医学影像学：呼吸系统影像学（三）-呼吸常见病

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1、呼吸系统影像学呼吸系统影像学（三）（三） Imaging of Respiratory System v支气管病变支气管病变v肺炎肺炎v肺结核肺结核v肺肿瘤肺肿瘤v纵隔病变纵隔病变支气管病变v气管、支气管异物foreign body in the bronchusv先天性支气管囊肿 congenital bronchial cystsv气管肿瘤neoplasmv支扩bronchiectasisv儿童，青年多见，多见于左下叶、右中儿童，青年多见，多见于左下叶、右中叶及右下叶。叶及右下叶。v咳嗽、咳痰、咯血咳嗽、咳痰、咯血cough, Purulent foul-smelling sputum ,

2、 emptysis, or haemoptysis. 支气管扩张支气管扩张bronchiectasisBronchiectasis支扩vBronchiectasis is defined as localized, irreversible dilatation of the bronchial tree. vcongenital or aquired -vThere are several causes of bronchiectasis, postinfectious causes; congenital defects of a structure nature; chronic gra

3、nulomatous infection such as tuberculosis. BronchiectasisBronchiectasisvPathologyPathologyDamage of bronchus wallDamage of bronchus wallPression of bronchus increasePression of bronchus increaseCircumference tissue draughtv支气管壁破坏支气管壁破坏v支气管内压增加支气管内压增加v周围组织牵拉（疤痕、肺不张等）周围组织牵拉（疤痕、肺不张等）BronchiectasisBronc

4、hiectasisvBronchiectasis can be divided into three Bronchiectasis can be divided into three morphologic types: cylindrical,saccular, morphologic types: cylindrical,saccular, mixed type.mixed type.柱状、囊状或静脉曲张型。柱状、囊状或静脉曲张型。vCylindrical bronchiectasis refers to a Cylindrical bronchiectasis refers to a g

5、eneralized more or less regular widening of generalized more or less regular widening of the large bronchi.the large bronchi.vSaccular bronchietasis shows that the Saccular bronchietasis shows that the bronchi terminate in sac-like cavities.bronchi terminate in sac-like cavities.BronchiectasisBronch

6、iectasisX-ray manifestation:vThe plain film may be normal if only a small part is involved and there is no secondary infection.vThe most common appearance on plain film is increasing of lung markings. The bronchial walls may be visible either as single or parallel line opacities.vThere are paths of

7、opacity when infection occures. v无异常发现v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、管状、杵状、囊状蜂窝状影杵状、囊状蜂窝状影，或卷发状卷发状。v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反复发作。X-ray manifestationBronchiectasis: lung markings of the left low lobe increase,and small sac( sac-like cavities)Bronchogram: saccular bronchictasis in the left lungB

8、ronchiectasisvCT is helpful especially in the more 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.vThe signet ring sign refers to the thickened and

9、dilated bronchus, saccular bronchiectasis can be diagnosed most reliably by CT, sometime we can see air-fluid level in the dilated bronchus.vHRCT：支气管壁增厚，管腔增宽。：支气管壁增厚，管腔增宽。 呈呈“轨道征轨道征”或或“印戒征印戒征”。v柱状、囊状或静脉曲张型。柱状、囊状或静脉曲张型。vbronchictasisvtram line 轨道征v signet-ring sign 印戒征v air-fluid level in the sac.支扩伴

10、黏液栓形成bronchictasistram line and the signet-ring sign in cross-section.Question:where is the 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AVMPneumoniavThe causative organisms are variable:病病原体多样原体多样v感染：细菌、病毒、真菌、支原体、衣原体、感染：细菌、病毒、真菌、支原体、衣原体、立克次体、寄生虫立克次体、寄生虫v

11、理化性：类脂性、毒气、药物、放射线等理化性：类脂性、毒气、药物、放射线等v免疫和变态反应免疫和变态反应PneumoniavPneumonia can cause a wide variety of abnormal findings on the chest radiograph. vCommonly, it presents as alveolar consolidation, which can be segmental or lobar, or may be patchy, fluffy, alveolar infiltrates-without any segmental distri

12、bution(bronchopneumonia pattern).vPneumonia also may present as diffuse alveolar disease or as diffuse interstitial disease. vIt also can present as single or multiple nodules. vThe presence of pneumonia sometimes may be masked by an associated pleural effusion, congestive failure, or adult respirat

13、ory distress syndrome(ARDS).PneumoniavAccording to the radiologic appearance, pneumonia can be commonly divided into v lobar pneumoniav bronchopneumoniav interstitial pneumoniaLobar pneumoniavLobar pneumonia most commonly is caused by S.pneumoniae肺炎链球菌, but it can also occur with other organisms. vL

14、obar 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 interstitial tissue. The out-pouring of fluid is generally considered to result from a local sensitivity reaction to the polysaccharides in the

15、capsule of the pneumococcus. The bacteria are rapidly carried by the edema fluid from alveolus to alveolus Lobar pneumoniavEarly stage: Inflammatory edemavConsolidation stage vResolution stageLobar pneumoniavEarly stage: Inflammatory edema vThe infection and edema have usually spread throughout a se

16、gment of the lung.v 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 aerated.Lobar pneumoniavConsolidation stage vThe lung is characterized by a rather dense shadow of uniform opacity. vIf the bronchi r

17、emain 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 consolidation of lung. vIf adequate antibiotic treatment is given, no further spread takes place.1.1.大叶性肺炎大叶性肺炎 病理过程病理过程充血期：充血期：

18、12-24hr。毛细血管充血，少量浆液渗出，肺泡部分仍含气；实变期实变期：2-5d，分红色和灰色肝硬变期，肺泡内充满炎性渗出物。消散期消散期：1w后开始,2-3w消散。 线表现线表现l可无异常或肺纹理增粗。l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。l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 right middle lober consolidation of right upper lober Lobar pneumoniavResolution stagevThe homogenicit

19、y 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 here and there are filled with air. vThe pathologic consists of intermingled areas of consolidation of varying degree, aeration of the alveoli and areas of

20、atelectasis. The latter are often represented on the film by streak-like shadow. These shadows disappear as the lung re-expands and resolution is completed.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，

21、可见支气管充气征consolidation of right and left upper lober (air bronchogram) Bronchopneumonia (lobular pneumonia) vIt is commonly seen in infants and elderly patients by infection by Staphylococcus aureus金葡菌, most gram-negative bacteria and some fungi. vIt begins as a bronchial infection and has a tendency

22、 to involve separate parts of the lung. The infection spreads along the bronchial walls and results in infiltration of the interstitial tissues with little involvement of the alveolar air space. vIn most cases, both consolidations of the alveolar air spaces and interstitial infiltration are present.

23、Bronchopneumonia (lobular pneumonia)vThe radiologic manifestations depend on the severity of the disease. vMild bronchopneumonia results in peribronchial thickening and poorly defined air-space opacities. vMore severe disease results in inhomogeneous, patchy areas of consolidation that usually invol

24、ve several lobes. Bronchopneumonia (lobular pneumonia)vConsolidation involving the terminal and respiratory bronchioles and adjacent alveoli results in poorly defined centrilobular nodular opacities measuring 4 to 10 mm in diameter (air-space nodules); extension to involve the entire secondary lobul

25、e(lobular consolidation) may be seen. vBronchopneumonia frequently results in loss of volume of the affected segments or lobes. When confluent, bronchopneumonia may resemble lobar pneumonia.小叶性肺炎影像学表现v病变部位：两肺中下野的内中带v肺纹改变：增多、增粗、模糊vX-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vCT表现：两中下肺支

26、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 right 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 一周后复查，有吸收机遇性感染op

27、portunity infectionvimmune deficiency accompany with infection or tuberculosis and so on v免疫缺陷者伴随的感染或结核等vEg. HIV infection: 细菌，真菌，病毒，TB，PCP （肺孢子虫肺炎）男，男，35岁岁咳嗽、胸闷气急半月咳嗽、胸闷气急半月HIV抗体阳性抗体阳性AIDS patient with pulmonary cryptococcal infection.（新型隐球菌）Lung abscessvHematogenous abscess血源性的脓肿 is rather rare no

28、w. Abscesses occur most often as a complication of aspiration of food, vomitus, or foreign body; of bacterial pneumonia; or bronchial obstruction. Anaerobic bacteria厌氧菌are often the cause. vOther 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. vAbscesses may also b

29、e secondary to septicemia败血病, and they occasionally develop in an infected pulmonary infarct.Lung abscessvSymptomatology resembles that of acute pnenmonia with fever, cough productive of purulent sputum脓痰, and leucocytosis白细胞增多. vDiabetics, alcoholics, and immunocompromised,免疫受损的individuals are at i

30、ncreased risk of developing lung abscess.Lung abscessvThe abscess resulting from aspiration most frequently occurs in the dependent segments of the lung- the posterior segments of the upper lobe and the superior segments of the lower lobe. vThe abscess first appears as a round but poorly defined are

31、a of segmental consolidation usually near the periphery of the lung. No fluid level is seen until bronchial communication is established. Lung abscessvAs the abscess ruptures into the bronchus a translucent ring with a fluid level is seen in the middle of the opaque segment. vThe inner walls of the

32、cavity are smooth. Adjacent parenchymal consolidation is also present. vMultiple cavities may develop within consolidated lung(necrotizing pneumonia). vConventional tomography may show gas bubbles within an abscess indicating either a bronchial communication or possible infection with gas-forming or

33、ganisms. There is frequently an associated pleural effusion.Lung abscessvCT allows earlier detection of abscess formationvCT is also superior in defining the relationship of the process to the pleural cavity,.v Empyemas脓胸 tend to be lenticular凸出的 in shape, and their angle of interface with the chest

34、 wall is usually obtuse钝角. vA lung abscess is usually spherical and produces an acute angle with the chest wall. Lung abscessvAfter antibiotic treatment in favorable cases both the cavity and the surrounding consolidation gradually shrinks and disappears. The abscess heals completely and leaves no v

35、isible scar or sometimes a small area of fibrosis indicates the site. In some cases healing is slow and there is often a residual bronchiectasis of fusiform type.肺脓肿肺脓肿 lung abscessv急性化脓性肺炎期急性化脓性肺炎期：大片炎性浸润v脓肿形成期脓肿形成期：出现含液平空洞v慢性肺脓肿慢性肺脓肿：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v血源性肺脓肿血源性肺脓肿：两肺胸膜下多发性类圆性阴影，中间有小空

36、洞形成，可有液平，常累及胸膜Acute abscess: the cavity (fluid in cavity) and the surrounding consolidationChronic abscess肺脓肿治疗后周围炎症吸收脓肿，液平面肺脓肿引流后Tuberculosis of the lungvTuberculosis is an infectious disease that may affect any organ but shows a marked predilection for the lungs. Nowadays better standards of livin

37、g and hygiene have sharply reduced the incidence of tuberculosis. Despite recent advances in therapy and careful public health measures, TB remains 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 ex

38、posed to tubercle bacilli. Tuberculosis of the lungvThe main factor determining whether tuberculosis infection progresses to disease is the immune competence of the individual.v The disease is most commonly found in persons whose immune status is compromised by old age, alcohol abuse, diabetes, ster

39、oid therapy, or AIDS.Tuberculosis of the lungvTuberculosis is classically divided into v() primary tuberculosis. v() hematogenous tuberculosis.v() postprimary tuberculosis. v() tuberculous pleurisy .v() extraplumonary tuberculosis.primary tuberculosisvMost cases of primary tuberculosis due to inhale

40、 the tubercle bacilli. vIt is commonly seen in children or adolescents. vThe infection spreads from the initial focus in the lung to the regional and mediastinal lymph nodes by way of the lymphatic channels. Inhaled tubercle bacilli initially evoke a focal, nonspecific subpleural alveolitis that con

41、verts to a tuberculosis-specific inflammatory focus(Ghon focus) in about 10 days. Spread of tubercle via the lumphatics leads to a specific hilar lymphadenitis. vThe combination of the primary pulmonary focus, lymphangitis and lymphadenitis is known as the primary complex.primary tuberculosisvThe Gh

42、on focus is a circumscribed, small, peripheral consolidation. Hilar and mediastinal lymphadenitis presents as hilar enlargement and mediastinal widening. vOccasionally, lymphangitic stranding connecting the primary focus with the hilar lymphadenitis forms a dumbbell-shaped opacity. Segmental opacity

43、 may be due to segmental atelectasis distal to bronchial compression by enlarged lymph nodes.Right hilar enlargement and mediastinal wideningLeft hilar enlargement Left hilar enlargement and mediastinal wideningRight hilar enlargement and mediastinal wideningCentral caseous necrosisHematogenous tube

44、rculosis(Type )vMycobacteria entering the blood from the primary complex may become disseminated to numerous extrapulmonary sites. It may be classified as acute, subacute or chronic hematogenous dissemination tuberculosis. Miliary tuberculosisMilitary tuberculosis exhibits a finely mottled nodular p

45、attern resulting from summation of individual nodules. These may range 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,densityThree homogeneou

46、s:distribute,size,density Miliary tuberculosisMiliary 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. Three nonhomogeneous:distribute,size,densityThree inhom

47、ogeneous:distribute,size,densityPostprimary tuberculosis (Adult tuberculosis)vPostprimary tuberculosis is characterized by cavitating lesions in the upper lobes or apical segments of the lower lobes. vRupture of a parenchymal focus into an adjacent airway and subsequent endobronchial spread may lead

48、 to extensive pulmonary involvement. .Postprimary tuberculosis (Adult tuberculosis)vPostprimary tuberculosis produces a spectrum of radiographic manifestations; exudative, productive, cavitatory, and fibrotic changes frequently occur simultaneously. Because of the predilection for the apical and pos

49、terior segments of the upper lobe and the apical segment of the lower lobe, parenchymal changes in these regions should arouse suspicion of tuberculosisPostprimary tuberculosisPostprimary tuberculosisPostprimary tuberculosis (Adult tuberculosis)vExudative tuberculosis is characterized by a lobular,

50、caseous pneumonia with relative few epithelioid cells. Coalescence may occur to form larger foci of caseous pneumonia. vExudative tuberculosis manifests as confluent mottled opacities with indistinct contours. They gradually alter in appearance over a period of weeks in contrast to nonspecific pneum

51、onia, which may change within days.vcaseous pneumonia. Postprimary tuberculosis (Adult tuberculosis)vProductive tuberculosis is characterized by well-defined solid nodules, 1-2mm in diameter and rich in epithelioid cells; Productive tuberculosis produces sharply defined, irregular, polygonal opaciti

52、es admixed with calcified granulomata.Productive tuberculosisPostprimary tuberculosis (Adult tuberculosis)vTuberculomas 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,

53、conventional or computed tomography will show small satellite lesions and calcifications.TuberculomasTuberculomasPostprimary tuberculosis (Adult tuberculosis)vCavitating tuberculosis is active tuberculosis, the wall of the cavity contains infectious caseous material. Eventually, the cavity becomes f

54、ibrosed and may even acquire an epithelial lining. 30Y，糖尿病患者，典型薄壁空洞，卫星灶Postprimary tuberculosis (Adult tuberculosis)vThe tuberculous process heals by fibrosis, is associated with fibrous contraction and distortion of the lung architecture leading to emphysema, bronchiectasis, and bronchovascular dis

55、tortion. Radiologic manifestations of fibrotic tuberculosis include apical pleural thickening, parenchymal scarring, calcification, and fibrotic bands radiating from the hilum to the apex.Tuberculous pleurisy (type )vBacilli invade the pleura where they form tubercles, this is associated with develo

56、pment of a pleural effusion rich in lymphocytes. Exudative tuberculous pleuritis resembles other effusions radiographically. The effusion obliterates the costophrenic sulcus and layers in the lateral decubitus position.胸壁结核胸壁结核v渗出：结核性肺泡炎v增殖：结核性肉芽肿v进展：干酪样坏死、液化空洞、支气管和血行播散v愈合：吸收、纤维化、钙化，空洞愈合或净化肺结核 肺结核肺结

57、核v原发型肺结核(型)v血行播散型肺结核(型)v继发性肺结核(型)v结核性胸膜炎 (I型)v其他肺外结核其他肺外结核(型型) )原发型肺结核原发型肺结核 v原发综合征原发灶：近胸膜处渗出性病灶，病变可大可小结核性淋巴管炎：条索状，从原发灶向肺门引流结核性淋巴结炎：肺门及纵隔淋巴结增大以上三者构成哑铃状v胸内淋巴结结核 肿块型、炎症型血行播散型肺结核hematogenous disseminated pulmonary TB大量结核菌一次或短期多次进入血液播散至肺部。表现为两肺均匀分布粟粒大小的结节，密度相同，肺纹理不能显示。透视常难以分辨。CT能较早发现病变。表现为两肺广泛分布12mm小点状结

58、节，大小均匀，密度均匀，分布均匀，与支气管走向无关v亚急性或慢性血行播散型肺结核subacute or chronic hematogenous disseminated TB 血行播散型肺结核血行播散型肺结核v急性血行播散型肺结核少量多次血播。表现为大小不一，密度不同，以两中上肺为主。陈旧性病灶可为钙化，近期病灶表现为增殖或渗出继发型肺结核infiltration (secondary or postprimary)TB:肺尖、锁骨下区。上叶的尖后段和下叶的背段。v多型性改变v干酪型肺炎v结核球v晚期表现继发型肺结核v好发部位： 不同病理时相的病灶重叠在一起。 可渗出为主，干酪为主或空洞为主

59、v干酪型肺炎v结核球v晚期表现继发型肺结核v好发部位v多型性改变: 可占据肺段或肺叶，其中有虫蚀样空洞。支气管播散引起小叶性干酪性肺炎v结核球tuberculomav晚期表现继发型肺结核v好发部位v多型性改变v干酪型肺炎tuberculoma： 直径大多为2-3cm。圆形或椭圆形，境界清楚，密度均匀，也可见小空洞及钙化（层状、环状或斑点状）。周围常有纤维增殖性病灶，称卫星灶卫星灶v晚期表现继发型肺结核v好发部位v多型性改变v干酪型肺炎v结核球 纤维厚壁空洞，广泛纤维化及支气管播散灶共同存在。并有代偿性肺过度充气、支气管扩张及肺源性心脏病.又称慢性纤维空洞型肺结核chronic fibrous

60、cavitary TBLung neoplasm肺肿瘤肺肿瘤vThe incidence of primary lung carcinoma is increasing in all over the world. vMost lung tumors (over 98%) are bronchiogenic carcinoma 支气管肺癌支气管肺癌.Lung neoplasm肺肿瘤肺肿瘤vBenign:良性良性harmatoma, adenoma, angioma, fibroma错构瘤，腺瘤，血管瘤，纤维瘤错构瘤，腺瘤，血管瘤，纤维瘤v malignancy:恶性恶性 primary：lun

61、g carcinoma 肺癌，肺癌，sarcoma 肉瘤肉瘤Secondary：metastasis转移瘤转移瘤Harmatomavuncommon vasymptomatic; vsymptoms typically are present with central endobronchial lesions， include hemoptysis, recurrent pneumonia, and dyspnea.Harmatomavtypically round, well-marginated peripheral masses smaller than 4cm (range, 1 t

62、o 30cm).vtypical pattern ： popcorn calcificationv Calcification钙化 probably is present in less than 5% of lesions, Fat 脂肪can be detected by CT (attenuation ,-40 to -120 HU) in up to 50% of cases and is a diagnostic feature. primary bronchogenic carcinoma原发性支气管肺癌原发性支气管肺癌vmost common malignancy vrisk f

63、actor ：vcigarette smoking vEnvironmental and occupational exposure （3% to 17%）vInterstitial pulmonary fibrosis and focal scarring have been reported to increase the risk for bronchial carcinoma. vLung carcinoma(cancer)SCLC(small cell lung cancer) 小细胞肺癌小细胞肺癌NSCLC(non-small cell lung cncer）非小细胞肺癌非小细胞肺

64、癌vsquamous cell carcinoma 鳞癌鳞癌vAdenocarcinoma 腺癌腺癌vLarge Cell Carcinoma大细胞癌大细胞癌vcompound carcinoma 混合癌混合癌vbronchioloavelar carcinoma BAC细支气管肺泡癌细支气管肺泡癌Lung neoplasmLung neoplasmNSCLC(non-small cell lung cncer)vsqumous cell carcinoma is most commonly a central tumor developing at the level of the segm

65、ental and subsegmental bronchi in 66% of cases. These tumors are frequently lobulated and have a tendency to cavitate. vAdenocarcinoma is a peripheral tumor in 75% of cases with a predilection for the upper lobes and for regions of parenchymal fibrosis (“scar” carcinomas). vbronchioloavelar carcinom

66、a grows mainly within the alveoli respecting interstitial boundaries,may be unifocal of multifocal, when multifocal, it may produce alveolar cell carcinosis.According to type of growth vCentral type:Central type:Inter-tuberInter-tuberWall of tuberWall of tuberExtra-tuberExtra-tubervPeripheral type:Peripheral type:MassMassinflammationinflammationDiffuseDiffuseLung neoplasmCentral tumorCentral tumor vBronchial lumen : Bronchial stenosis，endoluminal or transmural growthCentral tumor: mass in the ri