呼吸系统影像诊断结核部分.ppt

呼吸系统影像诊断,Pulmonarytuberculosis,肺结核,由结核杆菌引起的慢性传染病基本病变basicpathologicalchanges：渗出exudation增殖proliferation干酪坏死caseousnecrosis,肺结核(pulmonarytuberculosis),临床表现：低热盗汗乏力食欲减退消瘦咳嗽咯血胸痛气促等急性血行播散者,可有高热寒战,愈合方式：吸收absorb纤维化fibrosis钙化calcify空洞净化或空洞疤痕性愈合cavitypurifyorcavityscarover,Pulmonarytuberculosis,干酪样坏死caseousnecrosis液化及空洞形成fluidifyandcavityformation播散dissemination:血行播散经淋巴管播散支气管播散局部扩展至邻近肺组织,Pulmonarytuberculosis恶化表现,肺结核活动性与转归进展期：新发现活动性病变，病变较前恶化增多出现空洞或空洞增大，痰结核杆菌阳性好转期：病变较前吸收好转，空洞闭合或缩小，痰内结核杆菌转阴（连续三月，每月查痰至少一次）稳定期：病变无活动，空洞闭合痰结核菌连续转阴达六个月以上，如空洞仍存在则痰菌转阴须一年以上,肺结核分类（2019年、中华结核病学会）,原发性肺结核（型）Primarytuberculosis(Type)包括原发综合征、胸内淋巴结结核血行播散型肺结核（型）Hematogenoustuberculosis(Type)包括急性、亚急性、慢性继发性肺结核（型）(secondarypulmonarytuberculosisType)包括浸润性肺结核Infiltrativetuberculosis、慢性纤维空洞性肺结核Chronicfibro-cavitarytuberculosis结核性胸膜炎（型）Pleuraltuberculosis(Type)包括结核性干性胸膜炎、渗出性胸膜炎、结核性脓胸其它肺外结核（型）(Type)包括骨关节结核、肾结核、肠结核、结核型脑膜炎,原发性肺结核(primarypulmonarytuberculosis),初次感染所发生的结核多见于儿童临床表现：低热、盗汗、乏力、食欲减退、轻咳X线表现分为：原发综合征primarycomplex胸内淋巴结结核,原发浸润(原发病灶)anexudativelesion:primaryfocus边缘较模糊的渗出性病灶云絮状影、多位于上中肺野近胸膜处淋巴管炎lymphangitis：原发病灶向肺门走行的条索状影streakyshadows淋巴结炎hilartuberculouslymphadenitis：肺门增大、纵隔边缘肿大淋巴结突向肺野enlargementofhilarlymphnodesormediastinallymphnodes,原发综合征primarycomplex,primarypulmonarytuberculosis,原发综合征的典型表现primaryfocus+lymphangitis+lymphadenitis形成哑呤状双极征象,primarypulmonarytuberculosis,primarycomplex,原发综合征治疗前、后原发病灶有吸收,primarypulmonarytuberculosis,胸内淋巴结结核intrathoracictuberculouslymphadenitis原发病灶吸收后原发性肺结核即表现为肺门或纵隔淋巴结肿大enlargelymphnodes称胸内淋巴结结核X线表现为肺门或气管旁分叶状肿块HilarandMediastinaltuberculousadenopathyThemarginoftheenlargelymphnodesmaybeclearorhazy.,primarytuberculosis,胸内淋巴结结核X线表现X-rayfeaturesofintrathoracictuberculouslymphadenitis,结节型（肿瘤型）thetypeoftumor：边界清楚炎症型thetypeofinflammation：边界模糊,为增大的淋巴结加淋巴结周围炎,primarypulmonarytuberculosis,typeoftumor,primarytuberculosis,typeofinflammation,Axialcontrast-enhancedCTscandemonstratesmultipleenlargedmediastinallymphnodes.centralareasoflowattenuationandperipheralenhancement,纵隔淋巴结结核CT表现,二血行播散型肺结核(hemo-disseminatedpulmonarytuberculosisoracutemiliaryTB),结核杆菌经血行播散所致分急性Acute、亚急性Sub-acute、慢性Chronic,急性血型播散型肺结核acutehematogenouspulmonarytubculosisoracutemiliaryTB概念大量结核杆菌一次或短期内数次进入血循环播散到肺引起者临床起病急、病情重，可有高热寒战气急、咳嗽等,急性血行播散型肺结核acutemiliaryTB,早期肺野可呈毛玻璃状密度增高,约10天后出现两肺弥漫性粟粒结节状阴影，1-2mm，边缘清晰大小均匀分布均匀密度均匀正常肺纹理被掩盖,X线表现粟粒性肺结核病灶小透视难以辨认，应常规照片,表现为：,急性血行播散型肺结核CT表现,可较早发现粟粒状阴影，1-2mm大小，边缘清晰numerousfine,nodulesbilaterally分布均匀thesamesize大小均匀thesamedensity密度均匀homogeneousdistribution正常肺纹理不能显示,亚急性或慢性血行播散型肺结核Sub-acuteorchronicmiliaryTB概念少量结核杆菌在较长时间内多次进入血流播散至肺所致临床症状可不明显或轻度结核中毒症状,亚急性或慢性血行播散型肺结核Sub-acuteorChronicmiliaryTB,大小不一,病灶可融合分布不均,两上中肺野为主密度不均,多种性质的结节病灶新旧不同可硬结钙化、纤维化、恶化者形成空洞或转为慢纤空伴代偿性肺气肿及胸膜增厚、粘连、钙化,alotofnodularshadowsinbothlungfields.Theshadowsarenotuniforminsize,indensityandindistribution.,AxialCTscandemonstratesbilateraldiffuse,coarse,linear,andnodularareasofincreasedattenuationwithcavitation(arrows),慢性血行播散型肺结核,类似亚急性期表现更多增殖、纤维化、钙化等,三继发性肺结核(secondarypulmonarytuberculosis),成年结核最常见类型基本病变多样：浸润病变、干酪病变、增殖病变、空洞病变、纤维化、钙化、结核球multiplebasicX-rayfeatures：exudation,proliferation,fibrosis,calcificationandcavitation分类：浸润性肺结核慢性纤维空洞性肺结核,浸润性肺结核infiltrativepulmonarytuberculosis,secondarypulmonarytuberculosis,临床结核中毒症状呼吸道症状好发于上叶尖段、后段及下叶背段thelesionattheapexandsubclavicularregionoftheupperlobeandthesuperiorsegmentofthelowerlobeuasually包括两种特殊类型：干酪性肺炎caseouspneumonia结核球tuberculoma影像表现：多种多样，一种基本病变为主或多种并存,浸润性肺结核影像表现,1.局限性斑片状影纤维化多见于上叶尖段后段、下叶背段thelesionattheapexandsubclavicularregionoftheupperlobeandthesuperiorsegmentofthelowerlobeuasually,secondarypulmonarytuberculosis,见干机体抵抗力极差，对结核菌高度过敏者病理：大叶性：大片渗出性结核性炎变发生干酪样坏死而形成小叶性：干酪空洞或干酪样化的淋巴结破溃经支气管播散形成临床：症状重，有明显中毒症状X线表现：大叶性：大片状或整个肺叶致密阴影，密度较大叶性肺炎为高虫蚀样空洞小叶性：散在小叶性致密影,infiltrativepulmonarytuberculosis,干酪性肺炎caseouspneumonia,浸润性肺结核影像表现,2.干酪性肺炎右上叶呈大片实变影，中心密度较高，边缘模糊，内可见多个不规则虫蚀状空洞,secondarypulmonarytuberculosis,infiltrativepulmonarytuberculosis,2.干酪性肺炎CT表现,secondarypulmonarytuberculosis,不规则虫蚀状空洞worm-eatencavities,浸润性肺结核影像表现,3.增殖性病变proliferation斑点状或小结节状，边缘较清,secondarypulmonarytuberculosis,浸润性肺结核影像表现,3.增殖性病变排列成树芽状或梅花瓣,为结核病的典型表现,secondarypulmonarytuberculosis,纤维组织包裹干酪样病灶形成Thetuberculomaisformedbyfibroustissueencystedcaseouslesion.,4结核瘤tuberculoma,Imagingmanifestionsoftuberculoma多见于上叶尖、后段、下叶背段typicallyintheupperlobes园形、卵园形、多边多角形阴影aroundorovalopaqueshadow直径2-3cm边缘光滑钙化多见Theremaybecalcificlesionwithwell-definedmarginandhighdensity可伴小空洞或裂隙样空洞多伴卫星病灶satellitelesionsTheselesionsarestableforlongperiodsoftime,结核球CT表现边缘清晰，轮廓光滑有卫星灶satellitelesions常见斑点、层状、环状钙化,secondarypulmonarytuberculosis,浸润性肺结核,浸润性肺结核X线表现,5.结核性空洞cavitation壁薄、内壁较规则无或浅液平面少数呈厚壁不规则空洞,secondarypulmonarytuberculosis,浸润性肺结核X线表现,6.支气管播散Endobronchialspreadoftuberculosis沿支气管分布的斑点状影，与分支状影，呈小叶中心分布树芽征tree-in-budappearance或相互融合成小叶阴影,secondarypulmonarytuberculosis,.,浸润性肺结核影像表现,7.硬结fibrosis,calcification:较高密度结节,边缘锐利钙化:骨样密度，斑片状或小块状为增殖性病灶好转,secondarypulmonarytuberculosis,infiltrativepulmonarytuberculosis,慢性纤维空洞型肺结核chronicfibro-cavitativepulmonaryTB属继发性肺结核，晚期类型.由于好坏交替，多种病理改变并存X线特征病变部位出现广泛纤维化WithmanyFibroticlesions：大量索条影、邻肺代偿气肿、牵引性支气管扩张、肺心病纤维厚壁空洞WithFibroticcavity支气管播散病灶withbronchogenicdissemination,chronicfibro-cavitativepulmonaryTB,双上肺广泛纤维化病灶内纤维厚壁空洞下肺可有点状支气管播散灶肺门上抬、下肺纹理呈垂柳状两上肺肋间隙变窄代偿性肺气肿,secondarypulmonarytuberculosis,secondarypulmonarytuberculosis,chronicfibro-cavitativepulmonaryTB,