渗出性胸腔积液在内科胸腔镜下特征比较及诊断相关因素分析

Comparison of characteristics and analysis of related factors for diagnosis of exudative pleural effusion under thoracoscopy

目的对比不同原因渗出性胸腔积液在内科胸腔镜下的特征、实验室检查及临床表现上的差异,为不明原因渗出性胸腔积液鉴别诊断提供依据。方法回顾性分析2018年1月至2020年12月于成都市第二人民医院行内科胸腔镜检查的113例渗出性胸腔积液患者的临床、检验和病理资料。结果113例患者中,108例经胸腔镜和病理活检明确诊断,确诊率为95.58%,根据胸膜活检结果,25.92%(28/108)患者为恶性肿瘤,66.67%(72/108)患者为结核性胸膜炎,4.63%(5/108)患者为急慢性非特异性炎症,2.78%(3/108)患者为化脓性胸膜炎。4类患者的胸腔积液颜色和透明度以及白细胞(WBC)、乳酸脱氢酶(LDH)、腺苷脱氨酶(ADA)、C反应蛋白(CRP)、淀粉酶(AMY)和葡萄糖(Glu)水平不同。LDH与ADA比值(LDH/ADA)可助于区分结核性胸膜炎与其他胸膜渗出液疾病,LDH/ADA≤16.7具有最佳的总体诊断效率,敏感度为94.3%,特异度为85.7%。胸腔镜检查显示,结核性胸膜炎患者镜下以胸膜充血水肿、广泛粘连、均匀一致结节为主(分别为87.50%,51.39%,47.22%),恶性胸腔积液患者镜下以胸膜增生增厚、大小不等结节、肿块为主要表现(分别为50.00%,75.00%,21.43%),炎性胸腔积液患者镜下以胸膜充血水肿、大小不等结节为主要表现(分别为100%,80.00%),化脓性胸膜炎镜下以胸膜充血水肿及广泛粘连为主要表现(分别为100%,66.67%)。结论内科胸腔镜对渗出性胸腔积液的诊断具有重要的价值。结核性胸膜炎和恶性胸腔积液是渗出性胸腔积液最常见的病因。临床表现、胸腔积液常规和生化等指标及内镜下特征性表现对各类型渗出性胸腔积液鉴别有较大提示意义。

Objective To compare the characteristics under medical thoracoscopy,laboratory examination and clinical manifestations among different causes of exudative pleural effusion,to provide the basis for the differential diagnosis of unexplained exudative pleural effusion.Methods The clinical,test and pathological data of 113 patients who underwent medical thoracoscopy of exudative pleural effusion who were hospitalized in the Chengdu Second People′s Hospital from January 2018 to December 2020 were retrospective analyzed.Results Among the 113 patients,108 cases were confirmed by thoracoscopy and pathological examination with a diagnosis rate of 95.58%(108/113).Pleural biopsy showed that 25.92%(28/108)of them were malignant pleural effusion,66.67%(72/108)were tuberculosis,4.63%(5/108)were acute and chronic inflammation,and 2.78%(3/108)were purulent.The color and transparency of pleural effusion and the levels of white blood cells(WBC),lactate dehydrogenase(LDH),adenosine deaminase(ADA),C reactive protein(CRP),amylase(AMY)and glucose(Glu)were different among tuberculosis,malignant,inflammation,and purulent cases.The lactate dehydrogenase to adenosine dehydrogenase ratio(LDH/ADA)could help distinguish tuberculous pleurisy from other exudative pleural effusion.The LDH/ADA ratio≤16.7 had the best overall diagnostic efficiency,with a sensitivity of 94.3%and a specificity of 85.7%.In the tuberculosis group the main microscopic manifestations were pleura hyperemia and edema,extensive adhesion and uniform small nodules(87.50%,51.39%,47.22%,respectively).In the malignant group the main microscopic manifestations were pleura hyperplasia and thicken,unequal size nodules and masses(50.00%,75.00%,21.43%,respectively).The main microscopic manifestations in inflammatory group were pleura hyperemia and edema and unequal size nodules(100%,80.00%,respectively).The main microscopic manifestations in the purulent group were pleural hyperemia,edema and extensive adhesion(100%,66.67%,respectively).Conclusion Medical thoracoscopy is an effective method for the diagnosis of unexplained exudative pleural effusion.Tuberculous pleurisy and malignant pleural effusion are the most common causes.Clinical manifestations,pleural fluid routine and biochemical indicators,as well as endoscopic characteristics,are of great significance for the differentiation of various types of exudative pleural effusion.