pp bimbingan koas toraks patologis dr. prim
TRANSCRIPT
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TORAKS PATOLOGIS
dr. Prim Ardianta B
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Deskripsi Kelainan RADIO OPAQUE
• Pebercakan (patchy)– Bercak/noda keras – Infiltrat/Bercak
lunak • Nodul
– Besar : 2-3 cm– Kecil : 0,5-2 cm– Halus/Milier : <0,5
• Massa– Ukuran > 3 cm
• Perselubungan / Konsolidasi– Fluffy– Cloudlike– Hazy
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Expertise
• Cor tidak membesar• Sinuses dan diafragma kanan/kiri normal• Pulmo:
– Hili normal– Corakan bronkovaskuler normal– Tidak tampak bercak lunak
Kesan :- Tidak tampak TB paru/kelainan paru lainnya
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PNEUMONIA
• Inflamasi parenkim paru oleh mikroorganisme– Alveoli– Interstitiel– Keduanya
• Inflamasi parenkim paru oleh sebab lainpneumonitis
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• Klasifikasi radiologis menurut Heirzman :– Lobaris– Lobularis (Bronkopneumonia)– Interstitiel
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Gambaran Radiologi
• Bayangan opak homogen• Air bronchogram (+)• Segmental • Tidak ada penarikan jaringan sekitar• Volume tetap
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Pneumonia Lobaris Kanan
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BRONKHOPNEUMONIA
• Bercak infiltrat/lunak trutama di lapangan bawah paru bisa disebut juga pneumonia infiltrat / mengenai segmen kecil (beberapa alveolus ) / Atypical pneumonia seperti pada SARS/Flu Burung
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Bronkhopneumonia Kanan
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ABSES PARU
• Bayangan bulat dinding tebal • Air fluid level• Tidak ada jaringan granulasi di dalamnya • Jaringan infiltrat di sekitarnya• Paling sering di lapangan bawah paru
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Abses Paru Kiri
Air fluid level
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Abses Paru Kiri
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TUBERCULOSIS PARU
Lesi primer biasanya terletak di jaringan interstitiel paru lobus medius atau inferior bagian tepi dekat pleura atau dekat hilus.
Lesi primer terjadi pada infant atau anak-anakLesinya berupa konsolidasi dlm milimeter menyebar
ke kelenjar hiler via vasa lymphatic.Pembesaran kelenjar lebih dominan, dapat berlanjut
dengan sembuh, kalsifikasi atau fibrosis bahkan penyebaran systemik.
Lesi primer : Ghon focusGhon focus – kelenjar : Primer complex
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Primary Infection
Tb pneumoniaFibrosisFibrocaseation
Miliary spreadEncapsulationcavitation
Primary complex
Hilar lymph nodeshomolateral
RecedesFibroticcalcified
Spread widely
TB pneumoniaMiliary
Caseation
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TB post primer
• Predileksi di lobus superior atau semen apical lobus inferior, jarang ada lymphadenopathy, cenderung pembentukan cavitasi
• Manifestasi radiologik :–Parenchymal disease dan
cavitasi–Airway disease–Pleural disease–Komplikasi lainnya
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Manifestasi RadiologikTB primer
1.Konsolidasi parenchymal.2.Atelectases.3.Lymphadenopathy.4.Pleural effusion.5.Penyebaran milier TB paru primer di Indonesia hampir selalu pada anakDi negara maju dapat terjadi pada orang dewasa
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Ada 5 macam kelainan radiologik :
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GAMBARAN RADIOLOGI
• Bercak lunak /perselubungan tipis seperti awan
• Pembesaran kelenjar hilus terutama pada anak-anak
• Garis fibrosis, garis-garis keras ,noda keras, opak padat bulat /tuberculoma
• Cavitas• Schwarte
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Lymphadenopathy
Hallmark of primary TBHilar – paratracheal - sub carinal – aortopulmonal –
mediastinalUnilateral – sebelah kanan – bilateral (31%)96% pada anakMenurun dengan bertambahnya umur49% usia 3 tahun, 9% usia 14 tahun, sangat jarang
pada usia dewasaDapat bersamaan dengan lesi kosolidasi
parenchymal dan atelectaseKompresi trachea, VCS syndrome, kompresi
oesophagus , fistulasi, pericarditisPemeriksaan CT scan utk lesi tersembunyi /sub
carinal (Moon dkk,1997) 19
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TB milier
1 – 7% kasusPenyebaran hematogenSering pada TB primerManifest setelah 6 bulan infeksi primerAnak < 2 tahun, dewasa, immunocompromisedKarakteristik berupa fine nodular - diffuse
distribution dan dapat berlanjut menjadi konsolidasi diffus - ARDS
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Conclusion
Radiologic feature of primary tuberculosis
– parenchymal disease (consolidation)– Lymphadenopathy (the hallmark)– pleural effusion
– miliary disease – atelectasis, which may be either lobar
or segmental The hallmark of primary tuberculosis
is hilar or mediastinal adenopathy21
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TBC Paru
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TBC Paru dengan cavitas
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PPOK
• Bronchitis Khronis• Corakan retikuler paru bertambah • Cuffing Sign • Trem Line
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Bronchitis Kronis dengan Bronchiectasi
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EMFISEMA PARU
• Hyperaerasi kedua paru• Barel Chest• Corakan bronchovasculer berkurang
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Emfisema Pulmonum
Bentuk jantung “tear drop”
ICS melebar
Diafragma mendatar
Hiperaerasi paru
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ASMA BRONCHIALE
• Dalam serangan ,kedua paru hyper lusen • Tidak dalam serangan, bisa normal atau
gambaran bronchitis khronis
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BRONCHIECTASIS
• Bayangan retikuler yang membentuk gambaran seperti sarang tawon ( Honey comb apperance )
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Bronchiectasis
Honeycomb appearance
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TUMOR PARU
• Primer, berupa bayangan opak padat• bentuk bulat /oval• batas tegas • Dinding bisa reguler / irreguler
(Spicula) )
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Tumor Paru Primer
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Tumor Paru Sekunder
• Bayangan opak padat bulat multipel ,coin lesion / Golf Ball
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Metastasis Intrapulmonal
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PNEUMOTHORAX
• Adanya udara dalam kavum pleura• Normal : tidak boleh ada udara
Pleura :• Parietal pleura : Lines chest wall, mediastinal
and diaphragmatic surfaces• Visceral pleura : Lines lungs, fissures
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Parietal Pleura
Visceral pleura
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Gambaran Radiologi
• Bayangan lusen tanpa corakan paru • Pleural sign ( pleura viceralis )• Pendorongan paru kolaps lihat adanya
crowded dari corakan bronchovasculer.
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Pneumothorax Kanan
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Pneumothorax Kanan dan Kolaps Paru Kanan
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40154 slides
Inspiration Expiration
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Hydropneumothorax
• Bayangan lusen tanpa corakan paru disertai adanya bayangan opak padat di bawahnya membentuk air fluid level
• Pleural sign pada daerah pneumothorax
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Hydropneumothorax Kiri
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EFUSI PLEURA
• Akumulasi cairan dalam rongga pleura dengan jumlah yang abnormal
• Normal : 1-20 cc• Dihasilkan pleura parietalis dan
diabsorbsi pleura viseralis
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Etiologi
• Etiologi terbanyak di Indonesia disebabkan oleh TBC
• Pada TBC, efusi timbul apabila telah terjadi penyebaran secara hematogen atau limfogen
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Patofisiologi
• Keadaan yang menyebabkan peningkatan tekanan hidrostatik pembuluh darah
• Penurunan tekanan onkotik koloid• Peningkatan tekanan negatif rongga pleura• Gangguan drainase limfatik• Peningkatan permeabilitas kapiler, serta• Ruptur pembuluh darah/pembuluh limfe
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Efusi Pleura
Upright:Meniscus
Decubitus:Effusion layered on downside
Lateral:blunted posterior sinus
• Sensitivitas:– Lateral decubitus>Lateral>PA
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47154 slides
Efusi Pleura Minimal
Normal:Sharp Angles
Blunted posterior costophrenic sulcus 47
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48154 slides
Efusi Pleura
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49154 slides
Lateral Decubitus
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50154 slides
Pleural Effusion in Supine Patient
• Pleural effusion layers posteriorly in a supine position
• Cause diffuse increased density
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Loculated Pleural Effusion
63-year-old man recovering from congestive heart failure: Effusion loculated in fissure
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ATELEKTASIS
• Berkurangnya udara dalam sebagian atau seluruh paru
• Ditandai dengan alveolus yang tidak mengandung udara
• Pada foto toraks tampak peningkatan densitas (“white”) paru yang terserang
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Etiologi
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Obstruksi
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Obstruksi
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Non Obstruksi
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Patofisiologi
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Patofisiologi
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Patofisiologi
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Gejala klinis
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Gambaran radiologi
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Tanda langsung
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Tanda tidak langsung
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Atelektasis Lobaris
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Atelectasis
Loss of lung volume
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Right upper lobe atelectasis
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Right middle lobe atelectasis
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Lateral view:
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RLL Atelectasis:
Triangular opacity in right lower hemithorax. The lateral border is the major fissure (not normally seen on frontal view). Right hilum is displaced caudally and partially obscured. The hyperexpanded RML outlines the cardiac border and right hemidiaphragm.
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Left upper lobe atelectasis: Opacity contiguous to the aortic arch. The mediastinum is shifted toward the left hemithorax, which is small in comparison to the right. The main pulmonary trunk and the left pulmonary artery are obliterated.
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Left upper lobe atelectasis in patient with incomplete major fissure: There is an ill-defined opacity in the left half of the left upper thorax. The trachea is deviated left and the left hilum is retracted superiorly. Vascular branches to the left lower lobe superior segment form an array of linear and tubular opacities. The arrow shows a vertical lucency separating the aortic arch from the vertical margin of the collapsed lobe (Luftsichel).
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LLL Atelectasis:
Notice the wedge shaped opacity behind the cardiac silhouette. The border is formed by the major fissure (arrow). The left hilum is partially obscured and displaced caudally. The left upper lobe is hyperexpanded accounting for the increased lucency in the left hemithorax.
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Complete left lung atelectasis: There is mediastinal displacement, opacification, and loss of volume in the left hemithorax. The cardiac silhouette (which is shifted left) is obscured, as are the left hilum and left hemidiaphragm.
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Post-obstructive atelectasis of RLL: The major fissure is visible as it has rotated into view. There are no air bronchograms seen within the atelectatic region of lung. The patient is intubated. The obstruction is likely due to mucous plugging.
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KISTA PARU
• Bayangan bulat lusen • Dinding tipis• Air fluid level bila disertai infeksi sekunder
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BULLA
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Having new impression ?Any suggestion ?
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78
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Contoh Soal
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80Normal
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81Normal
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82TB Paru Aktif
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83TB post primer
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84TB Milier
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85Bronchopneumonia Kiri Bawah
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86Pneumonia Lobus Inferior Kanan
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87Atelektasis
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88Atelektasis
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89Emfisema Paru
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90Efusi Pleura Kanan
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91Efusi Pleura Subpulmonal
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92Massa Paru Kanan
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93Vanishing Tumor
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94Abses Paru Kiri
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95Pneumonia Kanan
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96Bronkhiektasis
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97Kardiomegali
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98Pneumothorax Kanan
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99Abses Paru Kanan
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100Metastasis Intrapulmonal
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101Pneumoperitoneum
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102Hidropneumothorax
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103
CHD
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104Efusi pleura kiri dengan adenopathy hiler kiri
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105Adenopathy hiler
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THANK YOU 106