1、篇第十一章结核性胸篇第十一章结核性胸膜炎膜炎讲授目的和要求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Path
2、ogenesis: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 n
3、odules 结核结节3.Exudative effusion 渗出液临床表现Symptoms 症状1.Age,often seen in young people,but also in elderly people2.1.年龄，多见于年轻人，但也可见于老年人2.Fever,typically 3738C,but can be 39C3.2.发热，典型者37-38C，但也有39C者3.Chest pain,more severe when there is only little fluid.4.3.胸痛，胸水少时明显4.Breathlessness,when there is a lot
4、of fluid.4.气短，胸水多时明显Physical signs 体征1.Inspection:fullness of chest in the involved side.2.1.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 sound4.听诊：患侧呼
5、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CTPericardial Pericardial effusioneffusion心包积液心包积液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
6、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 protein 3gram/dl 蛋白含量 3gram/dl(2)Acid-fast staining for acid-fast
7、 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：细菌培养，细胞学检查，等等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s
8、ymptoms+physical signs+fluid exam.症状 体征 胸水检查 retrospective,exclusive.回顾性，排他性诊断标准 Is there pleural effusion?有无胸水？Is it transudate or 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.Endo
9、crine diseases 内分泌疾病Exudate 渗出液1.tumorous diseases1.肿瘤类疾病2.bacterial infection empyema purulent fluid reactive pleural fluid2.细菌感染 脓胸 脓性胸水 反应性胸水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1.anti-tuberculous chemotherapy2.1.抗结核病化疗In the same
10、 way as pul.Tuberculosis与肺结核相同 治 疗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2.drainage of pleural fluid2.引流胸水3.corticosteroids-controversial3.糖皮质激素 有争议Good in most cases.大多数患者预后良好预 后结核性胸膜炎应与哪些疾病相鉴别？复习思考题 结结 语语
