curs 5 pleurezii 2011
DESCRIPTION
medicina interna-pleureziiTRANSCRIPT
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PLEUREZIILE
Revărsat lichidian în cavitatea pleurală
TRANSUDATE EXUDATE
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Pleura
Mezoteliu - celula microvili (glicoproteine, ac hialuronic)
- celula activa stimuli inflamatori : cytokine, f de
crestere schimb metabolic - ‘transcitoza’
F colagen - I, III elastina
Vase - sanguine, limfatice
- suprafata 4 m2
- lichid interpleural 0,3ml/kg-1
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1. Circulatia sanguina si limfatica pleurala
- pleura viscerala- “ circ functionala pulmonara ”
arteriole - capilare - v pulmonare
- capilar limfatic submezotelial - peribronsiolar
- - trunchi limfatic dr
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1. Circulatia sanguina si limfatica pleurala
- pleura parietala - “ circ sistemica” arteriole -
capilare -
circulatie limfatica comunica direct cu spatiul
pleural
- stomata limfatice - lacune submezoteliale, limfatice mamere,
intercostale, etc… trunchi limfatic
dr ductul limfatic
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Lichidul interpleural
- filtrat plasmatic :1700 cel/mm3
- 75% macrofage, 23% limfocite, 1% cel mezoteliale
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1. Dinamica lichidului pleural
- efuziune : capilarele pleura parietala
- resorbtie : “stomata” limfatice pleura viscerala
- forte Starling diferentele de presiune pleura parietala si viscerala
- transfer solutie lichida - “pori mici” si “pori mari” = “ cleft intercelular” - transfer macromolecule - “transcitoza”
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1. Factori responsabili de efuziunea pleurala
1 crestere efuziune : capilarele pleura parietala
2 resorbtie : “stomata” limfatice pleura viscerala
3 creste permeabilitatea capilarelor endoteliale
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PLEUREZII patogenie:
- creşterea presiunii hidrostateice capilare pleura viscerala (IC, compresie vena cavă superioară)
- scăderea presiunii coloidosmotice (hipoalbuminii)
1. TRANSUDATE
- revărsat lichidian intrapleural ce depăşeşte capacitatea de drenaj a
limfaticelor pleurale
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2. EXUDATE
- hiperpermeabilizarea membranei bazale capilare pl viscerala
(infecţii, boli autoiimune, reacţii
alergice)
- reducerea drenajului limfatic - pl parietala
- obstructie “stomata limfatice” - (invazie tumorală a pleurei, fibroză postradioterapie)
- cresterea presiunii limfatice (invazie tumorală a ganglionilor mediastinali - metastaze, limfoame)
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Epidemiologie
- 37% tuberculoza
- 2% - alte cauze
- 17% neoplazii
- 4,5% embolii pulmonare
- 15% insuficienta cardiaca
- 17% pneumonii
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1. EXUDATE
- infecţii - tuberculoase - parapneumonice (S. aureus, BGN, S. pneumoniae, L. pneumophila, M. pneumoniae)
- neoplasme - cancer bronhopulmonar, - metastaze (adenocarcinom sân, prostată, ovar, gastric,tiroidă, colon, etc),
- limfoame (Hodgkin,nonhodgkin)
- mezoteliom
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EXUDATE
- tromboembolism pulmonar
- boli tesut conjunctiv (Lupus eritmatos sistemic, PR, periarterita nodoasă)
- boli şi reacţii imune (RAA, S.Dressler, postmedicamentoase- nitrofurantoin,etc)
- afecţiuni subdiafragmatice (abces subfrenic, abces intrahepatic, pancreatită)
- alte etiologii (S. Meigs, iradiere, pneumotorax spontan, mixedem)
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2. TRANSUDATE
- insuficienţa cardiacă
- ciroză
- sindrom nefrotic
- sindrom malabsorbţie
- neoplazii - atelectazii, “plaman in capcana”
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3. Hemotorax
- posttraumatic
- tulburări de drenaj a canalului toracic sau colateralelor acestuia
4. Chilotorax
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1. Inflamatia pleurei
LPS, bacterii, trombina
mezotelii
creste permeabilitat
ea endoteliala
PMN, monocite adera la mezotelii (via CD11/CD18) si migreaza
in spatiul pleural
TNF INF
VEGF exprima ICAM exprima cadherine
contractia mezotelii
“gapuri” pleurale
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1. Mezoteliul in boli infectioase
LPS, bacterii
mezotelii
chemotaxie PMN
TNF INF, IL-1
Il- 8 MIP (macrophage inflammatory protein)
MCP1 (monocite chemoatctic protein)
pleurezii parapneumonic
e
pleurezie tuberculoasa
raspuns LTH-1 la
Mycobcterium tuberculosis
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MANIFESTĂRI CLINICE:
- durere toracică, tuse, dispnee
- depind de etiologie cantitatea exudatului
- matitate - vibraţii vocale diminuate -absenţa murmurului respirator,
suflu pleuretic -egofonie, pectorilocvie
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Rx grafia pulmonară:
- informaţii boli pulmonare asociate mediastinul
- revărst lichidian marea cavitate pleurală
Ecografia:- mai sensibilă decât Rx:
•pleureziile cu cantitate mică de lichid
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Examenul lichidului pleural:
Pleurezii neoplazice
- Serocitrin
- Hemoragic
infarct pulmonar
tuberculoza
Pleurezii + Sindr hemoragipar, trat. anticoagulante
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Examenul lichidului pleural:
TransudatDensitate
Exudat< 1016
Proteine
Proteine pleura/ser
> 1016
< 3g/dl > 3g/dl
< 0,5 > 0,5
LDH < 200 Ul > 200UI
LDH pleura/ser < 0,6 > 0,6
Colesterol < 60 mg/dl > 60mg/dl
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Examenul lichidului pleural:
proteine
glucoză
LDH
ADA (adenosindeaminaza)
- biochimic
- enzimatic
- cytikine IL 2
TNF INF,
-markeri tumoraliACE, Cyfra, Ber Ep4, EMA
Calretin, Ecadherina
ph
Amilaza 2 ( salivara)
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Examenul lichidului pleural:
- glucoza scazuta- tuberculoza
- neoplazii
- empiem- ph scazut
LDH - cerscut
ADA (adenosin deaminaza) Amilaza 2 ( salivara)
- neoplazii
- tuberculoza
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Examenul lichidului pleural:
- citologic
eozinofile - boli tes conjunctiv, - reactii alergice -neoplazii
PMN - pleurezie parapneumonică - empiem
- pneumotorax
celule atipice - pleurezie neoplazică 60% cazuri
PMN, limfocite - tuberculoza la debut
limfocite - pleurezie tuberculoasă - inf virale - neoplazii
mezotelii - transudate
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Examenul lichidului pleural:
- imunocitologie
EMA - atg membrane cel epitaliale - pozitiv adenocarcinoame - negativ mezoteliom
ACE - pozitiv carcinoame - 80%cazuri
negativ mezoteliom
Ber Ep4 - pozitiv glicoproteine cel. epiteliale
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Examenul lichidului pleural:
- bacteriologicFrotiu Gram, culturi pentru aerobi, anaerobi, Lowenstein
- pleurezie tuberculoasă - paucibacilară informaţie diagnostică prin cultură pe mediu Lowensein în < 50% cazuri
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Biopsia pleurală oarbă cu :Ac Abraham
- 72% diagnostic histologic în pleureziile tuberculoase
- 80% diagnostic imunohistochimic în pleureziile tuberculoase
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Toracoscopia medicală cu biopsie pleurală dirijată şi toracoscopia chirurgicală
asistată video:
- indicată: diagnostic etiologic nu a fost stabilit prin ex. lichid pleural şi biopsia oarbă
- tumori pleurale
- mezoteliom
- pleurezia tbc - aspect zmeuriu al pleurei parietale şi viscerale
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Dignostic clinic de pleurezie
Examen radiologic
Examen lichid pleural( biochimic, bacteriologic, citologic, etc..)
Biopsie pleurală
Toracoscopie
Biopsie pleurală dirijată cu examen histologic, imunohistochimic
CT
Biopsie pleurală dirijată
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Pleurezii parapneumonice:
- S. aureus, BGN, L. pneumophyla
- Aspergiloza, CMV, actinomicoza, nocardia, P.carinii
- M. pneumoniae, C. pneumoniae,
- SIDA - S Kaposi tuberculoza
P. carinii
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Pleurezii parapneumonice:
- cantitate mică, medie de lichid pleural- exudat serocitrin, PMN, bacteriologie pozitivă frotiu şi culturi – in 25 % cazuri
- indicator evoluţie medie-severă
-prognostic favorabil
-tratament antiinflamator
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Empiem pleural:- parapneumonic: S. aureus, BGN, anaerobi -15% - traumatisme
- lichid pleural vascos, purulent
- ph acid, glucoza <, LDH> - ph alcalin - proteus- Tratament : drenaj pleural +
antibioterapie + fibrinolitice intra pleural
- afect subdiafragmatice - CT - ingrosare pleura parietala
- toracoscopie - drenaj, toracotomie
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Pleurezii neoplazice:patogeneza
- invazia tumorala a pleurei
- metastaze gg mediastinali cu reducerea drenajului limfatic
- exudate sero - citrine sau hemoragice - 99%
- atelectazii masive
- transudate - 1 %
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Invazia neoplazica a pleurei :patogeneza
- se detaseaza din tumora
- adera si trec prin peretele vascular
-celulele maligne
- adera la pleura
Ex: la ac hialuronic al mezoteliului prin ( melanom,etc) receptori CD44 ai cel
maligne - elibereaza factori de crestere si
angiogeneza
(bFGF , VEGF)
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Pleurezii neoplazice:
- frecventa la adulti si
varstnici
-40% din totalul pleureziilor
- afebrila 1 - durere toracica, tuse uscata
Tabloul clinic
- recidivanta
- cantitate medie, mare lichid
2. - semne tumorii primare, impregnare neoplazica
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Pleurezii neoplazice
- Rx. Pulmonar:
revarsat lichidian pleural
- tumora bronhopulmonara,
- adenopatii mediastinale,
- tumora pleurala
- Ecografia, CT: aduc elemente diagnostice
pentru tumori pleurale,pulmonare
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Pleurezii neoplazice:
- lichid pleural:
exudat serocitrin1. sero-hemoragic
glicopleurie <50mg/dl
2. pH <7,30
LDH >200 u/l
INF, TNF scazute
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Pleurezii neoplazice:
- lichid pleural:
transudat neoplazic
glicopleurie <50mg/dl
pH <7,30
LDH >200 u/l, LDHpleural / LDHseric >0,6
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Pleurezii neoplazice:
- lichid pleural:
limfocite 70%, PMN 10% hematii
hematii foarte frecvente
celule atipice 40-50% cazuri
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Pleurezii neoplazice
- Biopsia oarba
- 70% diagnostica
- Pleuroscopia (asistata video)
biopsie
- 99% cazuri diagnostica
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Pleurezii neoplazice
- Tratament
- radioterpie - - polichimioterapia - limfoame, san, prostata, ovar “smal cell
carcinoma”
- evacuarea lichidului pleural
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Pleurezii neoplazice
Pleurodeza
- indicatii: - amelirarea dispneei dupa evacuarea lich pleural
- pleurezii recidivante
- pH >7,20 -
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Pleurezii neoplazice
Pleurodeza
- contraindicatii: - neamelirarea dispneei dupa
evacuarea lichidului pleural
- atelectazie masiva, - limfangita carcinomatoasa
- “plaman in capcana”
- pH >7,20 -
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Pleurezii neoplazice
Pleurodeza
- tehnica: - talc, tetraciclina,
bleomicina, etopozid, INF,
- efecte adverse
- durere, IRA (talc)
- recidiva pleurezie
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Pleurezii neoplazice
Cateterism cu drenaj cronic
- pleurodeza ineficienta
Sunt pleuro-peritoneal
- pleurodeza ineficienta
Pleurectomie parietala
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Mezoteliomul pleural:
-10-30 cazuri la 1 milion barbati
80% - industria cu expunere la azbestIncidenta
- armament, nave, conductori, mateiale de constructie
-2 cazuri la 1 milion femei
20% - fara expunere evidenta la azbest
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Patogeneza leziunilor pleurale expunere la azbest
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Mezoteliomul pleural:
2. fara expunere evidenta la azbest
- erionit - zeolith vulcanic Turcia
- silicati amorfi -
- virus simian 40
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Expunerea la azbest
-AZBESTOZA PLEURALA BENIGNA
Histologic
EPITELIAL - 50%
-MEZOTELIOMUL PLEURAL unic, multiplu
PERITONEAL,
PERICARDIC
SARCOMATOS -35%
MIXT-20%
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Mezoteliomul pleural:
- frecvent la barbati adulti sivarstnici- afebril
- durere toracica, tuse uscata
Tabloul clinic
- recidivanta
- cantitate medie lichid
- Sindr. paraneoplazic: hiperplachetoza, TEP, anemie hemolitica, ADH, hipercalcemie
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Mezoteliom pleural
- Rx. Pulmonar:
- revarsat lichidian pleural
- tumora pleurala
- Ecografia, CT: aduc elemente diagnostice
pentru tumori pleurale
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Mezoteliom:
- lichid pleural:
exudat serocitrin1. sero-hemoragic
glicopleurie <50mg/dl
2. pH <7,30
acid hialuronic >
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Mezoteliom
- lichid pleural:
limfocite 70%, PMN 10% hematii
hematii foarte frecvente
celule mezoteliale >10% in<30% cazuri
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Mezoteliom- lichid pleural:
ex. imunohistochimic
epitelial - coexpresia: vimentina,
keratina - calretinina - reactie negativa HEA
(human endothelial antigen)
sarcomatos - atc epitelioizi in sarcom pleural (human endothelial antigen)
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Mezoteliom
- Stadializare:
Std I - tumora rezecabila fara adenopatie
Std II - tumora rezecabila cu adenopatie
Std III- tumora nerezecabila
Std IV - tumora cu metstaze
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Mezoteliom- prognostic:
- 5% supravietuire la 5 ani
- mai grav in forma
sarcomatoasa - tratament:
- chirurgucal - forma epiteliala - polichimioterapie ? - INF , IL2 intrapleural
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Azbestoza pleurala benigna
- manifestare clinica:
- pleurezie serofibrinoasa
- pleuroscopie:
- ingrosare pleurala, striuri negricioase prin depunere de azbest
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Chilotorax:
- 1. Traumatic : fisuri, rupturi canal toracic - traumatisme, chirurgia intra toracica, - chirurgia esofagului
- 2. Tumoral: adenopatii mediastinale masive
- 3. idiopatic
- 4. congenital ( S Down…)
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Chilotorax:
- lichid pleural - laptos
- lipide > 400mg/dl, triglicerige, chilomicroni- colesterol pleura/ colesterol ser >1
- Tgpleura/ Tg ser >1
- limfocite
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Chilotorax:
-Tratament : drenaj chirurgical- 1 l/zi - 5 zile
- ligatura duct toracic
- pleurodeza
- dieta: trigliceride lant mediu
- sunt pleuro-peritoneal
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Pseudochilotorax:
- lichid pleural- chiliform, “ cafea cu lapte”
- colesterol pleura/ colesterol ser >1
- transformarea pleureziilor cronice
- colesterolul este “retinut “ in spatiul pleural si se transforma capacitatea de legare
de lipoproteine
- 54% pleurezii tuberculoase
- 9 % artrita reumatoida
- echinococoza hepato-pulmonara
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Pleurezii etiologie rara
-Sindrom Dressler
-Sindrom Meigs
-Pancreatita
-Medicamentoase -nitrofurantoin, aciclovir, D-
penicilamina