医学影像学课件：七年制影像chest -呼吸常见病1支气管病变+肺炎+肺结核

1、Imaging diagnosis of respirotary diseasepart 1AiPing Chen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

2、有限。CT：发现病变、定位和定性诊断。 限度：定性缺乏特异性。MRI：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

3、haemoptysis. 儿童，青年多见，多见于左下叶、右中叶及右下叶。咳嗽、咳痰、咯血支气管扩张bronchiectasisBronchiectasis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; ch

4、ronic granulomatous 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BronchiectasisPathologyDamage of bronchus wallPression of bronchus increaseCircumference 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）BronchiectasisBronchiectasis can

5、 be 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.BronchiectasisX-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 occures.

7、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)BronchiectasisBronchographic investigation is important and necessary to delineate the total extent of the disease.

8、 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 lungBronchiectasisCT is helpful especially in the more

9、 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 bronchiectasis can be di

10、agnosed 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。bronchictasistram line 轨道征 signet-ring sign 印戒征 air-fluid level in the sac.支扩伴黏液栓形成bronchictasistram line and the signet-ring sign in cross-section.Question:where is th

11、e 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AVMPneumoniaThe 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PneumoniaPneumonia can cause a wide variety of abnormal findings on the chest radiograph. Commonly, i

12、t 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. It also can present as single

13、or multiple nodules. The presence of pneumonia sometimes may be masked by an associated pleural effusion, congestive failure, or adult respiratory distress syndrome(ARDS).PneumoniaAccording to the radiologic appearance, pneumonia can be commonly divided into lobar pneumonia bronchopneumonia intersti

14、tial pneumoniaLobar pneumoniaLobar 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 little change in the bronchi or intersti

15、tial 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 pneumoniaEarly stage: Inflammatory edemaConsolidati

16、on stage Resolution stageLobar pneumoniaEarly 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 because many of the alveoli are still aer

17、ated.Lobar pneumoniaConsolidation 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 field indicates that the density is due to c

18、onsolidation 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，胸膜侧最晚，可有胸膜增厚、纤维条索 lobar pneumoniaconsolidation of rig

19、ht upper lung and “air bronchogram “consolidation of right middle lober consolidation of right upper lober Lobar pneumoniaResolution stageThe homogenicity if the shadow of consolidation is lost and it becomes mottled as the exudate in various portions of the affected lung is absorbed and alveoli her

20、e 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 disappear as the lung re-expands and resolution is co

21、mpleted.Resolution stage in the right upper loberStreak like shadowResolution stage in the left lower loberconsolidation 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 (lobular pneumonia) It is commonly seen in infants and elderl

22、y 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 results in infiltration of the interstitial tissues with litt

23、le 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 on the severity of the disease. Mild bronchopneumonia results

24、 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 involving the terminal and respiratory bronchioles and adjacent alveo

25、li 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 loss of volume of the affected segments or lobes. When conflu

26、ent, 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 areas of consolidationLung markings increase and patchy in the rig

27、ht lower lobeLung markings increase and patchy in the right and left lungPatchy shadow in both of the lung Patchy shadow in both of the lung 机遇性感染opportunity infectionimmune deficiency accompany with infection or tuberculosis and 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 fem

28、ale 23 years olds HIVPatchy shadow in both of the lung AIDS and Pneumocystis carinii pneumoniaAIDS patient with pulmonary cryptococcal infection.（新型隐球菌）Lung abscessHematogenous abscess血源性的脓肿 is rather rare now. Abscesses occur most often as a complication of aspiration of food, vomitus, or foreign b

29、ody; 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 septicemia败血病, and they occasionally develop in an infected pulmonary infarct.L

30、ung abscessSymptomatology 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 developing lung abscess.Lung abscessThe abscess resulting from aspiration most

31、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 consolidation usually near the periphery of the lung. No fluid level is seen until

32、bronchial communication is established. Lung abscessAs 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. Adjacent parenchymal consolidation is also present. Multiple cavities may develop

33、 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 frequently an associated pleural effusion.Lung abscessCT allows earlier detection of

34、 abscess formationCT 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 obtuse钝角. A lung abscess is usually spherical and produces an acute angle with the chest

35、 wall. Lung abscessAfter 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 sometimes a small area of fibrosis indicates the site. In some cases healing is slow and the

36、re 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 in cavity) and the surrounding consolidationAcute abscess: the cavity (fluid in cavity) and

37、 the surrounding consolidationAcute abscess: the cavity (fluid in cavity) and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationChronic abscess: the cavity and the surrounding consolidationTuberculos

38、is of the lungTuberculosis 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 incidence of tuberculosis. Despite recent advances in therapy and careful public health measures, TB r

39、emains 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 the lungThe main factor determining whether tuberculosis infection progresses to disease is the im

40、mune 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 lungTuberculosis is classically divided into () primary tuberculosis. () hematogenous tuberculosis.()

41、postprimary tuberculosis. () tuberculous pleurisy .() extraplumonary tuberculosis.primary tuberculosisMost cases of primary tuberculosis due to inhale the tubercle bacilli. It is commonly seen in children or adolescents. The infection spreads from the initial focus in the lung to the regional and me

42、diastinal 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 focus(Ghon focus) in about 10 days. Spread of tubercle via the lumphatics leads to a specific hilar lympha

43、denitis. The combination of the primary pulmonary focus, lymphangitis and lymphadenitis is known as the primary complex.primary tuberculosisThe Ghon focus is a circumscribed, small, peripheral consolidation. Hilar and mediastinal lymphadenitis presents as hilar enlargement and mediastinal widening.

44、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 bronchial compression by enlarged lymph nodes.Right hilar enlargement and mediastinal wideningLeft hilar enl

45、argement Left hilar enlargement and mediastinal wideningRight hilar enlargement and mediastinal wideningLymph node enlargement in mediastinum After treatment enlargement lymph node disappearHematogenous tuberculosis(Type )Mycobacteria entering the blood from the primary complex may become disseminat

46、ed to numerous extrapulmonary sites. It may be classified as acute, subacute or chronic hematogenous dissemination tuberculosis. Miliary tuberculosisAcute miliary tuberculosisMilitary tuberculosis exhibits a finely mottled nodular pattern resulting from summation of individual nodules. These may ran

47、ge in size from 1-4mm in diameter.They completely obscure the normal lung markings in acute hematogenous dissemination tuberculosis. Three homogeneous:distribute,size,densityThree homogeneous: distribute,size,densityAcute miliary tuberculosisThree homogeneous:distribute,size,densityAcute miliary tub

48、erculosisAcute miliary tuberculosisAcute miliary tuberculosis Miliary tuberculosisSubacute or chronic miliary tuberculosistiny opacities are chiefly distributed in both upper and middle lung fields, the density of the opacities is not uniform and the size and shape of the opacities are not the same.

49、 Three nonhomogeneous:distribute,size,densitySubacute or chronic miliary tuberculosisThree inhomogeneous:distribute,size,densityThree homogeneous:distribute,size,densitySubacute or chronic miliary tuberculosisSubacute or chronic miliary tuberculosisPostprimary tuberculosis (Adult tuberculosis)Postpr

50、imary tuberculosis is characterized by cavitating lesions in the upper lobes or apical segments of the lower lobes. Rupture of a parenchymal focus into an adjacent airway and subsequent endobronchial spread may lead to extensive pulmonary involvement. .Postprimary tuberculosis (Adult tuberculosis)Po

51、stprimary tuberculosis produces a spectrum of radiographic manifestations; exudative, productive, cavitatory, and fibrotic changes frequently occur simultaneously. Because of the predilection for the apical and posterior segments of the upper lobe and the apical segment of the lower lobe, parenchyma

52、l changes in these regions should arouse suspicion of tuberculosisPostprimary tuberculosisPostprimary tuberculosisPostprimary tuberculosisPostprimary tuberculosis (Adult tuberculosis)Exudative tuberculosis is characterized by a lobular, caseous pneumonia with relative few epithelioid cells. Coalesce

53、nce may occur to form larger foci of caseous pneumonia. Exudative tuberculosis manifests as confluent mottled opacities with indistinct contours. They gradually alter in appearance over a period of weeks in contrast to nonspecific pneumonia, which may change within days.caseous pneumonia. Postprimar

54、y tuberculosis (Adult tuberculosis)Productive tuberculosis is characterized by well-defined solid nodules, 1-2mm in diameter and rich in epithelioid cells; Productive tuberculosis produces sharply defined, irregular, polygonal opacities admixed with calcified granulomata.Productive tuberculosisPostp

55、rimary tuberculosis (Adult tuberculosis)Tuberculomas measure 1-3cm in diameter and comprise a caseous core surrounded by a mantle of granulation tissue. They have smooth margins and predilection for the upper zones. In 80% of cases, conventional or computed tomography will show small satellite lesio

56、ns and calcifications.TuberculomasTuberculomasTuberculomasPostprimary tuberculosis (Adult tuberculosis)Cavitating tuberculosis is active tuberculosis, the wall of the cavity contains infectious caseous material. Eventually, the cavity becomes fibrosed and may even acquire an epithelial lining. Postprima