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1、病例(bngl)讨论第二季度外科(wik)、手术室、放射科第一页，共四十一页。病例(bngl)概况男性，41岁，因“反复间断咯血13年余，再发5个月，加重3天”入院。13年前无明显诱因咯血，起初为暗黑色血块，后为鲜红色血液，量不详，伴有轻咳，痰少，自服中药及休息后能自行止血，近2年发作减少，咯血量少，每年发作1-2次，常能自行缓解。5个月前咯血再发，量及次数较前增多，为鲜红色血液，2月前于广州医科大学第一附属医院住院诊治，考虑“肺结核后遗症”，经抗炎，止血化痰处理效果不佳，自动出院。于3天前症状加重，约一饭碗，为鲜红色血液，伴轻度头晕、心慌，伴刺激咳嗽，自觉全身发热。既往史、个人史无特殊。有吸
2、烟史，饮酒(yn ji)史。家族史无特殊。体格检查无阳性体征。第二页，共四十一页。2012年11月9日广医呼研所胸部CT+肺动脉造影示：1、肺动脉造影未见异常；2、拟左下肺前内基底段肺静脉少量附壁血栓形成；3、左上肺尖后段纤维性肺结核并含气不全。4、两上肺、右下肺背段胸膜下多发肺大泡形成。纤支镜检查：支气管粘膜充血，未见狭窄(xizhi)及占位病灶。肝胆脾胰肾彩超未见异常。第三页，共四十一页。2012年12月23日，血WBC 9.82109/L，中性粒细胞百分比78%，血红蛋白108/L，血小板正常。CRP12mg/L,ESR20mm/h。ALT35，AST29，GGT42，ALP72。GLU
3、5.6，凝血四项与D-聚体：PT（凝血酶原时间)17.7，PT/R(凝血酶原比值)1.55，PTINR（凝血酶原国际比值）1.52，Fbg1.36，TT19.0，D-聚体0.06。肾功UREA2.76，CRE84.1，UA293。痰涂片：未发现抗酸杆菌，血清肺支原体抗体（-），结核杆菌抗体（-），急诊(jzhn)胸部CT平扫加肺动脉CTA未见异常。第四页，共四十一页。经抗炎，止血处理2天效果不佳，咯血频繁，请耳鼻喉会诊，给予喉镜检查：咽喉炎。行鼻咽喉部MRI扫描未见异常。行胃镜检查未见异常。住院第三天再次行CT肺动脉造影并行肺动脉栓塞(shuns)术，术后3小时咯血仍增多，继续微泵垂体后叶素等
4、止血对症处理，住院16天出院。第五页，共四十一页。病例特点病例特点病程长，病程长，再次发作，再次发作，突然加重突然加重病情重病情重病情复杂病情复杂病史不完整病史不完整转归不明确转归不明确第六页，共四十一页。一、病例(bngl)特点1、病程长，再次发作，突然(trn)加重。中青年，男性，反复间断咯血13年余，再发5月，加重3天；2、病情重：咯血量较多，约一饭碗，为鲜红血液。3、病情复杂：缺乏阳性体征，仅胸部CT检查及血液检查阳性，发病以来缺乏明确诊断。4、病史不完整：缺乏详细治疗史、寄生虫接触史等。5、转归不明确：行CT肺动脉造影并行肺动脉栓塞术，术后3小时咯血仍增多，继续微泵垂体后叶素等止血对
5、症处理，住院16天出院。第七页，共四十一页。二、诊断(zhndun)本病初步诊断(zhndun)考虑：一、支气管内膜结核；二、左上肺纤维性肺结核；三、肺大泡；四、轻度失血性贫血；五、慢性咽喉炎。第八页，共四十一页。支持(zhch)点：1、本病主要临床表现为咯血伴低热；2、有陈旧结核的影像表现；3、CT提示肺部含气不全，考虑局部支气管有狭窄或阻塞；4、出血后CT检查肺部未见异常，考虑出血点位于左上肺含气不全区；5、再次肺动脉造影并肺动脉栓塞术后出血仍增多，考虑为支气管动脉引起的出血；6、CT示两上肺、右下肺背段胸膜下多发肺大泡形成；7、患者咯血，血红蛋白108/L；8、喉镜检查：咽喉炎。第九页，
6、共四十一页。鉴别(jinbi)诊断1、支气管扩张(kuzhng)（咯血常见，CT未提示可排除）2、肺ca（支持点：慢性咯血史、刺激性咳嗽，CT未见明确占位，但细小病变如支气管内膜CA未能排除）3、肺大泡破裂（多为胸腔内出血，CT未提示）4、血液病（少见，血液及骨髓检查未完善，暂不支持）5、肺寄生虫（未作粪便检查，CT未提示）第十页，共四十一页。116、上消化道出血(ch xi)（无消化道病史及体征，胃镜检查正常）7、循环系统病变（无消化系统病史及体征，未完善相关检查）8、免疫系统，系统性红斑狼疮（缺乏病史及体征，未作相关检查）9、先天性疾病，肺AV瘘、肺A瘤（肺A造影不支持）10、慢支肺气肿（
7、无病史及体征）第十一页，共四十一页。三、本病有何经验教训(jn yn jio xn)1、放宽思维，要把少见病、罕见病考虑进去。2、完善病史及相关检查，如循环系统、支气管动脉DSA、免疫系统、血液系统等。3、可试行诊断(zhndun)性治疗以明确诊断(zhndun)，可使用抗结核药物。4、在缺乏阳性体征时，要考虑执行相关辅助检查。第十二页，共四十一页。THANKS！第十三页，共四十一页。第十四页，共四十一页。Click to edit title styleThemeGallery is a Design Digital Content&Contents mall ThemeGallery is
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