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1、,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
2、 Dr.Koch in 1882 由Dr.Koch 于1882年发现 Acid-fast 抗酸染色性,一、食物多样，谷类为主，粗细搭配,谷类食物是中国传统膳食的主体，是人体能量的主要来源，也是最经济的能源食物。一般成年人每天摄入250g400g为宜。没有不好的食物，只有不合理的膳食，关键在于平衡。食物多样化才能摄入更多有益的植物化学物质。谷类为主是平衡膳食的基本保证。粗细搭配有利于合理摄取营养素。,二、多吃蔬菜水果和薯类,蔬菜水果是维生素、矿物质、膳食纤维和植物化学物质的重要来源，水分多、能量低。薯类含有丰富的淀粉、膳食纤维以及多种维生素和矿物质。富含蔬菜、水果和薯类的膳食对保持身体健康，保持
3、肠道正常功能，提高免疫力，降低患肥胖、糖尿病、高血压等慢性疾病风险具有重要作用。我国成年人每天吃蔬菜300g500g，最好深色蔬菜约占一半，水果200g400g，并注意增加薯类的摄入。注意合理烹调蔬菜。,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
4、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 3738C, but can be 39C 2. 发热，典型者37-38C，但
5、也有39C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
6、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 ex
7、amination 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 1.018WBC 500/cmm, predominated by polymorphs at early stage and ly
8、mphocytes 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 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
9、，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,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,Is there pleural effusion?有无胸水？Is it transudate or exudate?胸水是漏出液还是渗出液
10、？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. Endocrine diseases 内分泌疾病,Exudate 渗出液 1. tumorous diseases 1. 肿瘤类疾病 2. bacterial infectionempyema purulent fluidreactive pleural fluid 2. 细菌感染脓胸 脓性胸水反应性胸水
11、,3. connective tissue diseases 3. 结缔组织疾病 4. parasite infection, such as paragonimiasis 4. 寄生虫感染，如肺吸虫病 5. Others 5. 其他,anti-tuberculous chemotherapy 1. 抗结核病化疗 In the same 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 fluid 2. 引流胸水 3. corticosteroids - controversial 3. 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,
