胸腔積液巡診

DiagnosisofPleuralEffusions呼吸內(nèi)科：徐作軍2002.9PUMCH1胸腔積液的發(fā)生機(jī)制1微循環(huán)靜水壓增高充血性心力衰竭2微循環(huán)膠體滲透壓下降嚴(yán)重低蛋白血癥3胸腔內(nèi)壓力減低完全的肺塌陷4微循環(huán)滲透性改變肺炎5胸壁淋巴回流受阻惡性腫瘤6腹腔積液流入肝硬化腹水7其它外傷、食管破裂、胰腺炎、阿米巴等2漏出液病因充血性心力衰竭肝硬化腎病綜合征腹膜透析胸膜淀粉樣變上腔靜脈阻塞綜合征

縮窄性心包炎肺不張粘液性水腫肺栓塞尿液胸（Urinothorax）麥格（meig’s）綜合征3膠原血管疾病紅斑狼瘡類風(fēng)濕性關(guān)節(jié)炎Wegener肉芽腫Churg-Strauss綜合征干燥綜合征免疫母細(xì)胞淋巴結(jié)病非感染性胃腸道疾病胰腺炎食道破裂腹部手術(shù)滲出液病因（2）5淋巴疾病乳糜胸淋巴管肌瘤病黃指甲綜合征其它類肺栓塞石棉肺放射治療麥格（meig’s）綜合征血胸冠脈搭橋術(shù)后結(jié)節(jié)病滲出液病因（3）6藥物誘發(fā)的胸腔積液藥物誘發(fā)性狼瘡乙胺碘膚酮博來霉素絲裂霉素米諾地爾(Minoxidil)美西麥角(Methysergide)丹曲洛林（Dantrolene)IL-2滲出液病因（4）7滲出性胸腔積液的鑒別診斷葡萄糖<60mg/dL

肺炎旁胸腔積液類風(fēng)濕性關(guān)節(jié)炎惡性腫瘤結(jié)核性胸膜炎肺吸蟲病9pH<7.2膿胸復(fù)雜性肺炎旁胸腔積液類風(fēng)濕性關(guān)節(jié)炎食道破裂結(jié)核性胸膜炎惡性腫瘤肺吸蟲病血胸酸中毒滲出性胸腔積液的鑒別診斷10淀粉酶>正常值上限食道破裂胰腺炎惡性腫瘤滲出性胸腔積液的鑒別診斷11淋巴細(xì)胞>50％

淋巴瘤其它惡性腫瘤慢性感染：結(jié)核、霉菌結(jié)節(jié)病結(jié)締組織疾病滲出性胸腔積液的鑒別診斷13嗜酸細(xì)胞>5%胸膜腔內(nèi)積氣胸膜腔內(nèi)積血藥物誘發(fā)的胸腔積液石棉肺惡性腫瘤（淋巴瘤）寄生蟲病結(jié)節(jié)性多動脈炎嗜酸性粒細(xì)胞性肺病異物滲出性胸腔積液的鑒別診斷14乳糜胸外傷手術(shù)結(jié)核腫瘤淋巴瘤肝硬化腎病綜合征絲蟲病先天性異常滲出性胸腔積液的鑒別診斷151.PleuralFluidastheOnlyAbnormalityWithPrimaryDiseaseintheChestinfectionstuberculousandviralmalignancy

cancer,non-Hodgkin'slymphoma,andleukemiapulmonaryembolism

drug-inducedlungdisease

benignasbestospleuraleffusion(BAPE)

lymphaticabnormalitieschylothoraxandyellownailsyndrome

uremicpleurisyconstrictivepericarditishypothyroidism172.BilateralEffusions

transudativeeffusionscongestiveheartfailurenephroticsyndromehypoalbuminemiaperitonealdialysisconstrictivepericarditisexudativeeffusionsmalignancy(extrapulmonicprimarycarcinomas,lymphoma)lupuspleuritisyellownailsyndrome183.DiseasesBelowtheDiaphragmtransudates

hepatichydrothoraxnephroticsyndromeurinothoraxperitonealdialysisexudatespancreaticdiseasechylousascitessubphrenicabscesssplenicabscessorinfarction195.PulmonaryNodulesmostcommoncauses

metastaticcarcinomafromanonlungprimarytumor.Lesscommoncauses

Wegener'sgranulomatosisrheumatoidarthritissepticembolisarcoidosis21結(jié)核性與腫瘤性胸水的鑒別<65ug/ml<1>65ug/ml>1溶菌酶活力胸水／血液LDH2增高LDH4、5增高LDH同工酶多>7.40多<7.30PH大量間皮細(xì)胞淋巴細(xì)胞為主細(xì)胞類型多為大量,生長快多為中、少量胸液量（－）（＋）PPD試驗中、老年多見青、少年多見年齡腫瘤性結(jié)核性22結(jié)核性與腫瘤性胸水的鑒別效果不佳反應(yīng)較好抗TB治療腫瘤組織結(jié)核肉芽腫胸膜活檢<1g/L>1g/L類粘蛋白>700ng/ml<700ng/ml鐵蛋白>20ug/L>1<20ug/L<1CEA胸水／血液<45u/L<1>45u/L>1腺苷脫氨酶胸水／血液腫瘤性結(jié)核性23胸腔積液的診斷程序胸腔積液都不符合：漏出液診斷性胸腔穿刺測胸水蛋白及LDH符合1條及以上：滲出液治療原發(fā)?。盒乃?、腎病等1胸水/血清蛋白>0.52胸水/血清LDH>0.6