篇第十一章結(jié)核性胸膜炎課件

1、篇第十一章結(jié)核性胸膜炎篇第十一章結(jié)核性胸膜炎篇第十一章結(jié)核性胸膜炎篇第十一章結(jié)核性胸膜炎篇第十一章結(jié)核性胸膜炎篇第十一章結(jié)核性講授目的和要求1.掌握結(jié)核性胸膜炎的診斷及鑒別診斷。2.掌握結(jié)核性胸膜炎的治療原則。講授目的和要求1.掌握結(jié)核性胸膜炎的診斷及鑒別診斷。講授主要內(nèi)容 概述 病因和發(fā)病機(jī)制 病理 臨床表現(xiàn) 實(shí)驗(yàn)室和其他檢查 診斷標(biāo)準(zhǔn) 鑒別診斷 治療 講授主要內(nèi)容 概述Anatomy：解剖學(xué)：Visceral pleura臟層胸膜Parietal pleura壁層胸膜Latent space潛在腔隙概 述Anatomy：概 述I.Etiology: Mycobacterium tuberc

2、ulosis 病因：結(jié)核分枝桿菌 病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制Discovered by Dr.Koch in 1882由Dr.Koch 于1882年發(fā)現(xiàn)Acid-fast抗酸染色性Discovered by Dr.Koch in 1882Pathogenesis :two theories發(fā)病機(jī)制：兩種學(xué)說 Delayed hypersensitive reaction 遲發(fā)性高敏反應(yīng) Pleural infection 胸膜感染Pathogenesis :two theories 1.Pleural congestion with cell infiltration, unilateral

3、 in most cases. 胸膜充血，細(xì)胞浸潤，多數(shù)病例累及單側(cè)胸膜病 理病 理 In the early stage, polymorphs predominate. 早期以多型核細(xì)胞為主 Typically, lymphocytes predominate. 典型表現(xiàn)以淋巴細(xì)胞為主2. Tuberculous nodules 結(jié)核結(jié)節(jié)3. Exudative effusion 滲出液 In the early stage, polymo臨床表現(xiàn)Symptoms 癥狀A(yù)ge, often seen in young people, but also in elderly people1.

4、 年齡，多見于年輕人，但也可見于老年人Fever, typically 3738C, but can be 39C2. 發(fā)熱，典型者37-38C，但也有39C者臨床表現(xiàn)Symptoms 癥狀Chest pain, more severe when there is only little fluid.3. 胸痛，胸水少時明顯Breathlessness, when there is a lot of fluid.4. 氣短，胸水多時明顯Chest pain, more severe when tPhysical signs 體征Inspection: fullness of chest in

5、the involved side.1. 視診：患側(cè)胸廓飽滿2. Palpation: trachea shifts to the other side, weakness of vocal fremitus .2. 觸診：氣管向健側(cè)移位，觸覺語顫減低Physical signs 體征3.Percussion: dullness in the involved side.3. 叩診：患側(cè)實(shí)音4.Auscultation:disappearance of breathing sound4. 聽診：患側(cè)呼吸音消失3.Percussion: dullness in the 實(shí)驗(yàn)室和其他檢查1. Ch

6、est X-ray 胸片 Fluid is visible only when more than 300 ml. 胸水超過300ml時胸片可以發(fā)現(xiàn) CT is needed in a few cases. 少數(shù)病例需做CT實(shí)驗(yàn)室和其他檢查1. Chest X-ray 胸片篇第十一章結(jié)核性胸膜炎課件篇第十一章結(jié)核性胸膜炎課件篇第十一章結(jié)核性胸膜炎課件Pericardial effusion心包積液Pericardial effusion2. Ultrasonic examination 超聲檢查 More accurate than X-rays. 診斷胸水比X線準(zhǔn)確 Can provide

7、vital information for thoracentesis. 能為胸腔穿刺術(shù)提供關(guān)鍵資料2. Ultrasonic examination 超聲3. Thoracentesis and fluid examination - essential 胸腔穿刺術(shù)診斷的關(guān)鍵3. Thoracentesis and fluid exa(1)Fluid routine - exudate 胸水常規(guī)滲出液 specific gravity 1.018; 比重 1.018 WBC 500/cmm, predominated by polymorphs at early stage and lymp

8、hocytes later 白細(xì)胞計(jì)數(shù) 500/cmm, 早期以多型核細(xì)胞為主，以后以淋巴細(xì)胞為主 protein 3gram/dl 蛋白含量 3gram/dl(1)Fluid routine - exudate 胸(2) Acid-fast staining for acid-fast bacilli (not sensitive).(2)抗酸染色（不敏感）(3) Culture for tuberculous bacilli (time consuming).(3) 結(jié)核桿菌培養(yǎng)（費(fèi)時間）(4) Others: culture for bacteria, cytological exam,

9、 etc.(4) 其他：細(xì)菌培養(yǎng)，細(xì)胞學(xué)檢查，等等(2) Acid-fast staining for aci4.Pleural needle biopsy - tub. granuloma 4. 胸膜活檢 發(fā)現(xiàn)結(jié)核結(jié)節(jié)5.Others: Eos. count, liver function, immunoglobulin, 5. 其他檢查：血嗜酸細(xì)胞計(jì)數(shù)，肝功能，免疫球蛋白，等等4.Pleural needle biopsy - tsymptoms + physical signs + fluid exam. 癥狀 體征 胸水檢查 retrospective, exclusive. 回顧性，

10、排他性診斷標(biāo)準(zhǔn)symptoms + physical signs + fl Is there pleural effusion? 有無胸水？ Is it transudate or exudate? 胸水是漏出液還是滲出液？ What is the specific etiology? 胸水的病因是什么？鑒別診斷鑒別診斷Transudate 漏出液 1. Heart diseases 心臟病 2. Kidney diseases 腎臟病 3. Liver diseases 肝臟病 4. Malnutrition 營養(yǎng)不良 5. Endocrine diseases 內(nèi)分泌疾病Transudat

11、e 漏出液Exudate 滲出液1. tumorous diseases1. 腫瘤類疾病2. bacterial infection empyema purulent fluid reactive pleural fluid2. 細(xì)菌感染 膿胸 膿性胸水 反應(yīng)性胸水Exudate 滲出液3. connective tissue diseases3. 結(jié)締組織疾病4. parasite infection, such as paragonimiasis4. 寄生蟲感染，如肺吸蟲病5. Others5. 其他3. connective tissue diseasesanti-tuberculous chemotherapy1. 抗結(jié)核病化療In the same way as pul. Tuberculosis與肺結(jié)核相同 治 療治 療Keys 關(guān)鍵Initiate treatment as early as possible 早期Use multiple drug regimen 聯(lián)合Use adequate dosage 適量Give medicines in a regular bases 規(guī)律Treat patients long enough(6 mon.) 足程Keys 關(guān)鍵2. drainage of pleural fluid2. 引流胸