呼吸系统病理学课件.ppt

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1、病理學高雄榮民總醫院胸腔外科主任病理學為醫學領域的一門分支學科專門探討疾病在個體發生的起因發展及變化以及整個過程對患者產生的各種影響。呼吸系統呼吸系統上呼吸道疾病鼻腔、咽和喉；常見但致命疾病少見急性、慢性發炎息肉腫瘤肺臟和氣道疾病含氣管及支氣管胸膜及胸膜腔疾病鼻息肉(Nasal polyp)反覆鼻炎引起之鼻腔突起物非真正腫瘤可引起鼻腔阻塞手術治療，但容易復發Paranasal sinus急性、慢性發炎(2)鼻竇炎(sinusitis)Paranasal sinus發炎卡他性炎症鼻炎鼻竇炎急性慢性鼻竇炎顱腔骨髓炎和顱內感染急性、慢性發炎(4)急性會厭炎(acute epiglottitis)好發

2、於嬰幼兒多為流行性感冒嗜血桿菌引起可引起嚴重上呼吸道阻塞而死亡喉炎(laryngitis)感染、過敏、吸煙或其他化學性刺激引起白喉(diphtheria)：喉部偽膜上呼吸道腫瘤(1)鼻腔及副鼻竇腫瘤乳突狀瘤(papilloma)：三型，少數演變為惡性鱗狀細胞癌(squamous cell carcinoma)鼻咽癌(nasopharyngeal carcinoma)廣東腫瘤(Canton tumor)EB(Epstein-Barr virus)成年男性癌症死亡第13位(2002年)鼻涕帶血、留鼻血、鼻塞、頸部淋巴結腫大顱底侵襲未分化癌(undifferentiated carcinoma)或鱗

3、狀細胞癌未分化癌中常有癌細胞浸潤於淋巴組織間又稱淋巴上皮瘤(lymphoepithelioma)放射線治療上呼吸道腫瘤(2)喉癌(laryngeal carcinoma)中老年男性吸煙漸進性聲音沙啞、吞嚥困難、頸部淋巴結腫大多為鱗狀細胞癌laryngeal carcinoma肺臟和氣道疾病2002年非癌症之主要死亡原因肺炎：第7位支氣管炎、肺氣腫及氣喘：第11位結核病：第12位國人十大癌症死亡原因肺癌：男性第2位女性第1位炎症支氣管炎肺炎大葉性肺炎支氣管肺炎間質性肺炎吸入性肺炎肺膿瘍支氣管炎(Bronchitis)急性支氣管炎(acute bronchitis)感染或其他刺激物大多數自癒，少數

4、併發肺炎可氣道阻塞慢性支氣管炎(chronic bronchitis)二年、每年三個月、持續帶痰咳嗽吸煙氣管及支氣管黏液腺肥大，呼吸道上皮鱗狀化生細支氣管(bronchiole)亦常有發炎及管腔變窄可併發肺氣腫，氣道阻塞肺炎(pneumonia,pneumonitis)感染性肺炎細菌性肺炎大葉性肺炎、支氣管肺炎發燒、不適、咳嗽、有痰、胸痛及呼吸困難非典型肺炎(atypical pneumonia)間質性肺炎非感染性炎症吸入化學物質Pneumonia(RLL)支氣管肺炎(bronchopneumonia,lobular pneumonia)氣管炎或支氣管炎的延伸可形成多發性病灶兒童、老人葡萄球菌

5、、鏈球菌、嗜血桿菌慢性心衰竭及癌末病人常見大葉性肺炎(lobar pneumonia)炎症波及肺葉絕大部分或一整個或多個肺葉肺炎鏈球菌(Streptococcus pneumoniae)四階段水腫充血期紅色肝變期(red hepatization)：大量滲出液內含紅血球、嗜中性白血球、纖維蛋白灰色肝變期(gray hepatization)：紅血球遭破壞、纖維蛋白化膿性滲出液持續存在消解期(resolution)：滲出液堅實化後被酵素分解，再被巨噬細胞吞噬移除併發症：胸膜炎、胸膜腔滲液、胸膜腔積膿、肺膿腫、敗血症、腦膜炎、心內膜炎、關節炎等Lobar pneumonia間質性肺炎(inters

6、titial pneumonitis)肺泡中隔和間質組織炎症Atypical pneumonia肺炎黴漿菌(mycoplasma pneumoniae)、病毒或其他細菌Idiopathic interstitial pneumonia肺臟纖維化疾病SARS(2)(Severe Acute Respiratory Syndrome)飛沫、接觸體液傳染潛伏期3-7天、可能超過十天症狀(Fig 11-6)，出現症狀後始具傳染力X-ray and CT：肺部浸潤Pathology:patchy organizing pneumonia,diffuse alveolar damage,respirato

7、ry distress syndrome(呼吸窘迫),respiratory failure(呼吸衰竭)電子顯微鏡：SARS virus in type II pneumocytesNo vaccineMortality rate:15%吸入性肺炎(aspiration pneumonia)氣體、液體、固體微粒引起細菌感染、機械性阻塞及化學性傷害溺水、酒醉、昏迷、虛弱、食道或神經病變的病患污水、胃液和食物多為支氣管肺炎Aspiration pnemoniaSup.Segment,RLL肺膿腫(pulmonary abscess)局部化膿性病變病因：口咽部手術、上呼吸道感染、頭頸部膿腫、支氣管擴

8、張併發症：胸膜炎、腦膜炎、腦膿腫、全身性感染氣喘(asthma)支氣管通道收縮引起的陣發性呼吸困難及wheezing，又稱支氣管氣喘(bronchial asthma)心因性氣喘氣喘(asthma)分類外因性過敏性原因，又稱allergic asthma過敏原：花粉、塵螨、毛或微生物兒童期開始反覆發病IgE非過敏性原因Infectious asthma:常為病毒感染Occupational asthma:有機或無機物質引起內因性可經由drugs,pressure,sport,chemical substance or infection引起Mechanism:not clear氣喘(asthm

9、a)病理小支氣管及細支氣管為黏液阻塞黏液中可發現Eosinophil,Curschmann spiral,Charcot-Leyden crystal管壁水腫及炎症細胞浸潤管壁平滑肌spasm及肥大黏膜下層黏液腺增大Status asthmaticus支氣管擴張症(bronchiectasis)破壞管壁結構或增加外在牽引力支氣管和細支氣管不正常且永久性的擴大Etiology:TB,pneumonia,tumor,foreign body,asthma,chronic bronchitis,cystic fibrosis,congenital abnormality局部性或瀰漫性症狀：chron

10、ic productive cough,respiratory difficulty,clubbing finger,fever,pulmonary abscess,cyanosis,cor pulmonale,brain abscess,etc.肺膨脹不全(atelectasis)先天性Premature babyAssociated with hyaline membrane disease(neonatal respiratory distress syndrome,lack of surfactant)後天性因支氣管、肺臟或胸膜疾病引起的肺臟塌陷及無氣狀態易引起感染胸痛、呼吸困難、cy

11、anosis；無咳嗽或咳血肺氣腫(emphysema)肺臟腺泡不正常且永久性的擴大無纖維化現象Larger pulmonary compliance than normal individualsBarrel chestBroader definition includesSenile emphysema,compensatory emphysema,obstructive overinflation,interstitial emphysema肺氣腫(emphysema)Chronic Obstructive Pulmonary Disease(COPD)Respiratory diffic

12、ulty and airway obstructionEmphysema,chronic bronchiolitis,brochiectasia,bronchial asthmaPink pufferEmphysema,older age,rapid and short respiration,adequate oxygenation,no cyanosisBlue bloaterChronic bronchiolitis,younger age,much sputum,cor pulmonale,cyanosis,swellingPulmonary edema and pulmonary c

13、ongestionLeft heart failureMacrophage in alveoli(heart failure cell)Brown induration:血鐵質堆積+纖維化Pulmonary embolismEmboli from vein of lower extremitiesChest pain,respiratory difficulty,pulmonary infarction,sudden deathAdult Respiratory Distress Syndrome(ARDS)Diffuse alveolar damageAcute respiratory fa

14、ilureOverall mortality:50%Etiology:shock,infection,sepsis,fat embolism,drowning,aspiration of toxic substance,irradiation,drugsPathology:Exudative phase(acute phase):intra-alveolar edema,exudate,aggregation of inflammatory cells,type II pulmonary cells hyperplasia,hyaline membrane in alveoliOrganizi

15、ng phase:fibroblast hyperplasia in alveolar wall,hyaline membrane removed by macrophage,fibrosis of alveolar septum,cystic change of lung parenchymaARDSPneumoconiosisTumor of Lung肺癌最常見，多為bronchogenic carcinomaNo.1 cancer death in western countryNo.2 cancer death in Taiwan(2002)中老年男性常見女性增加中：吸煙女性增加Eti

16、ology:smoking,air pollution,chemical substance,radiation,genetic factor,scar cancerSmokingOdds ratio:10Amount,duration80%of lung cancer patients are smokers肺癌種類Non-small cell carcinomaSquamous cell carcinomaHilum,larger airway,1/3 of all lung Ca,smokingAdenocarcinoma1/3,female and non-smoker,scar ca

17、ncerBronchioloalveolar carcinoma沿肺泡壁生長，易誤為間質性肺炎Large cell carcinomaLess commonSmall cell carcinoma1/5,paraneoplastic syndrome,hilum,smoking,oat cell carcinoma,poor prognosis,chemotherapyClinical symptoms and ComplicationCough,weight loss,chest pain,dyspnea,hemoptysis,pneumonia,pleural effusion,hoars

18、eness,dysphagia,rib destruction,lung abscess,feverSuperior vena caval syndromeHorner syndromeApical tumor,Pancoast tumorCervical sympathetic ganglion invasionIpsilateral ptosis,miosis,and not sweating in the foreheadParaneoplastic syndromeEndocrine abnormalities,hypercalcemia,clubbing fingerTreatmen

19、t and Prognosis of Lung CancerWorst:small cell cancer,chemotherapy or radiationNSCLC:surgeryMetastatic lung cancer:Multiple,from breast,stomach,colon,ovary,uterus,prostate,bone,liver etc.Hamartoma,carcinoidOther lung diseasesSarcoidosisGranuloma,hilar lymph nodes or skin,eyes,liver,spleen and bone m

20、arrowAsteroid body and Schaumann body in multinucleated giant cellScandinavian and black peopleGood prognosis,spontaneous resolution 50%,steroid胸膜及胸膜腔疾病Visceral pleura,parietal pleura,pleural cavity,pleural fluidPleural effusionIncreased hydrostatic pressure:CHFDecreased oncotic pressure:Nephrotic s

21、yndrome,liver cirrosisIncreased vascular permeability:pleuritis,pneumonia,TB,lung abscess,pulmonary infarction,bronchiectasis,metastatic cancer,systemic infection or inflammationImpaired lymphatic drainage:mediastinal malignancyincreased negative pressure in pleural cavity:atelectasisPleural effusio

22、nFluid in Pleural CavityExudateInflammatory pleural effusion,parapneumonic pleural effusionIncreased vascular permeability due to inflammatory pleural diseasesPyothorax,empyemabacteria or fungusAdhesion,fibrosis,obliteration of pleural cavity,limitation of lung expansionTransudateImbalance of hydros

23、tatic and oncotic pressureHydrothoraxHemothoraxtrauma,ruptured aortic aneurysm,coagulopathy,inflammation,tumor ChylothoraxThoracic duct injury,impaired lymphatic drainage by tumorPneumothoraxSpontaneous pneumothoraxYoung male,subpleural bleb rupture,apexSimple pneumothorax:young healthy individualsC

24、omplicated pneumothorax:associated with emphysema,asthma or TBTraumatic pneumothoraxPenetrating trauma,barotraumaTension pneumothoraxPneumothoraxMesotheliomaBenign or malignantAsbestosis21.所謂歌手的結節是指：(A)鼻息肉(B)手指結節(C)喉癌(D)聲帶息肉22.鼻咽癌的發生跟下列何者關係密切：(A)乳突狀瘤(B)病毒感染(C)吸煙(D)外傷23.大葉性肺炎的初期病理變化為：(A)充血(B)灰色肝變(C)紅色肝變(D)纖維化24.氣喘病患體內何種抗體會明顯增加：(A)IgA(B)IgG(C)IgD(D)IgM25.支氣管擴張症好發於：(A)肺臟上葉(B)肺臟下葉(C)肺尖(D)肺門 26.新生兒呼吸窘迫症候群的發生與何者密切相關：(A)先天性畸形(B)休克(C)表面張力素不足(D)細菌性肺炎27.肺氣腫的病因不包括：(A)吸煙(B)礦物微塵(C)纖維化(D)肺水腫28.最易引起副贅瘤症候群的肺癌是(A)小細胞癌(B)大細胞癌(C)鱗狀細胞癌(D)腺癌29.與石綿塵最有關的腫瘤是(A)喉癌(B)良性間皮瘤(C)乳頭狀瘤(D)惡性間皮瘤30.心衰竭細胞出現在(A)心臟(B)肺臟(C)肝臟(D)腎臟