第二篇第十一章結(jié)核性胸膜炎

1、第二篇第十一章結(jié)核性胸膜炎講授目的和要求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 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: Mycobacterium tuberculosis 病因：結(jié)核分枝桿菌 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Pathogenesis :two theo

2、ries發(fā)病機(jī)制：兩種學(xué)說(shuō) Delayed hypersensitive reaction 遲發(fā)性高敏反應(yīng) Pleural infection 胸膜感染 1.Pleural congestion with cell infiltration, unilateral in most cases. 胸膜充血，細(xì)胞浸潤(rùn)，多數(shù)病例累及單側(cè)胸膜病 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)

3、節(jié)3. Exudative effusion 滲出液臨床表現(xiàn)Symptoms 癥狀A(yù)ge, often seen in young people, but also in elderly people1. 年齡，多見(jiàn)于年輕人，但也可見(jiàn)于老年人Fever, typically 3738C, but can be 39C2. 發(fā)熱，典型者37-38C，但也有39C者Chest pain, more severe when there is only little fluid.3. 胸痛，胸水少時(shí)明顯Breathlessness, when there is a lot of fluid.4. 氣短

4、，胸水多時(shí)明顯Physical signs 體征Inspection: fullness of chest in the involved side.1. 視診：患側(cè)胸廓飽滿(mǎn)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(jué)語(yǔ)顫減低3.Percussion: dullness in the involved side.3. 叩診：患側(cè)實(shí)音4.Auscultation:disappearance of breathing sound4. 聽(tīng)診：患側(cè)呼吸音消失實(shí)驗(yàn)室

5、和其他檢查1. Chest X-ray 胸片 Fluid is visible only when more than 300 ml. 胸水超過(guò)300ml時(shí)胸片可以發(fā)現(xiàn) CT is needed in a few cases. 少數(shù)病例需做CTPericardial effusion心包積液2. Ultrasonic examination 超聲檢查 More accurate than X-rays. 診斷胸水比X線準(zhǔn)確 Can provide vital information for thoracentesis. 能為胸腔穿刺術(shù)提供關(guān)鍵資料3. Thoracentesis and flu

6、id examination - essential 胸腔穿刺術(shù)診斷的關(guān)鍵(1)Fluid routine - exudate 胸水常規(guī)滲出液 specific gravity 1.018; WBC 500/cmm, predominated by polymorphs at early stage and lymphocytes 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(2) Acid-fast staining for acid-fast bacilli (not sensitive).

7、(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(shí)間）(4) Others: culture for bacteria, cytological exam, etc.(4) 其他：細(xì)菌培養(yǎng)，細(xì)胞學(xué)檢查，等等4.Pleural needle biopsy - tub. granuloma 4. 胸膜活檢 發(fā)現(xiàn)結(jié)核結(jié)節(jié): 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symptoms + phys

8、ical signs + fluid exam. 癥狀 體征 胸水檢查 retrospective, exclusive. 回顧性，排他性診斷標(biāo)準(zhǔn) Is there pleural effusion? 有無(wú)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(yíng)養(yǎng)不良 5. E

9、ndocrine diseases 內(nèi)分泌疾病Exudate 滲出液1. tumorous diseases1. 腫瘤類(lèi)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3. connective tissue diseases3. 結(jié)締組織疾病4. parasite infection, such as paragonimiasis4. 寄生蟲(chóng)感染，如肺吸蟲(chóng)病5. Others5. 其他anti-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.