醫(yī)學(xué)影像學(xué)課件：七年制影像chest -呼吸常見(jiàn)病1支氣管病變+肺炎+肺結(jié)核

1、Imaging diagnosis of respirotary diseasepart 1AiPing Chen小兒胸腺肺大泡呼吸系統(tǒng)影像觀察、分析和診斷X線投照條件是否正確投照位置是否正確兩側(cè)胸廓是否對(duì)稱(chēng)縱隔位置是否居中橫膈高度是否正常CT上下層面結(jié)合分析肺窗與縱隔窗結(jié)合分析斷面圖像與三維重建圖像結(jié)合分析平掃圖像與增強(qiáng)掃描圖像結(jié)合分析觀察、分析病灶病變的部位，數(shù)目病變的形態(tài)與大小病變的密度與邊緣病變對(duì)鄰近結(jié)構(gòu)的影響不同成像技術(shù)的優(yōu)選和綜合應(yīng)用不同成像技術(shù)的價(jià)值和限度X線：健康普查、胸部疾病的診斷和隨訪 限度：結(jié)構(gòu)重疊，小病灶漏診，如心影后方病灶或后肋膈角病灶；密度分辨率低，對(duì)縱隔病變的診斷

2、有限。CT：發(fā)現(xiàn)病變、定位和定性診斷。 限度：定性缺乏特異性。MRI：定位和定性均有一定優(yōu)勢(shì)。限度：肺組織信號(hào)弱，對(duì)微細(xì)結(jié)構(gòu)的顯示效果不好成像技術(shù)的優(yōu)選原則疾病發(fā)病階段、發(fā)病部位及病變性質(zhì)不同，不同成像技術(shù)在胸部應(yīng)用的優(yōu)勢(shì)不同，需要多種成像技術(shù)綜合應(yīng)用。經(jīng)濟(jì)優(yōu)先，簡(jiǎn)便優(yōu)先，實(shí)用優(yōu)先，安全優(yōu)先原則支氣管病變氣管、支氣管異物foreign body in the bronchus先天性支氣管囊腫 congenital bronchial cysts氣管腫瘤支擴(kuò)Clinical symptom: cough, Purulent foul-smelling sputum , emptysis, or

3、haemoptysis. 兒童，青年多見(jiàn)，多見(jiàn)于左下葉、右中葉及右下葉。咳嗽、咳痰、咯血支氣管擴(kuò)張bronchiectasisBronchiectasis支擴(kuò)Bronchiectasis is defined as localized, irreversible dilatation of the bronchial tree. congenital or aquired -There are several causes of bronchiectasis, postinfectious causes; congenital defects of a structure nature; ch

4、ronic granulomatous infection such as tuberculosis. 無(wú)異常發(fā)現(xiàn)支氣管及肺間質(zhì)慢性炎癥引起肺紋理增多，增厚，紊亂?？沙使軤?、杵狀、囊狀蜂窩狀影，或卷發(fā)狀。繼發(fā)感染：呈小斑片狀模糊影，常不易治愈，或于同一地方反復(fù)發(fā)作。X線表現(xiàn)BronchiectasisPathologyDamage of bronchus wallPression of bronchus increaseCircumference tissue draught支氣管壁破壞支氣管內(nèi)壓增加周?chē)M織牽拉（疤痕、肺不張等）BronchiectasisBronchiectasis can

5、 be divided into three morphologic types: cylindrical,saccular, mixed type.柱狀、囊狀或靜脈曲張型。Cylindrical bronchiectasis refers to a generalized more or less regular widening of the large bronchi.Saccular bronchietasis shows that the bronchi terminate in sac-like cavities.BronchiectasisX-ray manifestation:

6、The plain film may be normal if only a small part is involved and there is no secondary infection.The most common appearance on plain film is increasing of lung markings. The bronchial walls may be visible either as single or parallel line opacities.There are paths of opacity when infection occures.

7、Bronchiectasis:lung markings of the left low lobe increase,and small sac( sac-like cavities)Bronchiectasis: lung markings of the left low lobe increase,and small sac( sac-like cavities)BronchiectasisBronchographic investigation is important and necessary to delineate the total extent of the disease.

8、 In the bronchogram, the cylindric bronchiectasis may be show club-shaped dilatation of the bronchi, while the saccular bronchiectasis will show saccular or cystic dilation of the affected bronchi. Bronchogram: saccular bronchictasis in the left lungBronchiectasisCT is helpful especially in the more

9、 advanced forms of bronchiectasis, cylindrical bronchiectasis causes smooth dilatation of bronchi, recognizable as “tram line” when seen in the scan plane and as the signet-ring sign in cross-section.The signet ring sign refers to the thickened and dilated bronchus, saccular bronchiectasis can be di

10、agnosed most reliably by CT, sometime we can see air-fluid level in the dilated bronchus.HRCT：支氣管壁增厚，管腔增寬。 呈“軌道征”或“印戒征”。柱狀、囊狀或靜脈曲張型。bronchictasistram line 軌道征 signet-ring sign 印戒征 air-fluid level in the sac.支擴(kuò)伴黏液栓形成bronchictasistram line and the signet-ring sign in cross-section.Question:where is th

11、e bronchiectasis?肺先天性疾病肺發(fā)育異常肺隔離癥(bronchopulmonary sequestration) intralobar extralobar肺動(dòng)靜脈瘺肺AVMPneumoniaThe causative organisms are variable:病原體多樣感染：細(xì)菌、病毒、真菌、支原體、衣原體、立克次體、寄生蟲(chóng)理化性：類(lèi)脂性、毒氣、藥物、放射線等免疫和變態(tài)反應(yīng)PneumoniaPneumonia can cause a wide variety of abnormal findings on the chest radiograph. Commonly, i

12、t presents as alveolar consolidation, which can be segmental or lobar, or may be patchy, fluffy, alveolar infiltrates-without any segmental distribution(bronchopneumonia pattern).Pneumonia also may present as diffuse alveolar disease or as diffuse interstitial disease. It also can present as single

13、or multiple nodules. The presence of pneumonia sometimes may be masked by an associated pleural effusion, congestive failure, or adult respiratory distress syndrome(ARDS).PneumoniaAccording to the radiologic appearance, pneumonia can be commonly divided into lobar pneumonia bronchopneumonia intersti

14、tial pneumoniaLobar pneumoniaLobar pneumonia most commonly is caused by S.pneumoniae肺炎鏈球菌, but it can also occur with other organisms. Lobar pneumonia represents a type of inflammation of the lung characterized by out-pouring of exudates into the alveoli with little change in the bronchi or intersti

15、tial tissue. The out-pouring of fluid is generally considered to result from a local sensitivity reaction to the polysaccharides in the capsule of the pneumococcus. The bacteria are rapidly carried by the edema fluid from alveolus to alveolus Lobar pneumoniaEarly stage: Inflammatory edemaConsolidati

16、on stage Resolution stageLobar pneumoniaEarly stage: Inflammatory edema The infection and edema have usually spread throughout a segment of the lung. X-ray findings: The lung markings increase. It does not completely obscure the pulmonary vessels in the area because many of the alveoli are still aer

17、ated.Lobar pneumoniaConsolidation stage The lung is characterized by a rather dense shadow of uniform opacity. If the bronchi remain patent, the air column within them stands out as dark. The presence of an air bronchogram within a shadow in the pulmonary field indicates that the density is due to c

18、onsolidation of lung. If adequate antibiotic treatment is given, no further spread takes place.1.大葉性肺炎 病理過(guò)程充血期：12-24hr。毛細(xì)血管充血，少量漿液滲出，肺泡部分仍含氣；實(shí)變期：2-5d，分紅色和灰色肝硬變期，肺泡內(nèi)充滿炎性滲出物。消散期：1w后開(kāi)始,2-3w消散。 線表現(xiàn)可無(wú)異?；蚍渭y理增粗。均勻?qū)嵶冇埃c肺葉、段一致的高密度影，隨各肺葉形態(tài)不同而不同。不均勻斑片狀，逐漸吸收，胸膜側(cè)最晚，可有胸膜增厚、纖維條索 lobar pneumoniaconsolidation of rig

19、ht upper lung and “air bronchogram “consolidation of right middle lober consolidation of right upper lober Lobar pneumoniaResolution stageThe homogenicity if the shadow of consolidation is lost and it becomes mottled as the exudate in various portions of the affected lung is absorbed and alveoli her

20、e and there are filled with air. The pathologic consists of intermingled areas of consolidation of varying degree, aeration of the alveoli and areas of atelectasis. The latter are often represented on the film by streak-like shadow. These shadows disappear as the lung re-expands and resolution is co

21、mpleted.Resolution stage in the right upper loberStreak like shadowResolution stage in the left lower loberconsolidation of left upper lober 雙上葉見(jiàn)大片狀致密影，可見(jiàn)支氣管充氣征consolidation of right and left upper lober (air bronchogram) Bronchopneumonia (lobular pneumonia) It is commonly seen in infants and elderl

22、y patients by infection by Staphylococcus aureus, most gram-negative bacteria and some fungi. It begins as a bronchial infection and has a tendency to involve separate parts of the lung. The infection spreads along the bronchial walls and results in infiltration of the interstitial tissues with litt

23、le involvement of the alveolar air space. In most cases, both consolidations of the alveolar air spaces and interstitial infiltration are present.Bronchopneumonia (lobular pneumonia)The radiologic manifestations of bronchopneumonia depend on the severity of the disease. Mild bronchopneumonia results

24、 in peribronchial thickening and poorly defined air-space opacities. More severe disease results in inhomogeneous, patchy areas of consolidation that usually involve several lobes. Bronchopneumonia (lobular pneumonia)Consolidation involving the terminal and respiratory bronchioles and adjacent alveo

25、li results in poorly defined centrilobular nodular opacities measuring 4 to 10 mm in diameter (air-space nodules); extension to involve the entire secondary lobule(lobular consolidation) may be seen. Bronchopneumonia frequently results in loss of volume of the affected segments or lobes. When conflu

26、ent, bronchopneumonia may resemble lobar pneumonia.小葉性肺炎影像學(xué)表現(xiàn)病變部位：兩肺中下野的內(nèi)中帶肺紋改變：增多、增粗、模糊X-ray: 兩肺中下野的內(nèi)中帶沿支氣管分布，肺紋理增多、增粗、模糊，小葉滲出與實(shí)變表現(xiàn)為斑片狀模糊致密影，有融合傾向CT表現(xiàn)：兩中下肺支氣管血管束增粗，有大小不同結(jié)節(jié)和片狀陰影，12cm大小，邊緣模糊。病變之間除正常含氣肺組織外，還有12cm類(lèi)圓型透亮陰影，代表小葉性過(guò)度充氣patchy areas of consolidationLung markings increase and patchy in the rig

27、ht lower lobeLung markings increase and patchy in the right and left lungPatchy shadow in both of the lung Patchy shadow in both of the lung 機(jī)遇性感染opportunity infectionimmune deficiency accompany with infection or tuberculosis and so on 免疫缺陷者伴隨的感染或結(jié)核等Eg. HIV infection: 細(xì)菌，真菌，病毒，TB，PCP （肺孢子蟲(chóng)肺炎）HIV fem

28、ale 23 years olds HIVPatchy shadow in both of the lung AIDS and Pneumocystis carinii pneumoniaAIDS patient with pulmonary cryptococcal infection.（新型隱球菌）Lung abscessHematogenous abscess血源性的膿腫 is rather rare now. Abscesses occur most often as a complication of aspiration of food, vomitus, or foreign b

29、ody; of bacterial pneumonia; or bronchial obstruction. Anaerobic bacteria厭氧菌are often the cause. Other relatively Common agents are S.aureus金黃色葡萄球菌and Pseudomonas aeruginosa綠膿桿菌/綠膿假單胞菌. Abscesses may also be secondary to septicemia敗血病, and they occasionally develop in an infected pulmonary infarct.L

30、ung abscessSymptomatology resembles that of acute pnenmonia with fever, cough productive of purulent sputum膿痰, and leucocytosis白細(xì)胞增多. Diabetics, alcoholics, and immunocompromised,免疫受損的individuals are at increased risk of developing lung abscess.Lung abscessThe abscess resulting from aspiration most

31、frequently occurs in the dependent segments of the lung- the posterior segments of the upper lobe and the superior segments of the lower lobe. The abscess first appears as a round but poorly defined area of segmental consolidation usually near the periphery of the lung. No fluid level is seen until

32、bronchial communication is established. Lung abscessAs the abscess ruptures into the bronchus a translucent ring with a fluid level is seen in the middle of the opaque segment. The inner walls of the cavity are smooth. Adjacent parenchymal consolidation is also present. Multiple cavities may develop

33、 within consolidated lung(necrotizing pneumonia). Conventional tomography may show gas bubbles within an abscess indicating either a bronchial communication or possible infection with gas-forming organisms. There is frequently an associated pleural effusion.Lung abscessCT allows earlier detection of

34、 abscess formationCT is also superior in defining the relationship of the process to the pleural cavity,. Empyemas膿胸 tend to be lenticular凸出的 in shape, and their angle of interface with the chest wall is usually obtuse鈍角. A lung abscess is usually spherical and produces an acute angle with the chest

35、 wall. Lung abscessAfter antibiotic treatment in favorable cases both the cavity and the surrounding consolidation gradually shrinks and disappears. The abscess heals completely and leaves no visible scar or sometimes a small area of fibrosis indicates the site. In some cases healing is slow and the

36、re is often a residual bronchiectasis of fusiform type.肺膿腫 lung abscess急性化膿性肺炎期：大片炎性浸潤(rùn)膿腫形成期：出現(xiàn)含液平空洞慢性肺膿腫：周?chē)装Y吸收，代之以纖維組織增生，表現(xiàn)為紊亂的條索影及斑片陰影血源性肺膿腫：兩肺胸膜下多發(fā)性類(lèi)圓性陰影，中間有小空洞形成，可有液平，常累及胸膜Acute abscess: the cavity (fluid in cavity) and the surrounding consolidationAcute abscess: the cavity (fluid in cavity) and

37、 the surrounding consolidationAcute abscess: the cavity (fluid in cavity) and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationTuberculos

38、is of the lungTuberculosis is an infectious disease that may affect any organ but shows a marked predilection for the lungs. Nowadays better standards of living and hygiene have sharply reduced the incidence of tuberculosis. Despite recent advances in therapy and careful public health measures, TB r

39、emains a problem in the large reservoir of elderly patients who have previously been infected with tubercle bacilli and in the urban poor who continue to be exposed to tubercle bacilli. Tuberculosis of the lungThe main factor determining whether tuberculosis infection progresses to disease is the im

40、mune competence of the individual. The disease is most commonly found in persons whose immune status is compromised by old age, alcohol abuse, diabetes, steroid therapy, or AIDS.Tuberculosis of the lungTuberculosis is classically divided into () primary tuberculosis. () hematogenous tuberculosis.()

41、postprimary tuberculosis. () tuberculous pleurisy .() extraplumonary tuberculosis.primary tuberculosisMost cases of primary tuberculosis due to inhale the tubercle bacilli. It is commonly seen in children or adolescents. The infection spreads from the initial focus in the lung to the regional and me

42、diastinal lymph nodes by way of the lymphatic channels. Inhaled tubercle bacilli initially evoke a focal, nonspecific subpleural alveolitis that converts to a tuberculosis-specific inflammatory focus(Ghon focus) in about 10 days. Spread of tubercle via the lumphatics leads to a specific hilar lympha

43、denitis. The combination of the primary pulmonary focus, lymphangitis and lymphadenitis is known as the primary complex.primary tuberculosisThe Ghon focus is a circumscribed, small, peripheral consolidation. Hilar and mediastinal lymphadenitis presents as hilar enlargement and mediastinal widening.

44、Occasionally, lymphangitic stranding connecting the primary focus with the hilar lymphadenitis forms a dumbbell-shaped opacity. Segmental opacity may be due to segmental atelectasis distal to bronchial compression by enlarged lymph nodes.Right hilar enlargement and mediastinal wideningLeft hilar enl

45、argement Left hilar enlargement and mediastinal wideningRight hilar enlargement and mediastinal wideningLymph node enlargement in mediastinum After treatment enlargement lymph node disappearHematogenous tuberculosis(Type )Mycobacteria entering the blood from the primary complex may become disseminat

46、ed to numerous extrapulmonary sites. It may be classified as acute, subacute or chronic hematogenous dissemination tuberculosis. Miliary tuberculosisAcute miliary tuberculosisMilitary tuberculosis exhibits a finely mottled nodular pattern resulting from summation of individual nodules. These may ran

47、ge in size from 1-4mm in diameter.They completely obscure the normal lung markings in acute hematogenous dissemination tuberculosis. Three homogeneous:distribute,size,densityThree homogeneous: distribute,size,densityAcute miliary tuberculosisThree homogeneous:distribute,size,densityAcute miliary tub

48、erculosisAcute miliary tuberculosisAcute miliary tuberculosis Miliary tuberculosisSubacute or chronic miliary tuberculosistiny opacities are chiefly distributed in both upper and middle lung fields, the density of the opacities is not uniform and the size and shape of the opacities are not the same.

49、 Three nonhomogeneous:distribute,size,densitySubacute or chronic miliary tuberculosisThree inhomogeneous:distribute,size,densityThree homogeneous:distribute,size,densitySubacute or chronic miliary tuberculosisSubacute or chronic miliary tuberculosisPostprimary tuberculosis (Adult tuberculosis)Postpr

50、imary tuberculosis is characterized by cavitating lesions in the upper lobes or apical segments of the lower lobes. Rupture of a parenchymal focus into an adjacent airway and subsequent endobronchial spread may lead to extensive pulmonary involvement. .Postprimary tuberculosis (Adult tuberculosis)Po

51、stprimary tuberculosis produces a spectrum of radiographic manifestations; exudative, productive, cavitatory, and fibrotic changes frequently occur simultaneously. Because of the predilection for the apical and posterior segments of the upper lobe and the apical segment of the lower lobe, parenchyma

52、l changes in these regions should arouse suspicion of tuberculosisPostprimary tuberculosisPostprimary tuberculosisPostprimary tuberculosisPostprimary tuberculosis (Adult tuberculosis)Exudative tuberculosis is characterized by a lobular, caseous pneumonia with relative few epithelioid cells. Coalesce

53、nce may occur to form larger foci of caseous pneumonia. Exudative tuberculosis manifests as confluent mottled opacities with indistinct contours. They gradually alter in appearance over a period of weeks in contrast to nonspecific pneumonia, which may change within days.caseous pneumonia. Postprimar

54、y tuberculosis (Adult tuberculosis)Productive tuberculosis is characterized by well-defined solid nodules, 1-2mm in diameter and rich in epithelioid cells; Productive tuberculosis produces sharply defined, irregular, polygonal opacities admixed with calcified granulomata.Productive tuberculosisPostp

55、rimary tuberculosis (Adult tuberculosis)Tuberculomas measure 1-3cm in diameter and comprise a caseous core surrounded by a mantle of granulation tissue. They have smooth margins and predilection for the upper zones. In 80% of cases, conventional or computed tomography will show small satellite lesio

56、ns and calcifications.TuberculomasTuberculomasTuberculomasPostprimary tuberculosis (Adult tuberculosis)Cavitating tuberculosis is active tuberculosis, the wall of the cavity contains infectious caseous material. Eventually, the cavity becomes fibrosed and may even acquire an epithelial lining. Postprima