网膜疾病的超声诊断中国医大一院超声科康姝 检查腹膜和腹膜腔宜先用低频探头观察整个腹腔及盆腔。然后再换高频探头。女性病人还要应用经阴道探头，检查时要注意观察子宫及附件区、双侧盆壁及Douglas腔。壁层腹膜中的病灶不会随体位及呼吸运动，脏层腹膜、肠系膜、大网膜的病灶则通常探头加压可移动。正常腹膜、肠系膜、网膜的超声表现
腹膜分为壁层和脏层。正常壁层腹膜的超声表现为腹壁最深层的连续、平滑的高回声细线。肠系膜在声像图中表现为延长的叶状高回声，正常厚度约为0.7-1.2cm，其内的线状无回声为血管。当存在腹水时，肠系膜容易显示，表现为腹水内漂动的高回声，一端连于腹后壁，另一端连于肠管。网膜是由腹膜折叠形成的。正常状态下的大网膜在声像图中不易辨别。在存在腹水的时，大网膜的下部可以显示，表现为稍高回声，厚度随其内的脂肪含量而变化。腹水
腹水分为渗出液和漏出液。在病人平卧位时，腹水多分布于盆腔和侧腹部，尤其是右结肠旁沟。漏出液多为无回声。而渗出性腹水往往伴有分隔、肠管聚集等其他征象。乳糜性腹水是一种特殊类型的腹水，在声像图上，可以表现为点状回声或分层样液性回声。腹腔内新鲜出血表现为无回声或无回声内伴点状回声不规则运动。大量出血可以形成血肿，表现为均匀或不均匀的高回声团块。包裹性积液有时不易于囊肿、脓肿或血肿相区别。在声像图上，囊肿多为圆形或卵圆形，壁光滑，挤压临近结构。而包裹性积液多为不规则形状。腹膜肿瘤
腹膜转移癌
转移癌存在时多可以检查到腹水，可以见到分隔，有时也可以出现乳糜性腹水或腹腔积血。癌肿种植在腹膜上，可以形成低回声结节或不规则肿块。在癌肿较小时，还可以见到腹膜的线状结构，当肿块增大时，线状结构中断。肿块多朝向腹膜腔生长。当存在腹腔积液时，超声可以探及直径2-3mm大小的肿物。大网膜也是转移癌较易累及的部位。癌的广泛性浸润可以造成网膜增厚，甚至形成网膜饼，此时大网膜多呈高回声。增厚的网膜可以漂浮在腹水中，也可以与壁层或脏层腹膜粘连。转移癌还可以有肠系膜增厚，肠管、肠系膜、网膜粘连的表现。腹膜原发肿瘤
腹膜原发恶性肿瘤较少见，主要为恶性间皮瘤或淋巴瘤。90％的间皮瘤患者可以出现腹水。有文章报道腹水的量与肿瘤结节的量不成正比，这一点与腹膜转移癌不同。有时腹水内可以出现纤维条或分隔。腹膜间皮瘤的其他超声表现包括腹膜增厚，多表现为低回声，有者甚至为无回声，但后方回声不增强。有时可以出现大的不规则肿块，但这种不太常见。单发的结节较少见。网膜表现为低回声，内间杂高回声区，高回声为脂肪组织。腹膜假性黏液瘤
腹膜假性黏液瘤较少见，多由良性、交界性或恶性的卵巢或阑尾的黏液瘤引起。声像图表现为高回声的腹水，由液体的凝胶状性质所引起。与脓、血的颗粒状回声不同，本病腹水中的颗粒状高回声不能移动，肠管无法自由漂浮于腹水中，而是被肿块推移到中央或后方。由于其内的大量小囊状改变，假性黏液瘤有时可呈很高的回声。腹膜炎症性病变
腹腔脓肿
由于重力的原因，脓肿常发生在膈下、肝下和Douglas腔等处,也可以发生在肠间。脓肿的特点是：圆形或椭圆形的无回声区，边界较清楚，有不规则的壁。脓肿内可以含有组织碎屑和分隔。有时可以在脓肿内发现气体回声。在肥胖或术后的病人中，超声对鉴别有菌和无菌性的液性暗区受到限制。在脓肿内存在大量气体时，又和周围的肠襻不易鉴别。结核性腹膜炎
结核性腹膜炎是结核病的肺外表现中较常见的一种表现。结核性腹膜炎的临床表现可以和许多疾病相混淆。结核性腹膜炎可以分为三型：a.游离或包裹性积液。b.干酪性结节及粘连。c.由大网膜、肠系膜、肠管及纤维结构形成的肿块，有时可以伴有腹水。腹水是最常见的声像图表现。通常腹水内含有活动性较好的细纤维条。其他的表现包括腹膜的结节状增厚或出现不规则的低回声、网膜及肠系膜增厚、网膜呈高低回声间杂。其中网膜内的高回声被认为是由于淋巴管阻塞引起的脂肪沉积。肠系膜、门静脉周围、胰周及腹膜后的淋巴结肿大是结核性腹膜炎的另一个表现。淋巴结内髓质高回声范围可以减小或消失。硬化性腹膜炎
硬化性腹膜炎是连续性腹膜透析的主要合并症之一，是由于纤维结构形成，包围腹膜、网膜和肠管。超声对硬化性腹膜炎的诊断十分有帮助。有学者发现此病的最早的超声表现可能是部分肠管蠕动加快。腹水也是一个常见的特征。腹水内可以出现高回声的纤维条，最早主要出现在肝周。随着疾病的进展，肠管壁增厚，还可以出现钙化。肠管表面不光滑，似系于腹后壁。在疾病的晚期，就出现特征性的纤维条带。这些纤维条带出现在肠管前方，分布较密集、不规则，厚度1－4mm不等。节段性大网膜梗死
节段性大网膜梗死临床比较罕见。临床表现由于需要急性阑尾炎和胆囊炎鉴别。有文献报道此种疾病的典型的声像图表现是在肌紧张最明显的位置发现一个卵圆形或饼样的稍高回声包块，包块不可压缩。常见的位置在结肠肝曲或脐旁，与壁层腹膜相邻，在病人深吸气时扫查比较容易观察。与正常肠内容物不同，此包块不随呼吸运动，位置比较固定。参考文献
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