本文選題：彌漫性泛細(xì)支氣管炎　切入點：CT　出處：《第二軍醫(yī)大學(xué)》2012年博士論文　論文類型：學(xué)位論文

【摘要】：第一部分彌漫性泛細(xì)支氣管炎的CT診斷 目的:提高彌漫性泛細(xì)支氣管炎的CT診斷及鑒別診斷能力。 材料與方法:回顧性分析我院2001年～2011年收治的92例彌漫性泛細(xì)支氣管炎的CT表現(xiàn)。 結(jié)果:1、病灶分布：84例表現(xiàn)為雙肺彌漫性分布，其中82例以雙下肺野及肺外圍顯著，僅2例雙肺中上野病灶較下肺野明顯，6例表現(xiàn)為雙肺野內(nèi)散在斑片狀分布，2例局限于雙肺下葉。2、CT征象：①92例均可見小圓形小葉中心結(jié)節(jié)，結(jié)節(jié)位于支氣管血管分支頂端，被胸膜、肺靜脈、小葉外肺靜脈或支氣管（即次級肺小葉邊界）所包繞，并與這些結(jié)構(gòu)相距約2～3mm；結(jié)節(jié)呈顆粒狀，直徑約1mm，邊緣較模糊，無融合；部分可見結(jié)節(jié)與其近端細(xì)支氣管分出的線狀影相連，有些呈樹芽征；②細(xì)支氣管擴(kuò)張68例，呈管狀或靜脈曲張樣擴(kuò)張，10例伴有大囊狀支氣管擴(kuò)張，伴有管壁不規(guī)則增厚，次級肺小葉范圍外的支氣管擴(kuò)張及支氣管壁增厚也較常見，周圍氣道擴(kuò)張較近端明顯，在肺野中外帶突出，35例擴(kuò)張的支氣管內(nèi)可見粘液栓塞，CT上表現(xiàn)為管狀或分枝狀致密影；③58例可見周圍性空氣潴留，表現(xiàn)為周圍肺野透亮度不同程度增高，肺外圍區(qū)域和中心區(qū)域的透亮度有明顯差異，即外圍區(qū)密度較低，在窄窗上顯示更明顯。盡管兩者間無明確的分界線可見，但胸膜下區(qū)域在HRCT上幾乎表現(xiàn)為透亮影；④42例見斑片狀影，在肺內(nèi)呈散在分布，形態(tài)不規(guī)則，邊緣模糊，內(nèi)部密度不均勻，部分內(nèi)可見細(xì)支氣管充氣影，3例合并右肺中葉不張，1例見左上葉舌段不張；⑤空洞3例，，均為薄壁空洞；⑥其它：肺間質(zhì)纖維化9例，主要出現(xiàn)在雙肺下葉底部,表現(xiàn)為條索影和不規(guī)則網(wǎng)格狀影，肺動脈高壓（主肺動脈直徑27mm）8例，縱隔、肺門部分淋巴結(jié)腫大18例，6例伴有鈣化，胸膜增厚粘連17例，其中1例伴左側(cè)胸腔積液，合并胸腺瘤和肺癌各1例。3、CT分型與臨床分期的關(guān)系：CT分型Ⅰ型見于臨床分期1期病人，Ⅱ型見于2期病人，Ⅲ型或Ⅳ型見于2期或3期病人。 結(jié)論: CT是診斷彌漫性泛細(xì)支氣管炎的重要依據(jù)，結(jié)合臨床有助于鑒別診斷。 第二部分彌漫性泛細(xì)支氣管炎與支氣管播散性結(jié)核的臨床CT比較 目的：提高對DPB和支氣管播散性結(jié)核的鑒別診斷能力，以降低DPB的誤診誤治率，改善患者預(yù)后。 材料與方法：比較分析我院收治的92例DPB病人和122例以樹芽征為主要表現(xiàn)的支氣管播散性結(jié)核的臨床CT特點。 結(jié)果：DPB與TB患者的年齡(47.51±16.17歲vs50.58±16.76，P=0.820)、性別(47.83%vs45.90%，P=0.780)差異無統(tǒng)計學(xué)意義。而DPB患者合并副鼻竇炎的比率要顯著高于TB(78.26%vs5.73%，P0.001)。兩組病例主要的癥狀均為咳嗽、咳痰。咯血也比較多見于DPB和TB，兩者比較差異無統(tǒng)計學(xué)意義(29.35%vs25.41%，P=0.521)。而勞力性呼吸困難(96.74%vs19.67%，P0.001)和粗濕羅音(100%vs36.89%, P0.001)更多見于DPB患者。DPB病人外周血WBC計數(shù)和免疫球蛋白IgA水平顯著高于肺結(jié)核患者。肺功能檢查FEV1/FVC 70%，或動脈血氧分壓80mmHg的患者所占比率在DPB更高。胸部CT上所有的DPB患者病變均為雙側(cè)分布，而肺結(jié)核84.43%為雙側(cè)分布，兩者差異有統(tǒng)計學(xué)意義（P＜0.001）。肺結(jié)核和DPB患者最常見的CT征象是細(xì)支氣管炎和細(xì)支氣管擴(kuò)張。然而，在病變范圍上，DPB患者分布更廣泛。與TB相比，DPB患者細(xì)支氣管炎和細(xì)支氣管擴(kuò)張累及更多的肺葉(分別為5.11±1.13vs3.83±1.62，P＜0.001；4.72±1.44vs1.76±0.45，P＜0.001)。DPB患者細(xì)支氣管炎及細(xì)支氣管擴(kuò)張更多累及雙肺下葉、右肺中葉及左上葉舌段，而TB更多見于雙肺上葉及右肺下葉。肺內(nèi)斑片影及空洞更多見于TB患者(分別為87.70%vs45.65%，P＜0.001；80.33%vs3.26%，P＜0.001)。 結(jié)論：DPB和支氣管播散性結(jié)核的某些臨床及影像學(xué)特點對兩者具有一定的鑒別價值，但仍存在相當(dāng)大的交叉，因此當(dāng)鑒別困難時，有時為明確診斷，有必要采取有創(chuàng)性組組織學(xué)活檢。 第三部分CT對彌漫性泛細(xì)支氣管炎療效評價的價值 目的：探討CT對DPB患者病情評估及治療后療效評價的價值。 材料與方法：評價43例DPB病人阿奇霉素治療前和治療后6個月7項CT評分和肺功能參數(shù)之間的關(guān)系。 結(jié)果：1、43例均可見小葉中心結(jié)節(jié)及支氣管擴(kuò)張。37例（86.05%）小葉中心結(jié)節(jié)分布范圍廣泛，評分為3分，6例（13.95%）評分為2分。19例（44.19%）支氣管擴(kuò)張范圍廣泛，評分為3分，另外7例（16.28%）為2分，17例（39.53%）為1分。5例（11.63%）為重度支氣管擴(kuò)張（評分為3分），7例（16.28%）為中度支氣管擴(kuò)張（評分為2分），其余31例（72.09%）為輕度支氣管擴(kuò)張（評分為1分）。38例（88.37%）伴支氣管壁增厚。35例（81.39%）見粘液栓塞。31例（72.09%）可見空氣潴留。肺不張或?qū)嵶円娪?0例（46.51%）。阿奇霉素治療前CT評分總分由7項累計計算得出，總分為10.53±4.56分。2、阿奇霉素治療后，CT評分與治療前相比可見顯著下降（p0.01）。在各項CT征象評分中，治療后小葉中心結(jié)節(jié)、支氣管擴(kuò)張和粘液栓塞的范圍，以及支氣管壁增厚程度顯著降低（小葉中心結(jié)節(jié)，p0.01；支氣管擴(kuò)張，p0.01；粘液栓塞，p=0.016；支氣管壁增厚，p0.01）。然而，支氣管擴(kuò)張程度在治療前后無顯著差異，另外，肺氣腫和空氣潴留、不張和實變治療后也無顯著改善。3、治療后FVC%、FEV1%、PaO2均可見顯著提高（FVC%,71.05±18.64～87±21.01，p0.01；FEV1%,58.72±18.19～73.58±19.85，p0.01；PaO2，70.00±5.88～84.42±10.81mmHg, p0.01）。4、治療前CT評分與FVC%（r=-0.743,p0.01）、 FEV1%（r=-0.723,p0.01）、 PaO2（r=-0.469,p0.01）均有顯著的相關(guān)性。治療后小葉中心結(jié)節(jié)△CT評分與△FVC%（r=-0.683,p0.01）、△FEV1%（r=-0.579,p0.01）具有顯著相關(guān)性。 結(jié)論：CT評分可有效評價DPB病人氣道病變的嚴(yán)重程度，阿奇霉素治療后小葉中心結(jié)節(jié)、支氣管壁增厚及粘液栓塞為可逆性病變，肺野中心區(qū)支氣管擴(kuò)張為不可逆病變，小葉中心結(jié)節(jié)的變化是DPB患者治療后肺功能改善的主要因素，可利用CT對DPB進(jìn)行分期、指導(dǎo)治療、評估療效及隨訪。
[Abstract]:CT diagnosis of diffuse bronchiolitis in the first part
Objective: to improve the CT diagnosis and differential diagnosis of diffuse bronchiolitis.
Materials and methods: a retrospective analysis of the CT manifestations of 92 cases of diffuse bronchiolitis in our hospital from 2001 to 2011.
Results: 1 lesions: 84 cases showed diffuse distribution, including 82 cases with double lung and peripheral lung significantly, only 2 cases of lung lesions than in Ueno significantly lower lung field, 6 cases showed double lung field scattered and patchy in distribution, 2 cases were confined to the lower lung leaf.2, CT signs of the 92 cases showed small round centrilobular nodules, nodules in the bronchial vascular branches are top, pleura, pulmonary vein, pulmonary vein or bronchial extralobular (i.e. the secondary pulmonary lobule boundary) surrounded, and these structures are about 2 ~ 3mm; granular nodules, a diameter of about 1mm no, blurry edge, fusion; visible nodules with proximal bronchi into linear opacities connected, there was a tree in bud; the bronchiolar dilatation in 68 cases, tubular or varicose vein dilation, 10 patients with large cystic bronchiectasis, with irregular wall thickening, outside the scope of the secondary pulmonary lobule branch Bronchiectasis and bronchial wall thickening is common around airway dilation than proximal obviously in the lung in 35 cases with prominent dilated bronchial mucus visible embolism, CT showed tubular and branching density; the 58 cases showed peripheral air retention, performance for the surrounding lung touliangdu wild in different degrees increased brightness of peripheral lung region and the central region have obvious difference, namely the peripheral area of low density in the narrow window shows more obvious. Although no clear demarcation line between the two is visible, but the subpleural region in the HRCT is almost translucent shadow in 42 cases; the patchy shadow in the lung was. Scattered, irregular shape, edge, internal uneven density, some visible bronchial inflatable shadow, 3 cases with right middle lobe atelectasis, 1 cases of left lobe atelectasis; the cavity in 3 cases, all the other: thin-walled cavity; interstitial pulmonary fibrosis Of the 9 cases, mainly in the lung by the bottom, as the cable video and irregular grid shadow, pulmonary hypertension (pulmonary artery diameter 27mm) 8 cases, mediastinum, 18 cases of enlarged lymph nodes of lung door part, 6 cases with calcification, pleural thickening in 17 cases, including 1 cases with left pleural effusion, 1 cases of lung cancer complicated with thymoma and the relationship between.3, CT classification and clinical stages: CT type I type in clinical staging in 1 patients, type II in 2 patients, type III or type IV in 2 or 3 patients.
Conclusion: CT is an important basis for the diagnosis of diffuse bronchiolitis and it is helpful for differential diagnosis.
The clinical CT comparison of diffuse bronchiolitis and bronchoalveolar tuberculosis in the second part
Objective: to improve the differential diagnosis of DPB and bronchoalveolar tuberculosis, in order to reduce the misdiagnosis and mistreatment rate of DPB and improve the prognosis of the patients.
Materials and methods: the clinical CT characteristics of 92 cases of DPB patients and 122 cases of bronchial disseminated tuberculosis were compared and analyzed in our hospital.
Results: DPB and TB with age (47.51 + 16.17 vs50.58 + 16.76, P=0.820), gender (47.83%vs45.90%, P=0.780) showed no significant difference. The rate of DPB in patients with sinusitis was significantly higher than that of TB (78.26%vs5.73%, P0.001). The main symptoms of two cases were cough, sputum hemoptysis is also more. In DPB and TB, there was significant difference between the two groups (29.35%vs25.41%, P=0.521) and exertional dyspnea (96.74%vs19.67%, P0.001) and coarse rales (100%vs36.89%, P0.001) is more common in patients with DPB.DPB patients peripheral blood WBC count and immunoglobulin IgA levels were significantly higher in patients with pulmonary tuberculosis. Pulmonary function tests FEV1/FVC 70% or 80mmHg, PaO2 higher proportion of patients in DPB. Chest CT of all patients with DPB lesions were bilateral distribution, and bilateral distribution of pulmonary tuberculosis in 84.43%, the difference was statistically significant (P < 0. 001) CT. The most common symptoms in patients with pulmonary tuberculosis and DPB are bronchiolitis and bronchiolectasis. However, in the range of lesions, DPB were more widely distributed. Compared with TB, DPB patients with bronchiolitis and bronchiolectasis involving more lobes (5.11 + 1.13vs3.83 + 1.62, P < 0.001; 4.72 + 1.44vs1.76 + 0.45, P < 0.001) of.DPB patients with bronchiolitis and bronchiolectasis more involving both lower lobe, right middle lobe and left lobe, while TB is more common in upper lobe and lower lobe of right lung. Lung patchy shadow and cavity is more common in patients with TB (87.70%vs45.65%, P < 0.001; 80.33%vs3.26%, P < 0.001).
Conclusion: some clinical and imaging features of DPB and bronchogenic disseminated tuberculosis have certain differential value for both. However, there still exist considerable crossover. Therefore, when identifying difficulties, it is sometimes necessary to make a definite diagnosis. It is necessary to take invasive histologic biopsy.
The value of the third part CT for the evaluation of the curative effect of diffuse bronchiolitis
Objective: To explore the value of CT in evaluating the patient's condition of DPB and evaluating the curative effect after treatment.
Materials and methods: the relationship between 7 CT scores and pulmonary function parameters before and after treatment with azithromycin in 43 DPB patients and 6 months after treatment was evaluated.
緇撴灉錛

本文編號：1590194