Coass Infeksi Dan Keganasan Pada Thorax

8/10/2019 Coass Infeksi Dan Keganasan Pada Thorax

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INFEKSI DAN KEGANASAN

PADA THORAX

DEWI WIDYASARI


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PA vs. AP

PA Less stressful, better for heart

Diaphragm rounded

Caudal pulmonary vessels better visualized Better to see small amount of pleural air

AP Better for lungs

Hear appears elongated Flat diaphragmMickey Mouse ears

Better to see small amount of pleural fluid


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PA vs AP


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Right vs. Left Lateral

Right Lateral Better cardiac detail

R crus forward

See Cava go into it Left Lateral

Heart appears round

L crus forward

See Cava go past Anesthesia

Breed Differences


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Lateral View

Make a Plus sign

Bermuda triangle

Left atrium

Left Ventricle

Right Ventricle


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Thoracic and Pulmonary Vessels

Aorta

Caudal Vena Cava Cranial pulmonary

vessels Proximal third rib

Caudal pulmonaryvessels 9thrib where crosses

Veins are ventral andcentral


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The most common abnormalitie

in the thoracic cavity are:

Pneumothorax (Air)

Hydrothorax (Fluid)

Hemothorax (Blood) Chylothorax (Chyle)

Pyothorax (Pus)


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pneumothorax

Pneumothorax refers to the loss of negative

pressure in the thoracic cavity when air gains

entrance to the thorax. Most common causes:

Fractured Ribs Gunshot Wounds (See Photo)

Iatrogenic-thoracocenthesis-biopsy

Ruptured Lung

Ruptured Emphysematous Bulla Ruptured Parasitic Nodule

Ruptured Esophagus or Diaphragm.


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PNEUMOTHORAX


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PNEUMOPERITONEUM DUE TO PERFORATED PEPTIC

ULCER The CXR shows free air under the right hemidiaphragm, in addition to

features of hyperinflation. The possibilities include perforated peptic ulcer or GI

malignancy, recent laparoscopy/laparotomy, and peritoneal dialysis. It is important

to do an erect CXR for the free air to rise to the top of the abdomen. For patients

with a nasogastric tube in place, instillation of 200 ml of free air before the CXR mayaid the diagnosis


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MEDIASTINAL EMPHYSEMA (PNEUMOMEDIASTINUM)

The CXR shows free air in the mediastinum and subcutaneous tissues of

the neck (Fig. 16.2). The mediastinal air could have come from disruption of

the integrity of the lung, major airways, or the esophagus. A history of

trauma (e.g. motor vehicle accident with blunt injury to the anterior chest

wall by the steering wheel) or iatrogenic instrumentation (e.g. recentendoscopy) is important. Descending infections by gas-producing

organisms from the oral cavity and neck can cause severe mediastinitis

and result in a similar appearance.


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KELAINAN PLEURA

1. Penebalan pleura: e.c peradangan pleuritis

r.o : garis opaq linier

2. Schwarte:

- penebalan pleura yg tdk teratur +

perlekatan

- kalsifikasi pleura

r.o : opaq kehitaman


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3. Efusi pleura

Sedikit :

+/- 100 cc sudut costophrenicus tumpul (normal

lancip)

Banyak :Posisi PA berdiri : tampak kesuraman homogen

makin banyak membentuk garis lengkung lateral lebih

tinggi.

Masif :

seluruh hemithorax opaq homogen Posisi AP bagian

bawah dekat diafragma lebih suram


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4. Tumor pleura:

Jinak :

fibroma (batas jelas, costae intack) /

lipoma

Ganas :mesothelioma

Pl iti


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Pleuritis

Pleuritis can occur alone or in combination with pneumonia.

According to exudate: Fibrinous

Purulent (suppurative)

Empyema

Granulomatous

Chronic pleuritis typically results in pleural adhesions.

Etiology:

Most cases are infectious, although isolation is not alwayspossible.

Fibrinous pleuritis characterized by extensive deposition of

fibrin on pleural membrane


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Opacified HemithoraxThree Causes

Atelectasis

Pleural effusion

Pneumonia

Recognizing the Causes of an

Opacified Hemithorax
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Atelectasis

Opacified hemithorax from volume loss

Shift of heart and mediastinal structures

towardopacified hemithorax

Normally there are 2-10 cc of fluid in

the pleural space


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Atelectasis of right lungshift of the mediastinal structures

TOWARD the side of opacification


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Pleural Effusion

Opacified hemithorax from largeeffusion

Shift of heart and mediastinal

structures awayfrom side of opacifiedhemithorax


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Large right pleural effusion - shift of the mediastinal structures

AWAY from the side of opacification


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Pleural Effusions

Four Reliable Signs of CHF


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Pneumonia

Opacified hemithorax

No shift

Air bronchograms

The CXR shows opacities with air bronchograms involving both lung


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The CXR shows opacities with air bronchograms involving both lungfields. This is typical of severe pneumonia as evidenced by multilobar

involvement. Typical organisms include Streptococcus pneumoniae, Legionella,

and gram negatives l ike Klebsiella and Pseudomonas aeroginosa


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Pneumonia of LULno shift of the mediastinal

structures to either side; multiple air bronchograms


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Common Alveolar Lung Diseases

Pneumonia Pulmonary edema

Pulmonary hemorrhage

Aspiration
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Pulmonary edema

This disease is

fluffy and indistinctin its margins, it is

confluent and

tends to be

homogeneous. In

both upper lobes,

you can see airbronchograms.

This is an alveolar

(airspace) disease,

in this case

pulmonary edema

on a non-cardiogenic basis.
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Aspiration pneumoniaat both bases

Airspace Disease
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The CXR shows bilateral upper lobe infiltrates with cavities,

suggestive of active pulmonary tuberculosis. In general, thin-

walled cavities (5 mm) tend to be infective and


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The CXR of COPD typically demonstrates evidence of air trapping The signs


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The CXR of COPD typically demonstrates evidence of air trapping. The signs

are horizontality of the ribs, hyperinflated lungs (normally the right sixth rib

bisects the right hemidiaphragm), hyperlucent lung fields, bilateral symmetrical

attenuated pulmonary vasculature, long tubular heart, scalloping and flattening

o f t h e d i a p h r a g m


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DIAGNOSA BANDING PPOK

Asma Bronkiale

Gagal jantung kronis Bronkiektasis

Sindroma obstruksi pasca TB


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Fibrosis & kalsifikasi

BULA PARU


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BULA PARU

The CXR shows bilateral infiltrates and air bronchograms with


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The CXR shows bilateral infiltrates and air bronchograms with

a perihilar distribution. The heart size is normal. There are no

Kerley B lines or evidence of upper lobe venous diversion. All

these are typical features of PCP. PCP is the most common

life-threatening opportunistic infection in HIV disease.

There is a homogeneous density in the right upper zone and


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There is a homogeneous density in the right upper zone and

elevation of the transverse fissure. Instead of the transverse

fissure being straight, there is a bulge at the

medial end (Fig. 30.2), giving it an inverted S shape.


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KEGANASAN

Categorization

Parenchymal cancers

Leiomyomas, fibromas, chondromas

Bronchogenic lung cancer

Squamous cell (epidermoid)

Adenocarcinoma

Large cell carcinoma

Small (oat) cell


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Nodule (benign vs malignant)

Age (malignancy increases with patient age) Increases with malignancy

Size (size increases with malignancy)

85% of lesions > 3 cm are malignant

Calcification (lung cancer rarely calcify)

Benign pattern of ca++ rules out malignancy

Growth rate (stability of size over 2 year period

reliably excludes malignancy)


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MEDIASTINUM COMPARTEMEN

Anterior: posterior to sternumanterior

cardiac and tracheal borders

Posterior: posterior to a line 1cm dorsal to

anterior edge of vertebral bodies

Middle: between the two


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Diseases with Multiple Lung Nodules

Metastases Multiple AVMs

Rheumatoid nodules

Wegeners Granulomatosis
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Disease with Multiple CysticStructures

Cystic fibrosis

Bronchiectasis

Tuberculosis
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Cystic Fibrosis- interstitial

Middl di ti
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Middle mediastinum

Metastases to middle mediastinal nodes

Most metastases arise from intrathoracic

tumors, primarily lung

Extrathoracic- include genito-

urinary,melanoma, head and neck


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Posterior mediastinum

Neurogenic tumors

Tumors of esophagus

Primary and secondary tumors of the spine

M th i i


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Myasthenia gravis

Myasthenia gravis is associated with

thymoma

Th


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Thymoma

Older patients

Rarely before 20 y

20-50% asymptomatic

Symptoms: cough,dyspnea, hoarseness,

chest pain

Myasthenia gravis SVC syndrome

A thymic mass

Homogeneous soft-tissue

density

Oval, round, lobulated Sharply demarcated

Rarely cystic

Enhanceshomogeneously

May contain calcium


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The mass (red arrow)

silhouettes the right

heart border which isto say there is no

longer an edge of the

right heart seen. That

means the mass is (a)

touching the right

heart border (the massis anterior) and (b) the

mass is the same

density as the heart

(fluid or soft tissue

density). The mass is

athymoma.

Where in the chest is this mass?

Using the Silhouette Sign
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Lymphoma - CT


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Lymphoma CT

Nodes greater than 1cm in diameter - enlarged on CT , MRI

Multiple nodes smaller than 1cm suspicious

Enlarged nodes- discrete or fuse to form a single larger mass

Minor enhancement

Low density areas

Calcifications prior to therapy rare

commoner in more aggressive subtypes

seen occasionally following therapy

Carcinoma mass abo e right hil m


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Carcinoma mass above right hilum

E l d hil (b h i i )


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Enlarged hilum (bronchogenic carcinoma)


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Pancoast (superior sulcus) tumor

Bronchogenic tumor in the lung apex

Usually squamous cell type

Presents with:

Apical radiodensity

Horners syndrome

Thoracic outlet syndrome

Rib or vertebral destruction


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Pancoast tumor


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Tb paru lama & massa mediastnum


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Tb paru lama & massa mediastnum


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metastase

- Milier

- Coin lesion

- Coarse nodular

- Golf ball

- Lymphangitic spread

- Pleural effusion / ateletase

Coin lesion


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Coin lesion

Multiple pulmonary nodules and masses.


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p p y

You should think of pulmonary metastasis when you

see this presentation; although this case was due to a

less likely possibility, sarcoidosis

multiple malignant masses


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multiple malignant masses


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Pulmonary metastase


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Pulmonary metastase


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Peribronchial cuffing

Four Reliable Signs of CHF

Fluid in the

walls of the

bronchi make

them visible

and produce

numerous

doughnut

densities

throughout

the periphery

of the lung.

Coass Infeksi Dan Keganasan Pada Thorax

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