【醫(yī)藥健康】泌尿系結(jié)核Tuberculosis(B) of the Genitourinary Tract

1、tuberculosis(tb) of the genitourinary tract泌尿生殖系結(jié)核瑞金醫(yī)院泌尿外科urinary tb a disease of young adults. 60% between 2040y. infecting organism mycobacterium tuberculosis (結(jié)核分支桿菌，結(jié)核桿菌), tubercle bacilli infecting route(感染途徑) hematogenous route(血行途徑) from the lungs. primary sites(初發(fā)部位): kidney, prostate (前列腺)

2、other organs involved: direct extension pathogenesis(發(fā)病機理) tubercle bacilli hit the renal cortex(腎皮質(zhì)): normal resistance(抵抗力): organism destroyed sufficient virulence(致病力): clinical infection established.pathogenesis tb of kidney: progresses slowly, 1520y to destroy a kidney with good resistance. no

3、 clinical disturbance until the calyces / pelvis(腎盞/腎盂) involved.pathology(病理)kidney & ureter (輸尿管) grossly: a soft, yellowish localized bulge (隆起). on section: involved area filled with cheesy material (caseation, 干酪樣物質(zhì)).kidney & ureter walls of pelvis, calyces and ureter thickened. ulcerat

4、ion(潰瘍形成) in calyces. complete ureteral stenosis(輸尿管狹窄) autonephrectomy(腎自截). bladder urine normal and symptom absent.kidney & ureter basic lesiontubercle foci(結(jié)核結(jié)節(jié)) epithelioid reticulum(上皮樣網(wǎng)) peripheral giant cells heal by fibrosis(纖維化).kidney & ureter tb is a combination of caseation(干酪樣變

5、), cavitation(空洞形成) and healing by fibrosis &scarring(纖維化和疤痕愈合). depending on virulence vs resistance. calcification(鈣化): strongly suggestive of tb. secondary renal stones in 10%. left kidney: autonephrectomy right kidney: hydronephrosis & ureteral reflux (腎積水&輸尿管返流) contraction of the b

6、ladder (膀胱孿縮) 左腎萎縮萎縮腎外觀caseation & fibrosisl renal dysfunction on isotope scan (同位素掃描)calcification (鈣化)bladder tubercle form: white/yellow raised nodules(結(jié)節(jié)) surrounded by a halo of hyperremia(充血). tubercles break downdeep ragged ulcers bladder irritable. 膀胱結(jié)核，多個粟粒樣黃色小結(jié)節(jié)膀胱結(jié)核，結(jié)核性潰瘍diagnosis(診斷)

7、just saying you had turned a corner doesnt make it so. just saying there is massive destruction doesnt make it so. _john kerry just saying there is tb also doesnt make it so. we must provide demonstration of tubercle bacilli in urine by culture.diagnosis: symptoms(癥狀) no classic clinical picture of

8、renal tb. most are vesical in-origin(膀胱起源): burning, frequency(尿頻) & nocturia(夜尿), hematuria(血尿)diagnosis: signs(體征) kidneyno enlargement / tenderness(觸痛) external genitalia(外生殖器): thickened, nontender epididymis(附睪) chronic scrotal draining sinus(陰囊竇道) induration/nodulationof prostate & sem

9、inal vesicles(前列腺/精囊硬結(jié)) diagnosis: lab findings persistent pyuria(膿尿) without organism on culture. but acid-fast stains: 60%(+). culture for tb (1st morning urine): (+) percentage very high. tuberculin test(結(jié)核菌素試驗): (-) against tb.diagnosis: x-ray findings chest film plain film(平片平片): enlargement of

10、 1 kidney obliteration(消失) of the renal & psoas (腰大肌) shadow renal stones(腎結(jié)石) 10%diagnosis: x-ray findings excretory urograms(排泄性尿路造影排泄性尿路造影): “moth-eaten”(蚤咬) appearance of ulcerated calyces. obliteration of 1/more calyces. dilation of calyces. abscess cavities connecting with calyces. excreto

11、ry urograms: ureteral stricture with secondary dilatation. absence of function of the kidney. retrograde urographymru or ctdiagnosis: instrumental exams cystoscope(膀胱鏡膀胱鏡): tubercles & ulcers, contraction(孿縮) cystogram(膀胱造影膀胱造影): ureteral reflux(輸尿管返流)differential diagnosis鑒別診斷 chronic nonspecif

12、ic cystitis 慢性膀胱炎 epididymitis 附睪炎 multiple small renal stones and medullary sponge kidneys(海綿腎) urinary bilharziasis(血吸蟲病) bladder stones or cancer. treatment (治療)tb must be treated as a generalized disease! basic treatmentmedical 藥物 surgical excision(外科切除) merely adjuncttreatment: renal tb combina

13、tion of drugs(1st line): 1. isoniazid (inh, 異煙肼) 200300mg/d 2. rifapin (rfp, 利福平) 450600mg/d 3. ethambutol (emb, 乙胺丁醇) 15mg/kg/d 4. streptomycin (stm, 鏈霉素) 1g/d im 5. pyrazinamide (pza, 吡嗪酰胺) 1.52g/dtreatment: renal tb prefer inh + rfp + emb resistance to 1st line drugs: aminosalicylic acid (氨基水楊酸)

14、capreomycin (卷須霉素) cycloserine (環(huán)絲氨酸) ethionamide (乙硫異煙胺) viomycin (紫霉素)treatment: renal tb nephrectomy(腎切除腎切除) : 1. after 3 m, urine culture still (+) and gross involvement radiologically evident. 2. severe sepsis(膿毒癥), pain or bleeding from 1 kidney. 3. marked advanced on 1 side and minimal damage

15、 on the other. treatment: vesical tb tends to heal when treatment for the “primary” infection is given. ulcers : trans-urethral electrocoagulation (經(jīng)尿道電凝) extreme bladder contraction: urinary diversion(尿流改道); augmentation cystoplasty(節(jié)段性膀胱成形術(shù))treatment: general measures optimal nutrition: important

16、irritable bladder: bladder sedatives(鎮(zhèn)靜劑)prognosis(預(yù)后) relapse(復(fù)發(fā)): ureteral stenosis; vesical contraction prognosis overall control rate: 98% at 5 years urine study: every 6 m during treatment; every year for 10 years.case report a 56y male with left abdominal mass & anemia(貧血). x-ray showed a

17、large stone in l kidney with severe hydronephrosis.謝 謝肝癌是指發(fā)生于肝臟的惡性腫瘤，包括原發(fā)性肝癌和轉(zhuǎn)移性肝癌兩種，人們?nèi)粘Ｕf的肝癌指的多是原發(fā)性肝癌。原發(fā)性肝癌是臨床上最常見的惡性腫瘤之一，根據(jù)最新統(tǒng)計，全世界每年新發(fā)肝癌患者約六十萬，居惡性腫瘤的第五位。原發(fā)性肝癌按細胞分型可分為肝細胞型肝癌、膽管細胞型肝癌及混合型肝癌。按腫瘤的形態(tài)可分為結(jié)節(jié)型、巨塊型和彌漫型。原發(fā)性肝癌在我國屬于高發(fā)病，一般男性多于女性。中國是乙肝大國，我國的肝癌多在乙肝肝硬化的基礎(chǔ)上發(fā)展而來，丙肝病人也在逐漸增加，乙肝后也會發(fā)展為肝癌。目前我國發(fā)病人數(shù)約占全球的半數(shù)以上，占全球肝癌病人的55%，已經(jīng)成為嚴重威脅我國人民健康和生命的一大殺手，其危險性不容小視。1 發(fā)病原因發(fā)病原因總的來說，原發(fā)性肝癌的病因至今未能完全闡明，但已證明與以下因素密切相關(guān)： 1、病毒性肝炎：流行病學(xué)統(tǒng)計表明，乙肝流行的地區(qū)也是肝癌的高發(fā)地區(qū)，患過乙肝的人比沒有患過乙肝的人患肝癌的機會要高10倍之多。長期的臨床觀察中發(fā)現(xiàn)，肝炎