvar kalınlaşması ve lümen darlığı görülebilir, bu bulgular hematoma özgü değildir.

İnce barsak adenokarsinomu tümöral ayırıcı tanıdadır; ince barsak tümörlerinde duvar kalınlaşması, lümen darlığı ve proksimal segmentlerde genişleme görülebilir.

Duvar içi ödem ve hematom

kontrastlı seride her ikisi de katmanlanma veya hedef benzeri görünüm oluşturabilir; ancak hematomda bu katmanlar artmış atenüasyona sahiptir.

Tuzaklar

• Yalnız kontrastlı BT’de hematom boyanmış duvar gibi algılanabilir; kontrastsız görüntüde aynı duvarın zaten yüksek atenüasyonlu olup olmadığını kontrol et.
• Kollabe ans fizyolojik olarak kalın görünebilir; hematomda duvar içi yoğunluk artışı ve lümen daralması ardışık kesitlerde sürer.
• İntramural kanama ile eşlik eden iskemi birlikte bulunabilir; damar açıklığı ve ans duvarı kontrastlanmasını ayrıca incele.
• Komşu mezenterik yağ infiltrasyonu hematoma eşlik edebilir; tanıda kontrastsız BT'deki intramural hiperdensite, duvar kalınlaşması ve lümen daralması birlikte değerlendirilir.

Kendini dene

1. Antikoagülan kullanan hastada kusma ve karın ağrısı var. Kontrastsız BT’de jejunum çevresel kalın, spontan hiperdens ve lümen dar. Bu bulgularla en olası tanı nedir?

   • İntramural hematom
   • İskemik enterit
   • Jejunal lenfoma
   • Crohn striktürü
   Cevabı göster

   İntramural hematom. Kan ürünleri kontrast verilmeden önce de duvar içinde parlak görünür ve ansın geçiş kanalını sıkıştırabilir. İskemiyi ayırmada bağırsak duvarı kontrastlanmasının azalması veya kaybolması yardımcı olabilir.

2. Kontrastsız BT’de ince barsak duvarı kalınlaşmış ve lümen daralmış, ancak duvar içi atenüasyon artışı yok. Hematom tanısı bu bulgularla desteklenir mi?

   • Hayır; duvar içi atenüasyon artışı da aranır
   • Evet; kalınlaşma tek başına hematomu kanıtlar
   • Evet; lümen daralması hematoma özgüdür
   • Hayır; bu bulgular obstrüksiyonu dışlar
   Cevabı göster

   Hayır; duvar içi atenüasyon artışı da aranır. İntramural hematomun karakteristik BT bulguları duvar kalınlaşması, artmış duvar içi atenüasyon ve lümen daralmasını içerir; yalnız kalınlaşma ve daralma hematom tanısını desteklemek için yeterli değildir.

Kaynaklar

Bu sayfadaki 37 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 16 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.