CT1535:[转帖]胸部占位(结果已公布)

qinys

[emb6]6楼

阿圣

图像太少,不能连续观察,很难得出结论.

jiangjing

考虑(1)食道裂孔疝.2右位心。气管右移[提示右肺有部分不张。肺部发育不全]。食管囊肿。

liu.hui.yang

以下是引用xizhong在2005-7-4 15:36:57的发言：[br]胸片纵隔内可见液平面,结合ct考虑(1)食道裂孔疝(2)贲门失迟缓症.

wangjing81750

图片真的很少，我不知道怎么去分析，而且图片不是很清晰，纵隔很模糊，有没有淋巴肿？就图上所见，病灶为囊性，是食管还是胃，很难判断，如果不是，是不是纵隔囊肿？气管心脏等右移，建议把其他的图片一并发来。

ljy1981

right intrathoracic stomach

secondary to congenital hiatal hernia type iii and organoaxial torsion

findings
chest radiograph shows soft tissue opacity in the right lower hemithorax posterolateral to the heart.
this opacity obscures the right cardiac margin & right hemidiaphragm.
ct shows 5 x 3 x 3 cm-sized cystic mass in the right posterior mediastinum.
follow up chest radiograph and ct reveals an opacity with air-fluid level in the right thorax and the distal part of nasogastric tube is located within the mass.
a barium meal examination shows a partial right intrathoracic stomach and non-obstructive 1800 organoaxial torsion with the the greater curvature lying against the right chest wall. the esophagogastric junction is above the diaphragm.
at surgery, the gastric fundus was found to lie in the right chest cavity above the diaphragm and the esophageal hiatus was wide. the stomach was moved into the abdominal cavity and nissen fundoplication was done.

discussion
diaphragmatic hernias are classified as bochdalek&#39；s hernia (90%), hiatal hernia, and morgagni&#39；s hernia. the parahiatal hernias are characterized by herniation through a small defect adjacent to the esophageal hiatus. they are rarely seen and may be associated with previous trauma.
the hiatal hernias are classified according to their anatomic characterirstics: as sliding (type i), charaterized by a upward migration of the gastroesophageal junction into the posterior mediastinum, paraesophageal (type ii), characterized by an upward dislocation of the gastric fundus alongside a normally positioned gastroesophageal junction.
a mixed hernia (type iii), charaterized by upward dislocation of both cardia and gastric fundus. the paraesophageal hiatal hernia accounts for only five percent of al diaphragmatic defects. in fact, more than 90% of paraesophageal hernias are actually of the mixed type.
the end stage of a type i or type ii hernia occurs when the whole stomach migrates up into the chest by rotating 180 degree around its longitudinal axis with the cardia and pylorus as fixed points (intrathoracic stomach), and the last one is multiorgan hiatal hernia (type iv； herniation of viscera other than stomach).

a right intrathoracic stomach is a rare form of congenital hiatal hernia seen in childhood. it appears to have a male predominance and might be influenced by family history and genetics. unlike other congenital diaphragmatic defects, a right intrathoracic stomach are discovered later in childhood because of the absence of a mass effect, pulmonary hypoplasia, and signs of incarceration or strangulation.

the symptoms are usually chronic because of gastroesophageal reflux or compromising the gastric outlet. the esophageal hiatus is anatomically situated at the level of the t10 vertebra. in this case the lower esophagus is short and the gastroesophageal junction is located high above the esophageal hiatus. the intrathoracic, extrapleural stomach is not dilated or obstructed.


it must be differentiated from a morgagni&#39；s hernia and the rare right posterolateral bochdalek&#39；s hernia (lt : rt = 5 : 1 or 83-94% in lt), which usually contains the liver, small and large intestine and is associated with a mass effect and a shift of the mediastinal structures into the left hemithorax.


it also be differentiated from  mediastinal cysts. most mediastinal cysts are of congenital origin and include foregut-duplication cyst (bronchogenic, duplication, and neurenteric cysts), pleuropericardial cyst and thymic cyst.


mediastinal bronchogenic cysts result from abnormal budding of the ventral diverticulum of the foregut. usually there is no direct communication with the tracheobronchial tree, althouth connection by a stalk is common. thus infection is less likely. most mediastinal bronchogenic cyst are located in paratracheal (19%) and near the carina (52%), less commonly, they are located in paraesophageal (14%),  hilar, and miscel

shibing

后纵隔中下部囊性病灶，密度均匀，无明显强化，壁较薄，考虑：食管囊肿。