《2018年No.6 2014.3.7 学习指导 七年制影像chest -呼吸常见病1支气管病变+肺炎+肺结核- 陈爱萍-文档资料.ppt》由会员分享，可在线阅读，更多相关《2018年No.6 2014.3.7 学习指导 七年制影像chest -呼吸常见病1支气管病变+肺炎+肺结核- 陈爱萍-文档资料.ppt（153页珍藏版）》请在三一文库上搜索。
1、小儿胸腺,肺大泡,呼吸系统影像 观察、分析和诊断,X线,投照条件是否正确 投照位置是否正确 两侧胸廓是否对称 纵隔位置是否居中 横膈高度是否正常,CT,上下层面结合分析 肺窗与纵隔窗结合分析 断面图像与三维重建图像结合分析 平扫图像与增强扫描图像结合分析,观察、分析病灶,病变的部位，数目 病变的形态与大小 病变的密度与边缘 病变对邻近结构的影响,不同成像技术的优选 和综合应用,不同成像技术的价值和限度,X线：健康普查、胸部疾病的诊断和随访 限度：结构重叠，小病灶漏诊，如心影后方病灶或后肋膈角病灶；密度分辨率低，对纵隔病变的诊断有限。 CT：发现病变、定位和定性诊断。 限度：定性缺乏特异性。 M
2、RI：定位和定性均有一定优势。 限度：肺组织信号弱，对微细结构的显示效果不好,成像技术的优选原则,疾病发病阶段、发病部位及病变性质不同，不同成像技术在胸部应用的优势不同，需要多种成像技术综合应用。 经济优先，简便优先，实用优先，安全优先原则,支气管病变,气管、支气管异物 foreign body in the bronchus 先天性支气管囊肿 congenital bronchial cysts 气管肿瘤 支扩,Clinical symptom: cough, Purulent foul-smelling sputum , emptysis, or haemoptysis. 儿童，青年多见，
3、多见于左下叶、右中叶及右下叶。 咳嗽、咳痰、咯血,支气管扩张bronchiectasis,Bronchiectasis支扩,Bronchiectasis is defined as localized, irreversible dilatation of the bronchial tree. congenital or aquired - There are several causes of bronchiectasis, postinfectious causes; congenital defects of a structure nature; chronic granulomat
4、ous infection such as tuberculosis.,无异常发现 支气管及肺间质慢性炎症引起肺纹理增多，增厚，紊乱。可呈管状、杵状、囊状蜂窝状影，或卷发状。 继发感染：呈小斑片状模糊影，常不易治愈，或于同一地方反复发作。,X线表现,Bronchiectasis,Pathology Damage of bronchus wall Pression of bronchus increase Circumference tissue draught 支气管壁破坏 支气管内压增加 周围组织牵拉（疤痕、肺不张等）,Bronchiectasis,Bronchiectasis can be
5、 divided into three morphologic types: cylindrical,saccular, mixed type.柱状、囊状或静脉曲张型。 Cylindrical bronchiectasis refers to a generalized more or less regular widening of the large bronchi. Saccular bronchietasis shows that the bronchi terminate in sac-like cavities.,Bronchiectasis,X-ray manifestation
6、: The plain film may be normal if only a small part is involved and there is no secondary infection. The most common appearance on plain film is increasing of lung markings. The bronchial walls may be visible either as single or parallel line opacities. There are paths of opacity when infection occu
7、res.,Bronchiectasis:lung markings of the left low lobe increase,and small sac( sac-like cavities),Bronchiectasis: lung markings of the left low lobe increase,and small sac( sac-like cavities),Bronchiectasis,Bronchographic investigation is important and necessary to delineate the total extent of the
8、disease. In the bronchogram, the cylindric bronchiectasis may be show club-shaped dilatation of the bronchi, while the saccular bronchiectasis will show saccular or cystic dilation of the affected bronchi.,Bronchogram: saccular bronchictasis in the left lung,Bronchiectasis,CT is helpful especially i
9、n the more advanced forms of bronchiectasis, cylindrical bronchiectasis causes smooth dilatation of bronchi, recognizable as “tram line” when seen in the scan plane and as the signet-ring sign in cross-section. The signet ring sign refers to the thickened and dilated bronchus, saccular bronchiectasi
10、s can be diagnosed most reliably by CT, sometime we can see air-fluid level in the dilated bronchus.,HRCT：支气管壁增厚，管腔增宽。 呈“轨道征”或“印戒征”。 柱状、囊状或静脉曲张型。,bronchictasis tram line 轨道征 signet-ring sign 印戒征,air-fluid level in the sac.,支扩伴黏液栓形成,bronchictasis tram line and the signet-ring sign in cross-section.,Q
11、uestion:where is the bronchiectasis?,肺先天性疾病,肺发育异常 肺隔离症 (bronchopulmonary sequestration) intralobar extralobar 肺动静脉瘘,肺AVM,Pneumonia,The causative organisms are variable:病原体多样 感染：细菌、病毒、真菌、支原体、衣原体、立克次体、寄生虫 理化性：类脂性、毒气、药物、放射线等 免疫和变态反应,Pneumonia,Pneumonia can cause a wide variety of abnormal findings on t
12、he chest radiograph. Commonly, it presents as alveolar consolidation, which can be segmental or lobar, or may be patchy, fluffy, alveolar infiltrates-without any segmental distribution(bronchopneumonia pattern) Pneumonia also may present as diffuse alveolar disease or as diffuse interstitial disease
13、. It also can present as single or multiple nodules. The presence of pneumonia sometimes may be masked by an associated pleural effusion, congestive failure, or adult respiratory distress syndrome(ARDS).,Pneumonia,According to the radiologic appearance, pneumonia can be commonly divided into lobar p
14、neumonia bronchopneumonia interstitial pneumonia,Lobar pneumonia,Lobar pneumonia most commonly is caused by S.pneumoniae肺炎链球菌, but it can also occur with other organisms. Lobar pneumonia represents a type of inflammation of the lung characterized by out-pouring of exudates into the alveoli with litt
15、le change in the bronchi or interstitial tissue. The out-pouring of fluid is generally considered to result from a local sensitivity reaction to the polysaccharides in the capsule of the pneumococcus. The bacteria are rapidly carried by the edema fluid from alveolus to alveolus,Lobar pneumonia,Early
16、 stage: Inflammatory edema Consolidation stage Resolution stage,Lobar pneumonia,Early stage: Inflammatory edema The infection and edema have usually spread throughout a segment of the lung. X-ray findings: The lung markings increase. It does not completely obscure the pulmonary vessels in the area b
17、ecause many of the alveoli are still aerated.,Lobar pneumonia,Consolidation stage The lung is characterized by a rather dense shadow of uniform opacity. If the bronchi remain patent, the air column within them stands out as dark. The presence of an air bronchogram within a shadow in the pulmonary fi
18、eld indicates that the density is due to consolidation of lung. If adequate antibiotic treatment is given, no further spread takes place.,1.大叶性肺炎,病理过程 充血期：12-24hr。毛细血管充血，少量浆液渗出，肺泡部分仍含气； 实变期：2-5d，分红色和灰色肝硬变期，肺泡内充满炎性渗出物。 消散期：1w后开始,2-3w消散。,线表现 可无异常或肺纹理增粗。 均匀实变影，与肺叶、段一致的高密度影，随各肺叶形态不同而不同。 不均匀斑片状，逐渐吸收，胸膜侧最
19、晚，可有胸膜增厚、纤维条索,lobar pneumonia,consolidation of right upper lung and “air bronchogram “,consolidation of right middle lober,consolidation of right upper lober,Lobar pneumonia,Resolution stage The homogenicity if the shadow of consolidation is lost and it becomes mottled as the exudate in various port
20、ions of the affected lung is absorbed and alveoli here and there are filled with air. The pathologic consists of intermingled areas of consolidation of varying degree, aeration of the alveoli and areas of atelectasis. The latter are often represented on the film by streak-like shadow. These shadows
21、disappear as the lung re-expands and resolution is completed.,Resolution stage in the right upper lober,Streak like shadow,Resolution stage in the left lower lober,consolidation of left upper lober,双上叶见大片状致密影，可见支气管充气征,consolidation of right and left upper lober (air bronchogram),Bronchopneumonia (lo
22、bular pneumonia),It is commonly seen in infants and elderly patients by infection by Staphylococcus aureus, most gram-negative bacteria and some fungi. It begins as a bronchial infection and has a tendency to involve separate parts of the lung. The infection spreads along the bronchial walls and res
23、ults in infiltration of the interstitial tissues with little involvement of the alveolar air space. In most cases, both consolidations of the alveolar air spaces and interstitial infiltration are present.,Bronchopneumonia (lobular pneumonia),The radiologic manifestations of bronchopneumonia depend o
24、n the severity of the disease. Mild bronchopneumonia results in peribronchial thickening and poorly defined air-space opacities. More severe disease results in inhomogeneous, patchy areas of consolidation that usually involve several lobes.,Bronchopneumonia (lobular pneumonia),Consolidation involvin
25、g the terminal and respiratory bronchioles and adjacent alveoli results in poorly defined centrilobular nodular opacities measuring 4 to 10 mm in diameter (air-space nodules); extension to involve the entire secondary lobule(lobular consolidation) may be seen. Bronchopneumonia frequently results in
26、loss of volume of the affected segments or lobes. When confluent, bronchopneumonia may resemble lobar pneumonia.,小叶性肺炎影像学表现,病变部位：两肺中下野的内中带 肺纹改变：增多、增粗、模糊 X-ray: 两肺中下野的内中带沿支气管分布，肺纹理增多、增粗、模糊，小叶渗出与实变表现为斑片状模糊致密影，有融合倾向 CT表现：两中下肺支气管血管束增粗，有大小不同结节和片状阴影，12cm大小，边缘模糊。病变之间除正常含气肺组织外，还有12cm类圆型透亮阴影，代表小叶性过度充气,patchy
27、 areas of consolidation,Lung markings increase and patchy in the right lower lobe,Lung markings increase and patchy in the right and left lung,Patchy shadow in both of the lung,Patchy shadow in both of the lung,机遇性感染opportunity infection,immune deficiency accompany with infection or tuberculosis and
28、 so on 免疫缺陷者伴随的感染或结核等 Eg. HIV infection: 细菌，真菌，病毒，TB，PCP （肺孢子虫肺炎）,HIV female 23 years olds,HIV,Patchy shadow in both of the lung,AIDS and Pneumocystis carinii pneumonia,AIDS patient with pulmonary cryptococcal infection.（新型隐球菌）,Lung abscess,Hematogenous abscess血源性的脓肿 is rather rare now. Abscesses oc
29、cur most often as a complication of aspiration of food, vomitus, or foreign body; of bacterial pneumonia; or bronchial obstruction. Anaerobic bacteria厌氧菌are often the cause. Other relatively Common agents are S.aureus金黄色葡萄球菌and Pseudomonas aeruginosa绿脓杆菌/绿脓假单胞菌. Abscesses may also be secondary to se
30、pticemia败血病, and they occasionally develop in an infected pulmonary infarct.,Lung abscess,Symptomatology resembles that of acute pnenmonia with fever, cough productive of purulent sputum脓痰, and leucocytosis白细胞增多. Diabetics, alcoholics, and immunocompromised,免疫受损的individuals are at increased risk of
31、developing lung abscess.,Lung abscess,The abscess resulting from aspiration most frequently occurs in the dependent segments of the lung- the posterior segments of the upper lobe and the superior segments of the lower lobe. The abscess first appears as a round but poorly defined area of segmental co
32、nsolidation usually near the periphery of the lung. No fluid level is seen until bronchial communication is established.,Lung abscess,As the abscess ruptures into the bronchus a translucent ring with a fluid level is seen in the middle of the opaque segment. The inner walls of the cavity are smooth.
33、 Adjacent parenchymal consolidation is also present. Multiple cavities may develop within consolidated lung(necrotizing pneumonia). Conventional tomography may show gas bubbles within an abscess indicating either a bronchial communication or possible infection with gas-forming organisms. There is fr
34、equently an associated pleural effusion.,Lung abscess,CT allows earlier detection of abscess formation CT is also superior in defining the relationship of the process to the pleural cavity,. Empyemas脓胸 tend to be lenticular凸出的 in shape, and their angle of interface with the chest wall is usually obt
35、use钝角. A lung abscess is usually spherical and produces an acute angle with the chest wall.,Lung abscess,After antibiotic treatment in favorable cases both the cavity and the surrounding consolidation gradually shrinks and disappears. The abscess heals completely and leaves no visible scar or someti
36、mes a small area of fibrosis indicates the site. In some cases healing is slow and there is often a residual bronchiectasis of fusiform type.,肺脓肿 lung abscess,急性化脓性肺炎期：大片炎性浸润 脓肿形成期：出现含液平空洞 慢性肺脓肿：周围炎症吸收，代之以纤维组织增生，表现为紊乱的条索影及斑片阴影 血源性肺脓肿：两肺胸膜下多发性类圆性阴影，中间有小空洞形成，可有液平，常累及胸膜,Acute abscess: the cavity (fluid
37、 in cavity) and the surrounding consolidation,Acute abscess: the cavity (fluid in cavity) and the surrounding consolidation,Acute abscess: the cavity (fluid in cavity) and the surrounding consolidation,Chronic abscess: the cavity and the surrounding consolidation,Chronic abscess: the cavity and the
38、surrounding consolidation,Chronic abscess: the cavity and the surrounding consolidation,Tuberculosis of the lung,Tuberculosis is an infectious disease that may affect any organ but shows a marked predilection for the lungs. Nowadays better standards of living and hygiene have sharply reduced the inc
39、idence of tuberculosis. Despite recent advances in therapy and careful public health measures, TB remains a problem in the large reservoir of elderly patients who have previously been infected with tubercle bacilli and in the urban poor who continue to be exposed to tubercle bacilli.,Tuberculosis of
40、 the lung,The main factor determining whether tuberculosis infection progresses to disease is the immune competence of the individual. The disease is most commonly found in persons whose immune status is compromised by old age, alcohol abuse, diabetes, steroid therapy, or AIDS.,Tuberculosis of the l
41、ung,Tuberculosis is classically divided into () primary tuberculosis. () hematogenous tuberculosis. () postprimary tuberculosis. () tuberculous pleurisy . () extraplumonary tuberculosis.,primary tuberculosis,Most cases of primary tuberculosis due to inhale the tubercle bacilli. It is commonly seen i
42、n children or adolescents. The infection spreads from the initial focus in the lung to the regional and mediastinal lymph nodes by way of the lymphatic channels. Inhaled tubercle bacilli initially evoke a focal, nonspecific subpleural alveolitis that converts to a tuberculosis-specific inflammatory
43、focus(Ghon focus) in about 10 days. Spread of tubercle via the lumphatics leads to a specific hilar lymphadenitis. The combination of the primary pulmonary focus, lymphangitis and lymphadenitis is known as the primary complex.,primary tuberculosis,The Ghon focus is a circumscribed, small, peripheral
44、 consolidation. Hilar and mediastinal lymphadenitis presents as hilar enlargement and mediastinal widening. Occasionally, lymphangitic stranding connecting the primary focus with the hilar lymphadenitis forms a dumbbell-shaped opacity. Segmental opacity may be due to segmental atelectasis distal to
45、bronchial compression by enlarged lymph nodes.,Right hilar enlargement and mediastinal widening,Left hilar enlargement,Left hilar enlargement and mediastinal widening,Right hilar enlargement and mediastinal widening,Lymph node enlargement in mediastinum,After treatment enlargement lymph node disappe
46、ar,Hematogenous tuberculosis(Type ),Mycobacteria entering the blood from the primary complex may become disseminated to numerous extrapulmonary sites. It may be classified as acute, subacute or chronic hematogenous dissemination tuberculosis.,Miliary tuberculosis,Acute miliary tuberculosis Military
47、tuberculosis exhibits a finely mottled nodular pattern resulting from summation of individual nodules. These may range in size from 1-4mm in diameter. They completely obscure the normal lung markings in acute hematogenous dissemination tuberculosis. Three homogeneous:distribute,size,density,Three ho
48、mogeneous: distribute, size, density,Acute miliary tuberculosis,Three homogeneous:distribute,size,density,Acute miliary tuberculosis,Acute miliary tuberculosis,Acute miliary tuberculosis,Miliary tuberculosis,Subacute or chronic miliary tuberculosis tiny opacities are chiefly distributed in both uppe
49、r and middle lung fields, the density of the opacities is not uniform and the size and shape of the opacities are not the same. Three nonhomogeneous:distribute,size,density,Subacute or chronic miliary tuberculosis,Three inhomogeneous :distribute,size,density,Three homogeneous:distribute,size,density,Subacute or chronic miliary tuberculosis,Subacute or chronic miliary tuberculosis,Postprimary tuberculosis (Adult tuberculosis),Postprimary tuberculosis is characterized