呼吸系统放射学诊断-刘辉-2课件

RespiratoryRadiology

刘辉

DepartmentofRadiology,thesecondXiangyahospital

空洞与空腔cavityandaircontainingspace肺内病变组织发生坏死，坏死组织经引流支气管排出而形成

Cavityisformedasaresultoftissuenecrosisandcommunicatedwiththebronchus.空洞cavity薄壁空洞Thin-walledcavity

洞壁厚3mm以下内壁光滑境界清楚的园形透亮区，见于肺结核结核性空洞常无或仅少量液体多为薄壁TBcavitywithalittleornotfluidlevel

虫蚀样空洞（无壁空洞）实变肺野内多发小的透亮区，虫浊样，见于干酪性肺炎癌性空洞内壁多呈结节状

Thick-walledcavityIrregularinnerling肺脓疡空洞多有明显液片多为厚壁

Thickwallcavitywithsurroundexudativelesionsassociatedwithafluidlevel

空腔性病变右下肺囊肿肺部基本病变

肺间质病变

interstitiallesion:发生在间质的弥漫性病变:即病变主要分布在支气管血管周围、

小叶间隔、肺泡间隔.X线表现

肺纹理增粗、网状strip纹理、蜂窝状honeycomb

或伴广泛小结节影netting-nodules（间质结节）弥漫性肺间质病变(diffuseinterstitialdisease)HRCT：

小叶内间质增粗—

小叶内细支气管血管周围

和肺泡间隔的间质增厚弥漫性肺泡病变diffusealveolardisease广泛分布，含气支气管征，毛玻璃密度

胸膜病变pleurallesion少量胸腔积液pleuraleffusionX线表现

先积聚于后肋膈角

液量300ml以上时侧肋膈角变平变钝

pleuraleffusion大量胸腔积液pleuraleffusion患侧肺野均匀致密，或仅肺尖透亮纵隔向健侧移位肋间隙增宽大量积液pleuraleffusion

纵隔？

肋骨？

横膈？左全肺不张胸腔心包积液CT表现

pleuraleffusion

包裹性积液Loculatedpleuraleffusion叶间积液interlobarfissurepleuraleffusion斜裂或水平裂梭形，两端与叶间裂相连液量多时呈球形

叶间积液interlobarfissurepleuraleffusion叶间积液interlobarfissurepleuraleffusion气胸

pneumothorax

空气进入胸腔形成aircomeintochestcavity.

Cause:

壁层胸膜破裂

脏层胸膜破裂Edgeofthecollapsedlungs肺与胸壁之间透明含气区increasedradiolucentarea，其中不见肺纹理

液气胸hydropneumothorax胸腔内气体与液体并存thereisfluidwithairaboveit,eitherinthepleuraspacepleuraladhesions,thickeningandcalcification轻度胸膜肥厚、粘连多见于肋膈角处costophrenicangle肋膈角变浅变平膈顶变平直而不呈园顶状flateningofthedomeofdiaphragm

呼吸时膈运动受限

膈胸膜粘连有时表现幕状突起

胸膜钙化pleuralcalcificationcalcificationalongthechestwallonthesurfaceofthepleuraPleuralcalcificationusuallyresultedfromTB,hemorrhage常见病X线诊断X-raydemonstrationsIncommondiseases支气管疾病—支气管扩张bronchiectasisEtiology：followingbychronicbronchitis,suppurativeinflammation,pulmonicpneumonia,pulmonaryatelectasisandfibrosisPathogenesis：慢性感染—支气管壁组织破坏；支气管内分泌物和长期咳嗽—支气管内压增高；肺不张和肺纤维化—外在性牵拉支气管疾病—支气管扩张bronchiectasiscontinuouscoughandpurulentsputumAhistoryofrecurrenthaemoptysisbronchiectasis分型：柱状扩张Cylindricalbronchiectasis囊状扩张Cysticbronchiectasis混合型扩张Mixedbronchiectasisbronchiectasis

X-线表现

PLAINFILM

正常morethan50%obscurerecognitionbronchiDilatedbronchi,sometimeswithfluidlevels,areseenonlyingrossdiseasebronchiectasis---CT：轨道征dilatationofthebronchus,whichusuallyisaccompaniedbybronchialwallthickening印界征signetringconfiguration:Dilatedbronchusandconcomitantpulmonaryartery囊柱状改变Largeellipticalcircularopacities肺炎pneumoniaAccordingtoanatomicdistributing,pneumoniacanbeasfollows:LobarpneumoniaBronchopneumoniainterstitialpneumoniaLobarpneumonia—临床causedbypneumococcusrapiddevelopmentofhighpyrexiaacharacteristicrustycolorsputum

Thebasicpathologiclesionisacuteinflammatoryexudationofthepulmonaryparenchyma

大叶性肺炎

pathologicchangings

充血期Thecongestivestage(itisabout24hoursafteronset)

红色肝变期Theredconsolidationstage

灰色肝变期Thegrayconsolidationstage

消散期Resolutionstage

Lobarpneumonia充血期ItmaybenoX-raychangesorwithanincreaseoflungmarkingsorwithafaintshadowintheinflammatoryareamanyofthealveoliarestillaeratedLobarpneumonia----肝变期TheX-rayfeatureisalargehomogenousradiopaqueshadowthereisnovolumelossairbronchogramiscommonBordersoftheshadowappearasasharplydefinedmarginLobarpneumoniaLobarpneumoniaLobarpneumoniaLobarpneumoniaResolutionstage

thealveolarexudatesareabsorbedtherearefilledwithairinthealveolitheshadowofconsolidationbecomesscatterresorptionmaybedelayeduptooneortwomonthsLobularpneumonia(bronchopneumonia)causedlobularpneumoniaarestreptococcus,staphylococcus,pneumococcusThecommonsymptomsarefever,cough,purulentsputumandpleuriticpainetc

Smallbronchuswallcongestandswelling,interstitialinflammationinvolvingimmersinglobularpatchyopacitiesandconsolidation小支气管不同程度阻塞--Emphysemaorlobularatelectasis

Bronchopneumonia病理变化Lobularpneumonia

X-rayfeaturesThereisintensificationoflungmarkingsSmallpatchyopaqueshadowsareseeninthemiddleandlowerlungfieldsespeciallybytheheartborderEmphysemaofthebothlungsisusuallyvisible.Confluenceofthesepatchyopacitiesmayproducesegmentallargeareaofconsolidation.Delayedorincompleteresolutionmayresultinbronchiectasisandfibrosis

间质性肺炎interstitialpneumoniaInterstitialpneumoniainvolvesmainlytheinterstitialtissueoflungs,includingthebronchovascularbundlesandintralobularseptaitmaybecausedbyviralorbacterialinfectionClinicsigns：shortnessofbreath,cough,cyanosispathology：

interstitialinflammationimmersing

Lymphatitis,lymphadenitis

Smallbronchusinflammation---obstructemphysemaandatelectasis

肺泡也可轻度炎性浸润

多伴不同程度的间质纤维结缔组织增生interstitialpneumoniaX-rayfeaturesofinterstitialpneumoniaTherearefinestreak-like,net-like,nodularornod-reticularshadowsEmphysemaofbothlungsininfantpatientsPossiblythereisenlargementandincreaseindensityofthehilarshadowCT,especiallyHRCTcandepicttheearlysignofinterstitialpneumonia.Itmaypresentasthickenedseptainterstitialpneumonia

肺脓肿pulmonaryabscessPurulencebacteria---inflammationfocus-Necrosisandfluidify---abscessinfectapproach：inhale

hematogenousdirectspreedstage：acute,subacuteandchronicstage

病理：渗出与实变—坏死液化—空洞形成:ThelungabscessbeginsasanareaofgangrenousbronchopneumoniaRadiologicalfeatures排脓之前：大片致密影排脓以后：大片影内出现空洞与液平面pulmonaryabscess---AcutestageLungabscess急性期高烧寒战、咳嗽、咳脓臭痰、胸痛等symptomsincludehighpyrexiaandpleuriticpainpulmonarynecrosishasoccurredThesputumisoftenfoulsmellingandblood-stainedpulmonaryabscess-Subacutestagedefinedastheperiodbetween6weeksand3monthsaftertheonsetofinfectionfibrosisofthewallbecomesestablishedappearsasacavityormultipleabscesscavitieswithfluidlevelasairentersthesefocithecavitywiththickwallsurroundedbyexudativelesionpulmonaryabscessChronicstageAfter3monthstheabscesswasconsideredtobechronic持续性咳嗽咳痰等X-rayfeatures:空洞周围纤维组织增生形成厚壁空洞oneormoreirregularcavitiesandwithmultiloculationsomefibroticlesionsbythecavityorinthecavitarywallThickenedpleuraareusuallyseenpulmonaryabscess血源性肺脓疡：hematogenouspulmonaryabscess膈下脓肿或肝脓肿扩展到肺

形成肺脓肿：pulmonaryabscesshematogenouspulmonaryabscess

肺结核Pulmonarytuberculosis

由结核杆菌引起的慢性传染病basicpathologicalchanges：渗出exudation增殖proliferationPulmonarytuberculosis

愈合方式：

吸收absorb

纤维化fibrosis

钙化calcifycavitypurifyorcavityscaroverPulmonarytuberculosis

干酪样坏死caseation

液化及空洞形成necrotic

materialbeextruded----formationofacavity

播散:血行播散hematogenousdissemination

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

结核病临床分类（1998）

In1998,theChineseAntituberculousAssociationadaptedanewclassificationofpulmonarytuberculosis.Ithasbeendividedinto5types:Primarytuberculosis(TypeⅠ)Hematogenouspulmonarytuberculosis(TypeⅡ)Secondarypulmonarytuberculosis(TypeⅢ)Tuberculouspleuritis(TypeⅣ)Extrapulmonarytuberculosis(TypeⅤ)

原发性肺结核primarytuberculosis

原发性肺结核primarycomplexThecombinationoftheprimarypulmonarytuberculousfocus,lymphangitisandintrathoraciclymphadenitisItoccurschieflyinchildren临床表现：低热、盗汗、乏力、食欲减退、轻咳X线表现分为：原发综合征胸内淋巴结结核

原发综合征primarycomplexanexudativelesionintheanyportionofthelungfieldenlargementofhilarlymphnodesormediastinallymphnodeslymphangitisstreakyshadows原发综合征治疗前后primarycomplex

TheprimaryfocusisusuallyabsorbedX线表现

结节型（肿瘤型）：边界清楚

炎症型：边界模糊

增大淋巴结加淋巴结周围炎intrathoracictuberculouslymphadenitisprimarytuberculosis

Axialcontrast-enhancedCTscandemonstratesmultipleenlargedmediastinallymphnodes血行播散型肺结核hematogenouspulmonarytubculosis

（粟粒性肺结核）急性acute亚急性subacute慢性chronic

急性血型播散型肺结核acutehematogenouspulmonarytubculosisoracutemiliaryTB

概念

Theonsetofthediseaseissudden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febrile寒战气急、咳嗽等coughandbreathlessness

急性血型播散型肺结核acutemiliaryTB

X线表现

NochangesintheearlystageAbout2weeksafteronset,itwillbegintoshowalotoffine,pin-pointmottlingopacitiesvaryingupto1-2mmindiameter分布distribution均匀、大小size相同、密度相同正常肺纹理不能显示acute

miliaryTBHigh-resolutionCTscanobtainedwithlungwindowingdemonstratesnumerousfine,nodulesbilaterallyacutemiliaryTB

Subacuteorchronichematogenouspulmonarytuberculosis亚急性或慢性血行播散型肺结核

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

状恶化者病灶融合形成空洞或转为慢纤空SubacuteorchronichematogenouspulmonarytuberculosisX-rayfeaturesalotofnodularshadowsinbothlungfieldsTheshadowsarenotuniforminsize,indensityandindistributioninfiltrativepulmonarytuberculosisSymptomsmanypatientsdiagnosedbyX-raylowpyrexia,lassitude,weightloss,nightsweats,coughproductiveofmucoidsputumandhaemoptysisinfiltrativepulmonarytuberculosisX-rayfeatures:multiplebasicX-rayfeatures：exudation,proliferation,fibrosis,calcificationandcavitationthelesionisattheapexandsubclavicularregionoftheupperlobeandthesuperiorsegmentofthelowerlobe

干酪性肺炎caseouspneumonia

ThecaseouspneumoniaoccursinpoorhealthpatientThepatientisusuallywithhighfever病理：

大叶性：大片渗出性结核性炎变

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

caseouspneumonia

X-rayfeaturesmultiplecavitiesusuallyseenusuallywithbronchogenicdisseminatedfocusinbothlowfieldsinfiltrativepulmonarytuberculosisThetuberculomaisformedbyfibroustissueencystedcaseouslesionThesizeislargerthan1.5cmindiameter多见于上叶尖、后段、下叶背段

Infiltrativepulmonarytuberculosis—结核瘤结核瘤X-rayfeaturesaroundorovalopaqueshadowwithwell-definedmarginandhighdensitytypicallyintheupperlobesTheremaybecalcificlesion“Satellite”lesionsTheselesionsarestableforlongperiodsoftimeCavitationisextremelyrarewithtuberculomainfiltrativepulmonarytuberculosisinfiltrativepulmonarytuberculosisinfiltrativepulmonarytuberculosis

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

Symptoms:repeatedlowpyrexia,coughproductiveofmucoidsputumandhaemoptysisSomepatientsmaybewithoutmarkedsymptomschronicfibro-cavitativepulmonaryTB

Imagefeatures:

WithFibroticcavity(纤维厚壁空洞)WithmanyFibroticlesions(广泛纤维化)

Usuallywithbronchogenicdisseminationtothelowerlungfields支气管播散病灶

结核性胸膜炎tuberculosispleuritispleuraleffusion

PleuralthickeningCTcandemonstratepleuraleffusionandthickenedpleuraclearlyAxialcontrast-enhancedCTscandemonstratesalarge,right-sidedpleuraleffusion

原发性支气管肺癌primarybronchogeniccarcinoma

primarybronchogeniccarcinoma

PrimarybronchogeniccarcinomaarisesfromthebronchialepitheliumbronchialglandsepitheliumofthealveolusTheincidenceofthecarcinomaisnowsteadilyincreasingprimarybronchogeniccarcinoma

Bronchogeniccarcinomaisusuallyclassifiedhistologicallyintosquamouscellcarcinomaadenocarcinoma(includingalveolarcellcarcinoma)undifferentiatedcarcinomassmallcell(oatcell)variouslargecelltypesClinicalfeaturesCough,haemoptysis,sputum,breathlessnessObstructionofthebronchusSpreadtothepleuraTumorinvasionofmediastinum(1)leftrecurrentlaryngealnervepalsy(2)superiorvenacavalobstruction(3)Dysphagia(4)phrenicnerveparalysis(5)apicaltumors