医学课件咯血（hemoptysis）

咯 血 (hemoptysis) 原南京中大附属医院神内科主任、硕士生导师 佛山大学医学院医学系孟红旗教授、主任医师 Professor、Doctor director 、Neurologist Hemoptysis Hemoptysis is the expectoration of blood from airway blow larynx. Hemoptysis patients should be examined the nose, mouth and upper respiratory tract to be found the hemorrhagic spot. 喉 Hemoptysis the quantity of blood may vary from streaks and flecks in the sputum to massive hemorrhage. minimal bleeding may be an early indicator of the presence of serious bronchopulmonary disease. hemorrhages of even moderate degree may life threatening. Hemoptysis About 50 percent of the chest films of the hemoptysis patient show no abnormalities or only minimal nonspecific change. Hemoptysis may be the initial or the sole(唯一的 )symptom of bronchopulmonary disease. These factors sometimes cause the diagnostic problem. 咯 血 喉及喉以下呼吸喉及喉以下呼吸 道任何部位的出道任何部位的出 血，经口排出血，经口排出 与口腔、鼻、咽与口腔、鼻、咽 部出血鉴别部出血鉴别 上消化道出血引上消化道出血引 起的呕血鉴别起的呕血鉴别 The distinction between hemoptysis and hematemsis 咯血与呕血的鉴别 咯咯 血血 呕呕 血血 病因病因 肺结核、支气管扩张症、肺炎、肺脓肺结核、支气管扩张症、肺炎、肺脓 肿、肺癌、心脏病等肿、肺癌、心脏病等 消化性渍病、肝硬化、急性糜烂出消化性渍病、肝硬化、急性糜烂出 血性胃炎、胆道出血等血性胃炎、胆道出血等 出血前症状出血前症状 喉部痒感、胸闻、咳嗽等喉部痒感、胸闻、咳嗽等 上腹不适、恶心、呕吐等上腹不适、恶心、呕吐等 出血方式出血方式 咯出咯出 呕出，可为喷射状呕出，可为喷射状 血色血色 鲜红鲜红 棕黑、暗红、有时鲜红棕黑、暗红、有时鲜红 血中混有物血中混有物 痰、泡沫痰、泡沫 食物残渣、胃液食物残渣、胃液 反应反应 碱性碱性 酸性酸性 黑便黑便 除非咽下，否则没有除非咽下，否则没有 有，可为柏油样便，呕血停止后仍有，可为柏油样便，呕血停止后仍 持续数日持续数日 出血后痰性状出血后痰性状 常有血痰数日常有血痰数日 无痰无痰 读研究生期间值班。一名食管癌术后2天的病人，术后一直很平稳， 胃肠减压（通过右鼻孔）引出暗红色血液。量也不多。有咳嗽，但无 咳痰带血，也无咯血。夜间突然出现咯血，为鲜红色带泡沫血痰。胃 肠减压量2小时增加了200多毫升。血性液颜色较为新鲜。左鼻孔出血 ，也为鲜红色血液。我在这方面也没经验，静点了止血药，正迷惑于 病人是呕血，还是咯血，病人还是出血不止。家属反复来找我去看， 我立即打电话请示了那个治疗组教授，我当时并没有说鼻孔也出血， 教授首先考虑是吻合口出血。于是急诊行胃镜检查。结果吻合口及残 胃没有活动性出血。没有阳性结果，我发蒙了。值班一名老护士跟我 说，“病人能不能有鼻出血。下胃管时，很费力”我立刻醒悟，急请耳 鼻喉科会诊，结果发现是后鼻道出血。给予填塞止血。血很快就不出 了。第二天早上交班，主任还表扬了我，说我观察仔细。我得感谢那 个护士。没有她一句话提醒，我还在发！ 一位当地医院诊断为肝硬化原发性肝癌患者出现“ 呕血“,考虑食管-胃底静脉曲张或急性胃黏膜病变 出血,在当地医院保守治疗无效,以“消化道出血“急 诊转入我科.入科后值班查体时发现患者“吐出“的 血非常新鲜,且小量持续的“呕吐“.向主任汇报,主任 指示“仔细检查口腔“,结果发现患者右侧扁桃体II度 大,表面糜烂大面积渗血,急请五官科会诊.初诊“扁 桃体出血-扁桃体癌?“, 遂行手术治疗. 术后血止. 病理:扁桃体癌. 体会:经验主义要不得. 几天前一位20岁的学生，大量气胸，压缩 95，找外科会诊后，给予闭式引流，但 过了几分钟患者诉胸闷加重，开始咳粉红 色泡沫样痰，是压缩的肺突然复张引起了 肺水肿，主任说就少交代了一句话，让放 气时慢慢放，放一会用夹子夹一会儿。幸 亏抢救及时，小命保住了。 Etiology 1.Bronchial disease 2.lung disease 3.cardiovascular disease 4.constitutional disease 1.Bronchial disease hemoptysis occur in bronchiectasis, chronicbronchitis, endobronchial tuberculosis and bronchogenic carcinoma. Also occur in the benign bronchogenic tumor, foreign body, bronchogenic nonspecific ulceration. The inflammatory process lead to the increase the permeability (通透性） of capillary and rapture of vessels in bronchial mucosa and then induce hemoptysis. blood-streaked sputum occasionally occur in the course of acute bronchitis. 支气管疾病：支气管扩张症 支 气 管 肺 癌 咯血的病因和机制 1、支气管疾病 支气管扩张，支气管肺癌、支 气管结核、慢性支气管 炎、支 气管结石、支气管腺瘤、支气 管粘膜非特异性溃疡等。 出血机制： 炎症或肿瘤等损害支气管粘膜 或病灶处的毛细血管通透性增 高或粘膜下血管扩张破裂等 2.Lung disease The sputum of pneumococcal pneumonia is described as “rusty” in appearance. Pulmonary TB is the common cause of the hemoptysis. Cavitious TB may cause the expectoration of frank blood from pulmonary cavity. Lung abscess may be related to putrid smelling sputum and expectoration of blood. hemoptysis occur in 25 percent of the patient of pulmonary embolism and infarction. pulmonary fungi and parasite infection may also serve as the sources of hemoptysis. 肺部疾病肺部疾病: : 肺结核 肺 炎 2、肺部疾病 肺结核、肺炎、肺脓肿 、肿瘀血、肺梗塞、肺 真菌病、 肺吸虫病、肺 泡微结石、肺泡炎、肺 气铁血黄素沉着症、肺 出血、肾炎综合征等。 咯血的原因: 毛细血管通透性增高 小血管破裂 小动脉瘤破裂 动静脉瘘破 肺结核并咯血 结核病变使毛细血管通透性增高（少量 咯血） 病变侵蚀小血管破溃（中等量咯血） 病变空洞壁动脉瘤破裂出血或继发性支 扩形成小的动静脉瘘破裂出血（大量咯血 ） 3.Cardiovascular disease Pink frothy sputum - acute pulmonary edema blood streaked sputum-acute pulmonary congestion blood comes from pulmonary capillaries which ruptured under high intravascular pressure. Hemoptysis due to mitral stenosis is frequently induced by physical exercise or excitement. Blood comes from a break in the pulmonary veins which have ruptured under high pressure. The bleeding is due to rupture of endobronchial vessels that from collateral(间接的) channels between the bronchial veins and pulmonary venous system. Many pulmonary emboli do not lead to pulmonary infarction, when they do, frank hemoptysis occurs in the minority (少数)of instance. when hemoptysis occur in the pulmonary infarction of the heart failure patient, the blood sputum usually appears within a few hours to a day after the embolus, and this is due to necrosis and hemorrhages into the alveoli. Hemoptysis is also associated with congenital cardiac disease and aortic aneurysms 心 血 管 疾 病 咯血的原因 二尖瓣狭窄 急性肺水肿（急性左心衰） 咳浆液性粉红色泡沫样痰。 肺梗塞 （剧烈胸痛、咯血、休克），咳粘稠暗红色血痰。 先天性心脏病 （房间隔缺损，动脉导管未闭等） 因肺动脉高压咯血；有明显的病理性心脏杂音 咯血的机制 肺瘀血致肺泡壁或支气管内膜毛细血管破裂 支气管黏膜下层支气管静脉曲张破裂 二尖瓣狭窄 因肺淤血压力 致肺泡壁或 支气管内膜毛 细血管破裂 所 致。若支气管 粘膜下支气管 静脉曲张破裂 大咯血。 4.Constitutional disease Blood spitting may also occur in the patients suffering from certain disease, such as hemophilia（血友 病）, leukemia and infectious disease, connective tissue disease. 4.其它 血液病 血小板减少性紫癜、白血病、再生障厚性疾病、血友病等 急性传染病 流行性出血热、肺出血型钩端螺旋体病等。 风温性疾病 Wegener肉芽肿、白塞病、结节性多动脉炎，系统性红斑狼疮等。 其它： 气管、支气管子宫内膜异位症、绒癌、肺转移、外伤、异物等。 Clinical manifestation 1.the patients age. 2.the amount of coughing up blood. 3.color and character 1.The patients age Hemoptysis is often seen in pulmonary TB, bronchiectasis and rheumatic heart disease (mitral stenosis) for most youth. Cancer is now the disease that patients think of when they expectorate blood, just as it was TB 50 years ago. Elder patient with bloody sputum or streaked of bloody sputum, especially in the males with long history of smoking. cancer should be taken into account. Patients close contact with TB suffer, TB should be considered. Paragonimiasis (肺吸) may suspected in the people with history of eating raw or improperly cooked crabs or crayfish. Epidemic hemorrhagic fever, lepto-spirosis also can cause hemoptysis, they are endemic disease. 临床表现 1.年龄 (1)青壮年咯血常见于肺结核、支气管扩 张症、二尖瓣狭窄等。 （2）40岁以上有长期吸烟史（纸烟20支 /日20年以上年）者，应高度注意支气 管肺癌的可能性。 （3）儿童慢性咳嗽伴少量咯血与低色素 贫血，而注意特发性含铁血黄素沉着症 的可能。 2.The amount of coughing up blood Hemoptysis can be classified into three groups according to the amount of coughing blood. Massive: expectoration 500ml/24hr. Moderate: 500ml expectoration 100ml/24hr minimal: expectoration 100ml即为大咯血)。 大量咯血主要见于肺结核空洞，支气管扩张症和慢性肺脓 肿。 支气管肺癌的咯血主要表现为持续或间断痰中带血 ，少有大咯血。 3.Color and character. To a hemoptysis patient,it is necessary to ascertain the exact nature of the sputum, the sputum must be examined both grossly and microscopically. Brisk (肉色)bleeding is commonly associated with specific focal ulceration of the bronchus, such as bronchogenic carcinoma, a foreign body, bronchiectasis or a bleeding aortic aneurysm. Slow bleeding strongly suggests venous bleeding which is more likely to be the result of increased in blood flow through the bronchial venous system such as may occur as a result of mitral stenosis or bronchiectasis. 3、颜色和性状 鲜红色：肺结核、支气管扩张症、肺脓肿等。 铁锈色痰：肺炎球菌大叶性肺炎、肺吸虫病和肺 泡出血。 砖红色胶冻样血痰：肺炎杆菌肺炎。 暗红色：二尖瓣狭窄肺瘀血。 粘稠暗红色：肺梗塞。 浆液性粉红色泡沫样血痰：急性左心衰肺水肿 。 Accompanying symptom Hemoptysis with fever: pulmonary tuberculosis,pneumonia, lung abscess, lopeospirosis, epidemic hemorrhagic fever, bronchogenic carcinoma. Hemoptysis with chest pain: lobar pneumonia ,pulmonary infarction, pulmonary TB, lung cancer. Hemoptysis with putrid sputum: lung abscess cavitious TB, bronchiectasis. Hemoptysis with irritating cough: bron