结核性胸膜炎.pptx

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1、讲授目的和要求1.掌握结核性胸膜炎的诊断及鉴别诊断。2.掌握结核性胸膜炎的治疗原则。第1页/共33页讲授主要内容 概述 病因和发病机制 病理 临床表现 实验室和其他检查 诊断标准 鉴别诊断 治疗 第2页/共33页Anatomy：解剖学：Visceral pleura脏层胸膜Parietal pleura壁层胸膜Latent space潜在腔隙概 述第3页/共33页I.Etiology:Mycobacterium tuberculosis 病因：结核分枝杆菌 病因和发病机制第4页/共33页Discovered by Dr.Koch in 1882由Dr.Koch 于1882年发现Acid-fas

2、t抗酸染色性第5页/共33页Pathogenesis:two theories发病机制：两种学说 Delayed hypersensitive reaction 迟发性高敏反应 Pleural infection 胸膜感染第6页/共33页 1.Pleural congestion with cell infiltration,unilateral in most cases.胸膜充血，细胞浸润，多数病例累及单侧胸膜病 理第7页/共33页 In the early stage,polymorphs predominate.早期以多型核细胞为主 Typically,lymphocytes pred

3、ominate.典型表现以淋巴细胞为主2.Tuberculous nodules 结核结节3.Exudative effusion 渗出液第8页/共33页临床表现Symptoms 症状1.Age,often seen in young people,but also in elderly people1.年龄，多见于年轻人，但也可见于老年人2.Fever,typically 37 38C,but can be 39C2.发热，典型者37-38C，但也有39C者第9页/共33页3.Chest pain,more severe when there is only little fluid.3.胸

4、痛，胸水少时明显4.Breathlessness,when there is a lot of fluid.4.气短，胸水多时明显第10页/共33页Physical signs 体征1.Inspection:fullness of chest in the involved side.1.视诊：患侧胸廓饱满2.Palpation:trachea shifts to the other side,weakness of vocal fremitus.2.触诊：气管向健侧移位，触觉语颤减低第11页/共33页3.Percussion:dullness in the involved side.3.叩

5、诊：患侧实音4.Auscultation:disappearance of breathing sound4.听诊：患侧呼吸音消失第12页/共33页实验室和其他检查1.Chest X-ray 胸片 Fluid is visible only when more than 300 ml.胸水超过300ml时胸片可以发现 CT is needed in a few cases.少数病例需做CT第13页/共33页第14页/共33页第15页/共33页第16页/共33页Pericardial Pericardial effusioneffusion心包积液心包积液第17页/共33页2.Ultrasoni

6、c examination 超声检查 More accurate than X-rays.诊断胸水比X线准确 Can provide vital information for thoracentesis.能为胸腔穿刺术提供关键资料第18页/共33页3.Thoracentesis and fluid examination-essential 胸腔穿刺术诊断的关键第19页/共33页(1)Fluid routine-exudate 胸水常规渗出液 specific gravity 1.018;比重 1.018 WBC 500/cmm,predominated by polymorphs at e

7、arly stage and lymphocytes later 白细胞计数 500/cmm,早期以多型核细胞为主，以后以淋巴细胞为主 protein 3gram/dl 蛋白含量 3gram/dl第20页/共33页(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)结核杆菌培养（费时间）(4)Others:culture for bacteria,cytological exam,etc.(4)其他

8、：细菌培养，细胞学检查，等等第21页/共33页4.Pleural needle biopsy-tub.granuloma 4.胸膜活检 发现结核结节5.Others:Eos.count,liver function,immunoglobulin,5.其他检查：血嗜酸细胞计数，肝功能，免疫球蛋白，等等第22页/共33页symptoms+physical signs+fluid exam.症状 体征 胸水检查 retrospective,exclusive.回顾性，排他性诊断标准第23页/共33页 Is there pleural effusion?有无胸水？Is it transudate or

9、 exudate?胸水是漏出液还是渗出液？What is the specific etiology?胸水的病因是什么？鉴别诊断第24页/共33页Transudate 漏出液 1.Heart diseases 心脏病 2.Kidney diseases 肾脏病 3.Liver diseases 肝脏病 4.Malnutrition 营养不良 5.Endocrine diseases 内分泌疾病第25页/共33页Exudate 渗出液1.tumorous diseases1.肿瘤类疾病2.bacterial infection empyema purulent fluid reactive pl

10、eural fluid2.细菌感染 脓胸 脓性胸水 反应性胸水第26页/共33页3.connective tissue diseases3.结缔组织疾病4.parasite infection,such as paragonimiasis4.寄生虫感染，如肺吸虫病5.Others5.其他第27页/共33页1.anti-tuberculous chemotherapy1.抗结核病化疗In the same way as pul.Tuberculosis与肺结核相同 治 疗第28页/共33页Keys 关键Initiate treatment as early as possible 早期Use multiple drug regimen 联合Use adequate dosage 适量Give medicines in a regular bases 规律Treat patients long enough(6 mon.)足程第29页/共33页2.drainage of pleural fluid2.引流胸水3.corticosteroids-controversial3.糖皮质激素 有争议第30页/共33页Good in most cases.大多数患者预后良好预 后第31页/共33页结核性胸膜炎应与哪些疾病相鉴别？复习思考题第32页/共33页感谢您的观看！第33页/共33页