内科胸腔镜对不明原因胸腔积液的诊断价值
摘要
研究目的：
探讨内科胸腔镜检查对经常规检查仍不能明确病因的胸腔积液患者的诊断价值,明确引起胸腔积液的疾病谱,比较不同原因胸腔积液的胸腔镜下表现差异,并探讨内科胸腔镜检查的安全性。
方法：
回顾性分析2011年10月至2012年10月期间,共计约1年时间,在山东省立医院呼吸科住院的胸腔积液患者的临床资料,共计104例。男59例,年龄在18-80岁之间。平均年龄51.1岁。所有患者经常规检查仍未明确病因且己行内科胸腔镜检查。所选取的患者需满足的条件：(1)结合患者临床表现及胸部CT示胸腔积液；(2)经常规检查,包括胸水常规、胸水生化、肿瘤标志物(CEA)及脱落细胞学检查等,仍未能明确病因。但分析胸腔积液性质,考虑为渗出性积液患者；(3)均完善血常规、凝血常规、病毒系列、心电图、肺功能等检查,无明显内科胸腔镜检查术禁忌症；(4)所有患者签署知情同意书后行内科胸腔镜检查。在胸腔镜术中监护Sa02、血压、脉搏及呼吸变化,评估手术安全性。对胸腔积液行内科胸腔镜检查患者的临床资料、镜下表现及病理结果等进行描述性统计分析,分析其一般情况、临床表现、镜下表现及病理结果的特点。其中观察指标记录不完整者该项指标不列入统计分析。采用SPSS18.0软件包进行数据分析。计量资料以均数±标准差(x±s)描述,计数资料以百分数(%)描述,并对部分数据进行显著性差异分析。
结果：
1.104例胸腔积液患者病理组织活检结果如下：(1)确诊恶性肿瘤72例(69.2%),其中原发于胸膜的间皮瘤14例(13.5%),胸膜转移瘤58例(55.8%)。(2)炎症共计29例(27.9%),其中结核性胸膜炎24例(23.1%),慢性非特异性炎症2例,化脓性胸膜炎3例。最终有诊断不明的患者3例(2.9%)。胸腔积液病理诊断率为97.1%。肿瘤性和结核性积液病理诊断率为92.3%。恶性胸腔积液组织压片查到癌细胞的占42例,诊断率为65.6%。
2.观察两组进行胸腔镜检查后良性积液与恶性积液的镜下表现。良心积液以结核性胸膜炎为主,主要表现为胸膜均匀的充血和水肿,小结节状或粟粒状结节,胸膜腔粘连程度较重,无明显白斑。而恶性积液组的胸膜表现为不均匀增厚或明显的粗糙肿胀,胸膜上可见明显结节,主要为大的结节或肿块状的突起。部分结节融合成团,如葡萄状,卵石状或是菜花状。肿瘤组约1／3的情况下,白斑样变化明显,而胸膜粘连程度相对较轻。
3.胸腔镜检查术中所有患者均耐受性好,术后有皮下气肿、发热、切口术后疼痛及复张性肺水肿等均可发生,发生率均较低,无需特殊处理,无严重并发症发生。
结论
1.内科胸腔镜诊断率高,大大提高了胸腔积液的诊断的精确性,为治疗提供病理依据。
2.此次研究中显示引起胸腔积液的常见原因为恶性肿瘤与结核。在总体上恶性的占首位,前两位分别是肺癌和恶性胸膜间皮瘤,除此之外来自乳腺、消化道、甲状腺、胸腺、淋巴结等。
3.良性与恶性积液的颜色、镜下表现有明显差异。由此,我们可根据病变大体形态特征、分布范围等对病变进行初步的定性判断。
4.胸腔镜检查术前准备、术中、术后无严重并发症发生,且术中、术后疼痛、发热、皮下气肿发生率低且程度较轻,故该检查安全性高。
Objective:To investigate Medical Thoracoscopy's diagnostic value in patients with pleural effusion,who are still not clear after routine examination.And get a clear cause of pleural effusion disease spectrum, at the same time compare the thoracoscopic performance differences in different causes of pleural effusion. And also investigate Safety department of Medical Thoracoscopy.
Methods:Retrospective analysis of patients'clinical data, who with pleural effusion in the Department of Respiratory Medicine in Shandong Provincial Hospital hospital, from October2011to October2012, a total of104cases.59cases are male and other are females, ranged18～80years. Average age is51.1years old. All patients by routine examination not yet clear cause and line of medical thoracoscopy. The patients need to meet the conditions:(1) Clinical manifestations and chest CT show pleural effusion;(2) All patients do routine examination, including pleural effusion conventional, pleural effusion chemical, tumor markers(CEA), and cytological examination, yet have not clear cause. But analysis of the nature of pleural effusion, consider exudative effusion;(3) All patients improve blood routine examination, Coagulation routine, virus check, ECG, lung function and other tests, no one show significant medical thoracoscopy surgery contraindications;(4) All patients sign informed consent underwent medical thoracoscopy. Care SaO2, blood pressure, pulse and respiration in the operation to assess the safety.Statistical analysis of clinical data, endoscopic and pathological results and analysis of the general situation, the clinical manifestations of the characteristics of endoscopic and pathological results. Use SPSS18.0software packages for data analysis. Measurement data were described as mean±standard deviation (x±s), count data described in percentage (%).Do ignificant difference on the part of the data analysis.
Result:
1.104cases of pleural effusion in patients with pathological biopsy results are as follows:(1) diagnosis of malignant tumors in72cases (69.2%), one of the primary pleural mesothelioma in14cases (13.5%), pleural metastases in58patients (55.8%).
(2) inflammation of a total of29cases (27.9%), including24cases of tuberculous pleurisy (23.1%),2cases of chronic non-specific inflammation, purulent pleurisy three cases. Final3cases (2.9%) of patients with unknown diagnosis. Pleural effusion pathological diagnosis was97.1%. Neoplastic and tuberculous effusion pathological diagnosis was92.3%. Malignant pleural effusion organizations tablet found in cancer cells accounted for42cases, the diagnosis was65.6%.
2.Benign effusion and malignant effusion Endoscopic findings were observed after thoracoscopy. Conscience effusion tuberculous pleurisy based, mainly for the a uniform pleural congestion and edema, small nodular or miliary nodules, heavier degree of adhesion of the pleural cavity, no significant leukoplakia. Malignant pleural effusion performance rough uneven thickening or obvious swelling visible on the pleural nodules significantly, mainly for large nodule or mass-like protrusions. Some nodules integration into the group, such as grape-like, pebble-like or cauliflower-like. Oncology Group about1/3of the case the alphoid changed significantly, and degree of pleural adhesions relatively light.
3. All patients were well tolerated in operation. Subcutaneous emphysema, the fever, incision postoperative pain and the re-expansion pulmonary edema can occur, but the incidence rate is low,and no special treatment.And no serious complications occur.
Conclusion:
1. The medical thoracoscopy has high diagnosis rate,and greatly improve the accuracy of the diagnosis of pleural effusion,it gets pathological basis for the treatment.
2.This study shows the patients with pleural effusion caused by the common cause are cancer and tuberculosis. Vicious in general accounted for the first, the first two are lung cancer and malignant pleural mesothelioma, in addition from the breast, digestive tract, thyroid, thymus, and lymph nodes.
3Benign and malignant effusion color, endoscopic findings are significantly different. Thus, we can according to the lesion gross morphological characteristics, distribution and other lesions a preliminary qualitative judgments.
4.Before in snd after the operation,there are no serious complications.And intraoperative, postoperative pain, fever, subcutaneous emphysema have low incidence and to a lesser extent, so that the operation is safe.
探讨内科胸腔镜检查对经常规检查仍不能明确病因的胸腔积液患者的诊断价值,明确引起胸腔积液的疾病谱,比较不同原因胸腔积液的胸腔镜下表现差异,并探讨内科胸腔镜检查的安全性。
方法：
回顾性分析2011年10月至2012年10月期间,共计约1年时间,在山东省立医院呼吸科住院的胸腔积液患者的临床资料,共计104例。男59例,年龄在18-80岁之间。平均年龄51.1岁。所有患者经常规检查仍未明确病因且己行内科胸腔镜检查。所选取的患者需满足的条件：(1)结合患者临床表现及胸部CT示胸腔积液；(2)经常规检查,包括胸水常规、胸水生化、肿瘤标志物(CEA)及脱落细胞学检查等,仍未能明确病因。但分析胸腔积液性质,考虑为渗出性积液患者；(3)均完善血常规、凝血常规、病毒系列、心电图、肺功能等检查,无明显内科胸腔镜检查术禁忌症；(4)所有患者签署知情同意书后行内科胸腔镜检查。在胸腔镜术中监护Sa02、血压、脉搏及呼吸变化,评估手术安全性。对胸腔积液行内科胸腔镜检查患者的临床资料、镜下表现及病理结果等进行描述性统计分析,分析其一般情况、临床表现、镜下表现及病理结果的特点。其中观察指标记录不完整者该项指标不列入统计分析。采用SPSS18.0软件包进行数据分析。计量资料以均数±标准差(x±s)描述,计数资料以百分数(%)描述,并对部分数据进行显著性差异分析。
结果：
1.104例胸腔积液患者病理组织活检结果如下：(1)确诊恶性肿瘤72例(69.2%),其中原发于胸膜的间皮瘤14例(13.5%),胸膜转移瘤58例(55.8%)。(2)炎症共计29例(27.9%),其中结核性胸膜炎24例(23.1%),慢性非特异性炎症2例,化脓性胸膜炎3例。最终有诊断不明的患者3例(2.9%)。胸腔积液病理诊断率为97.1%。肿瘤性和结核性积液病理诊断率为92.3%。恶性胸腔积液组织压片查到癌细胞的占42例,诊断率为65.6%。
2.观察两组进行胸腔镜检查后良性积液与恶性积液的镜下表现。良心积液以结核性胸膜炎为主,主要表现为胸膜均匀的充血和水肿,小结节状或粟粒状结节,胸膜腔粘连程度较重,无明显白斑。而恶性积液组的胸膜表现为不均匀增厚或明显的粗糙肿胀,胸膜上可见明显结节,主要为大的结节或肿块状的突起。部分结节融合成团,如葡萄状,卵石状或是菜花状。肿瘤组约1／3的情况下,白斑样变化明显,而胸膜粘连程度相对较轻。
3.胸腔镜检查术中所有患者均耐受性好,术后有皮下气肿、发热、切口术后疼痛及复张性肺水肿等均可发生,发生率均较低,无需特殊处理,无严重并发症发生。
结论
1.内科胸腔镜诊断率高,大大提高了胸腔积液的诊断的精确性,为治疗提供病理依据。
2.此次研究中显示引起胸腔积液的常见原因为恶性肿瘤与结核。在总体上恶性的占首位,前两位分别是肺癌和恶性胸膜间皮瘤,除此之外来自乳腺、消化道、甲状腺、胸腺、淋巴结等。
3.良性与恶性积液的颜色、镜下表现有明显差异。由此,我们可根据病变大体形态特征、分布范围等对病变进行初步的定性判断。
4.胸腔镜检查术前准备、术中、术后无严重并发症发生,且术中、术后疼痛、发热、皮下气肿发生率低且程度较轻,故该检查安全性高。
Objective:To investigate Medical Thoracoscopy's diagnostic value in patients with pleural effusion,who are still not clear after routine examination.And get a clear cause of pleural effusion disease spectrum, at the same time compare the thoracoscopic performance differences in different causes of pleural effusion. And also investigate Safety department of Medical Thoracoscopy.
Methods:Retrospective analysis of patients'clinical data, who with pleural effusion in the Department of Respiratory Medicine in Shandong Provincial Hospital hospital, from October2011to October2012, a total of104cases.59cases are male and other are females, ranged18～80years. Average age is51.1years old. All patients by routine examination not yet clear cause and line of medical thoracoscopy. The patients need to meet the conditions:(1) Clinical manifestations and chest CT show pleural effusion;(2) All patients do routine examination, including pleural effusion conventional, pleural effusion chemical, tumor markers(CEA), and cytological examination, yet have not clear cause. But analysis of the nature of pleural effusion, consider exudative effusion;(3) All patients improve blood routine examination, Coagulation routine, virus check, ECG, lung function and other tests, no one show significant medical thoracoscopy surgery contraindications;(4) All patients sign informed consent underwent medical thoracoscopy. Care SaO2, blood pressure, pulse and respiration in the operation to assess the safety.Statistical analysis of clinical data, endoscopic and pathological results and analysis of the general situation, the clinical manifestations of the characteristics of endoscopic and pathological results. Use SPSS18.0software packages for data analysis. Measurement data were described as mean±standard deviation (x±s), count data described in percentage (%).Do ignificant difference on the part of the data analysis.
Result:
1.104cases of pleural effusion in patients with pathological biopsy results are as follows:(1) diagnosis of malignant tumors in72cases (69.2%), one of the primary pleural mesothelioma in14cases (13.5%), pleural metastases in58patients (55.8%).
(2) inflammation of a total of29cases (27.9%), including24cases of tuberculous pleurisy (23.1%),2cases of chronic non-specific inflammation, purulent pleurisy three cases. Final3cases (2.9%) of patients with unknown diagnosis. Pleural effusion pathological diagnosis was97.1%. Neoplastic and tuberculous effusion pathological diagnosis was92.3%. Malignant pleural effusion organizations tablet found in cancer cells accounted for42cases, the diagnosis was65.6%.
2.Benign effusion and malignant effusion Endoscopic findings were observed after thoracoscopy. Conscience effusion tuberculous pleurisy based, mainly for the a uniform pleural congestion and edema, small nodular or miliary nodules, heavier degree of adhesion of the pleural cavity, no significant leukoplakia. Malignant pleural effusion performance rough uneven thickening or obvious swelling visible on the pleural nodules significantly, mainly for large nodule or mass-like protrusions. Some nodules integration into the group, such as grape-like, pebble-like or cauliflower-like. Oncology Group about1/3of the case the alphoid changed significantly, and degree of pleural adhesions relatively light.
3. All patients were well tolerated in operation. Subcutaneous emphysema, the fever, incision postoperative pain and the re-expansion pulmonary edema can occur, but the incidence rate is low,and no special treatment.And no serious complications occur.
Conclusion:
1. The medical thoracoscopy has high diagnosis rate,and greatly improve the accuracy of the diagnosis of pleural effusion,it gets pathological basis for the treatment.
2.This study shows the patients with pleural effusion caused by the common cause are cancer and tuberculosis. Vicious in general accounted for the first, the first two are lung cancer and malignant pleural mesothelioma, in addition from the breast, digestive tract, thyroid, thymus, and lymph nodes.
3Benign and malignant effusion color, endoscopic findings are significantly different. Thus, we can according to the lesion gross morphological characteristics, distribution and other lesions a preliminary qualitative judgments.
4.Before in snd after the operation,there are no serious complications.And intraoperative, postoperative pain, fever, subcutaneous emphysema have low incidence and to a lesser extent, so that the operation is safe.
引文
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[1]谢灿茂,唐可京.胸腔积液的诊断与鉴别诊断—呼吸系统疾病(12).新医学.2006.(11)：759-761.
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[4]徐文亭.胸水pH测定对结核性与恶性胸水鉴别诊断意义讨论.临床检验杂志,1988,6(3)：161
[5]Conde MB, Loivos AC, Rezenda VM, et al. Yield of sputum in duction in diagnosis of pleural tuberculosis [J]. Am J Respir Crit Care Med,2003,167:723-725.
[6]彭巧丽结核性胸腔积液的诊治进展J ournal of Pathogen B iology.2008 J ul; 3 (7):543-545.
[7]吴秋玲,徐永健,张珍祥,等.结核性与恶性胸腔积液中的白介素和Y干扰素的变化[J].中华结核和呼吸杂志,2000,23(1)：8.
[8]Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy:a direct comparative study [J]. Eur Respir J,2003,22:589-591.
[9]Tsiouris A,Walesby RK. Malignant p leural mesothelioma:current concepts in treatment [J]. Nat Clin Pract Oncol,2007,4(6):344-352.
[10]Robinson BW,Musk AW, Lake RA. Malignant mesothelioma [J].Lancet,2005, 366 (9483):397-408.
[11]王小震,李宁,王绿化,等.恶性胸膜间皮瘤的临床研究进展[J].癌症进展杂志,2006,4(1)：20-26.
[12]Matchaba PT, Volmink J. Steroids for t reating tuberculous pleurisy[J]. Cochrane Database System Review,2000, (2):CD001876.
[13]林强,周允中,孙德魁,等.胸膜间皮瘤的诊断和治疗[J].上海医学,1996,19(7)：416
[14]Nagesh BS, Sehgal S, Jindal SK, et al. Evaluation of polymerase chain reaction for detection of Mycobacterium tuberculosis in pleural fluid [J]. Chest,2001,119 (6):1737-1741.
[15]蒙佳莲.朱应康.黄明锋.雷权.赵海滨.吕金鑫胸腔积液性质鉴别实验室诊断研究进展[期刊论文]-医学信息(下旬刊)2011,24(1)
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[17]Ferrer J;Roldan J;Teixidor J Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy[外文期刊] 2005
[18]Conde MB, Loivos AC, Rezenda VM, et al. Yield of sputum induction in diagnosis of pleural tuberculosis [J]. Am J Respir Crit Care Med,2003, 167:723-725.
[19]吕鹏.张良明.耿冬梅.刘云波.刘丹萍良恶性胸腔积液鉴别诊断的研究进展[期刊论文]-实用心脑肺血管病杂志2011,19(5)
[20]黄晓英.余世庆.李丹奇.张祖贻纤维支气管镜在胸膜疾病诊断中的应用价值[期刊论文]-中国内镜杂志2007(2)
[21]张新华,徐海洋.65例恶性间皮瘤诊治分析[J].中国肿瘤临床,2001,28(1)：69-70
[22]李永怀；祝杨；王勋伟胸腔镜检查诊断不明原因的胸腔积液临床分析[期刊论文]-临床肺科杂志2009(10)
[23]Sharma SK, Banga A. Pleural fluid interferon2γ and adenosine deaminase levels in tuberculosis pleural effusion:a cost effectiveness analysis[J]. J Clin Lab Anal,2005,19:40-46.
[24]刘海涛胸腔积液生化诊断指标及临床意义[期刊论文]-医学综述2003,9(8)
[25]Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax:state of the art. Eur Respir J.2006;28:637-50.
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[30]马龙艳,孙昕,梁春宝,等.内科胸腔镜对不明原因胸腔积液患者的诊断评价.[J]中国内镜杂志,2009,15(12)：1320—2.
[31]Ishida A, Iwamoto Y, Miyazu Y, et al. Diagnosis of tuberculous pleurisy using a flexirigid thoracoscope [J]. J Bronchology,2004,11 (1):29-31.
[32]李月翠.周晶.李成行精细活检针在结核性胸膜炎诊断中的应用价值[期刊论文]-中华临床感染病杂志2010(1)
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