呼吸系統影像診斷學ImagingdiagnosticsoftheRespiratorysystem

鄭州大學第一附屬醫院放射科thefirstaffiliatedhospitalradiologydepartmentoftheZhengzhouUniversity

張焱ZhangYan〔四〕肺結核Pulmonarytuberculosis:1.臨床特點：clinicalcharacters〔1〕病原：pathogeny人或牛結核桿菌BacillustuberculosisorBacillustuberculosisbovis〔2〕病理：pathology①結核菌侵入人體后引起的根本病理變化為:basicpathologicalchangecausedbytuberculosis滲出及增殖exudationandproliferation②機體抵抗力低下時，病變那么出現:pathologicalchangeoflowresistance干酪樣壞死，液化及空洞形成caseousnecrosis,colliquationandporosis.③機體抵抗力強或經適當治療后病灶：pathologicalchangeoflowresistanceorpost–treatment吸收absorption纖維化fibrosis鈣化calcification空洞瘢痕閉合或凈化空洞cavitycloseorasepsiscavity〔3〕分期:stages①進展期：progression新發現病灶，病灶擴大newlesionandexpansion病灶邊界變模糊obscureborder出現空洞或空洞增大，痰結核菌陽性cavityappearanceorexpansion,spitpositive②好轉期：resolvingstage病灶縮小，邊界變清楚，病灶消失clarityofborderandlesseningordisppearanceoflesion空洞縮小或消失lessenordisappearofnidus痰結核菌轉陰性〔連續3月，1次/月〕spitnegative(3monthscontinous,1time/month)③穩定期：stationarystage病灶無活動lesioninactivity，空洞閉合cavitycloseup，痰結核菌連續6個月陰性〔至少1次/月〕spitnegative(6monthscontinus,1time/month)如有空洞，連續1年以上陰性，屬臨床治愈spitnegativecontinousmorethan1yearisclinicalcureifthecavityexsist再經觀察2年仍無活動，結核菌仍陰性focusinactivityformore2yearsandspitnegativecontinous如有空洞，需觀察3年以上為臨床痊愈clinicalcureshouldbeobservefor3yearsifthecavityexist2.影像表現：1978年全國結核病防治會議natinalconferenceforcureandprevetionoftuberculosis分為五個類型：Ⅰ型type：原發性肺結核primarypulmonarytuberculosis〔原發綜合征primarysyndrome，胸內淋巴結核intrathoracicscrofula〕Ⅱ型type：

血行播散型肺結核hematogenouspulmonarytuberculosis〔急性粟粒型肺結核acutemilitarytuberculosis，亞急性或慢性血行播散型肺結核subacuteorchronichematogenouspulmonarytuberculosis〕Ⅲ型：浸潤型肺結核〔含結核瘤和干酪肺炎〕exudativepulmonarytuberculosis(tuberculomaandcaseouspneumonia)Ⅳ型：慢性纖維空洞型肺結核chronicfibro-cavernouspulmonarytuberculosisⅤ型：胸膜炎型肺結核tuberculouspleurisy1998新制定中國結核病分類法：chinesegroupingoftuberculosis：Ⅰ型原發性肺結核primarypulmonarytuberculosis〔原發綜合征primarysyndrome，胸內淋巴結核intrathoracicscrofula〕Ⅱ型血行播散型肺結核hematogenouspulmonarytuberculosis〔急性粟粒型肺結核acutemilitarytuberculosis，亞急性或慢性血行播散型肺結核subacuteorchronichematogenouspulmonarytuberculosis〕Ⅲ型：繼發性肺結核secondarypulmonarytuberculosis〔含結核瘤tuberculoma、干酪肺炎caseouspneumonia、慢性纖維空洞型肺結核chronicfibro-cavernouspulmonarytuberculosis〕Ⅳ型：結核性胸膜炎tuberculouspleurisyⅤ型：其他肺外結核如骨結核、腎結核和結核性腦膜炎等extrapulmonarytuberculosissuchasbasaltuberculosis，nephrotuberculosisandtubercularmeningitis〔1〕原發型肺結核:〔Ⅰ型〕primarypulmonarytuberculosis①原發綜合征(primarysyndrome)：典型表現呈“啞鈴狀或雙極期〞:dumbbellorbipolarstage

A.肺野原發病灶：primarylesionoflungfeild

邊界模糊的云絮狀陰影，可大可小patchyshadowofobscureborderandInequalityofsizeB.肺門及縱隔淋巴結腫大：enlargementofhilarandmediastinallymphnodes

邊界清晰或模糊、圓或分葉狀塊影

the

borderisclearorobscureandthelesionisrotateorsublobe

C.淋巴管炎：angialymphitis

連接淋巴結和原發灶之間索條狀影thestreakshadowisconnectionoflymphnodesandprimarylesion②胸內淋巴結結核(tuberculosisofintrathoraciclymphonodes)：原發病灶吸收absorptionofprimarylesion但淋巴結核因干酪化而愈合緩慢，slowcicatrizationofscrofulabecauseofcaseation

故只有淋巴結炎adenolymphitis典型表現:classicalcharacters肺門或縱隔有圓或橢圓結節狀陰影，單個或多個singleormultiplenodositasrotateorellipselesionofhilusoflungormediastinal

邊界清晰者clearborder

：腫瘤型tumortype

邊界模糊者obscureboder：炎癥型Inflammatorytype

原發綜合征肺結核胸內淋巴結肺結核

primarysyndrometuberculosisofintrathoraciclymphonodes〔2〕血行播散型肺結核hematogenouspulmonarytuberculosis〔Ⅱ型〕①急性粟粒型肺結核〔acutemiliarytuberculosis〕：結核菌一次大量進入肺循環massofBacillustuberculosiscomeintopulmonarycircuIation所以肺部病變廣泛，臨床病癥較重pulmonarylesioniswideandclinicalsymptomissevere1.病變早期：earlystage

只見肺呈磨玻璃樣groundglasspulmonary2.發病10天大約后：10daysafteronste

見1.5~2mm大小的粟粒狀影miliarylesion大小一致，分布均勻，密度相似normalsize,densityandequalityofdistribution正常肺紋理看不清normallungmarkingcannotbeobserved3.治療后數月內吸收absorptionafterseveralmonths’treatment惡化那么融合，出現空洞amalgamationfordegenerationandcavitypresent②亞急性或慢性血行播散型肺結核:〔又稱慢性播散型肺結核，chronicdisseminatedpulmonarytuberculosis〕：結核菌少量，屢次進入肺循環fewBacillustuberculosiscomeintopulmonarycirculationtimeaftertime病癥較輕slightsymptom典型表現:classicalcharacters為結節狀病灶nodositaslesion主要分布在兩肺上、中部mediansuperiorlung〔少數可單側〕大小不一，分布不均，密度不一致，呈多種性質病灶abnormalsize,densityandasymmetryofdistributionandmultinature急性粟粒型肺結核亞急性、慢性血行播散型

肺結核〔3〕浸潤型肺結核〔infiltrativepulmonarytuberculosis〕:為繼發性肺結核，最常見secondpulmonarytuberculosisandbestcommonX線表現有三種形式：①常見表現：好發于兩肺或一側肺的鎖骨上、下區regionesofsupraclavicularorinfraclavicula

可以呈多種性質multinature，多種形態multianatomy，多個小葉性病灶multilesionofsublobe病灶邊界模糊obscureborder病灶可融合成大片或出現空洞lesionmergeortogethercavitypresent②結核瘤〔球〕tuberculoma：系干酪樣結核病變被纖維組織包繞而成caseastionoftuberculosiscircumfusedbyfibroustissue一般為圓或橢圓形致密影rotateorellipsehighdensitylesion大小2~3cm多數輪廓光滑outlineissmooth病灶內可有鈣化或小空洞calcificationorsmallcavityinthelesion病灶周圍常有衛星病灶satellitearoundthelesion③干酪性肺炎caseouspneumonia

：機體抵抗力差，對結核菌高度過敏而形成，分大葉性和小葉性Lowresistanceandhypersensitivetotuberculosis.Divideintolobarandlobularpneumonia.大葉性呈肺段或大葉實變陰影，內有無壁空洞，其余部位可有播散病灶Lobarpneumoniaishighdensitylesionofsegmentorlobarandcavitywithoutwallinit.Disseminatuslesionsinotherregions.小葉性病灶呈小片狀陰影，常與大葉性病灶同時存在Lobularlesionislobularshadowandcoexistwithlobarlesion

浸潤型肺結核

常見表現結核球浸潤型肺結核〔干酪性肺炎〕

平片斷層片〔4〕慢性纖維空洞型肺結核〔Ⅳ型〕Chronicfibrocavitarypulmonarytuberculosis①為各型結核惡化、好轉與穩定交替開展而來的晚期肺結核Latepulmonarytuberculosisbydegeneration,improvementandstabilizationofallt