第二篇 第十一章结核性胸膜炎.pptVIP

* * 结核性胸膜炎 （Tuberculous Pleural Effusion） 第二篇 呼吸系统疾病 赵建平 学时数：1学时 第十一章 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。 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 Anatomy： 解剖学： Visceral pleura 脏层胸膜 Parietal pleura 壁层胸膜 Latent space 潜在腔隙 概 述 I.Etiology: Mycobacterium tuberculosis 病因：结核分枝杆菌 病因和发病机制 Discovered by Dr.Koch in 1882 由Dr.Koch 于1882年发现 Acid-fast 抗酸染色性 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 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 In the early stage, polymorphs predominate. 早期以多型核细胞为主 Typically, lymphocytes predominate. 典型表现以淋巴细胞为主 2. Tuberculous nodules 结核结节 3. Exudative effusion 渗出液 临床表现 Symptoms 症状 Age, often seen in young people, but also in elderly people 1. 年龄，多见于年轻人，但也可见于老年人 Fever, typically 37～38?C, but can be 39?C 2. 发热，典型者37-38?C，但也有39?C者 Chest pain, more severe when there is only little fluid. 3. 胸痛，胸水少时明显 Breathlessness, when there is a lot of fluid. 4. 气短，胸水多时明显 Physical signs 体征 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 3.Percussion: dullness in the involved side. 3. 叩诊：患侧实音 4.Auscultation:disappearance of breathing sound 4. 听诊：患侧呼吸音消失 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 Pericardial effusion 心包积液 2. Ultrasonic 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 3. Thoracentesis and fluid examination ---- essential 胸腔穿刺术－－诊断的关键 (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 early 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