Case Conference II 醫學四 第三組 B9402030~B9402044

Final Pathology Conclusions Outline of today History Microscopic findings Gross findings Final Pathology Conclusions

HISTORY B9402034 陳怡婷 B9402040 許瑜真 B9402043 張琬菁

G-I WARD Yellowish sputum Electrolytes imbalance 時間： 1995/08/23 主訴：bloody stool 其他症狀： Yellowish sputum Electrolytes imbalance Normal 檢驗值 Na 136~149 mEg/l 124 K 3.7 ~ 5.5 mmol/L 3.5

G-I WARD Head injury（subdural hematoma） Left hemiparesis（從1988年） 過去病史： Head injury（subdural hematoma） Left hemiparesis（從1988年） 沒有hypertension和diabetes mellitus

G-I WARD 檢查-1 Gastric atrophy Duodenal ulcer Mild anemia Leukocytosis Panendoscopy Gastric atrophy Duodenal ulcer CBC Mild anemia Leukocytosis Normal 檢查值 WBC 4,000~11,000 16900 RBC 3.8-5.5 4.49 HGB 12-16％ 16.8％ HCT 37-55% 39.9％ SEGMENT 56-60% 93％

G-I WARD 檢查-2 Internal hemorrhoids Nodule（left upper lobe） Sigmoidocsopy Internal hemorrhoids X-ray Nodule（left upper lobe） Pneumonia（bilateral）

Chest Ward Bleeding of Hemorrhoids Stopped Developed of Progressive 呼吸淺短, 呼吸困難,肺積水: respiration rate: 26/min (12-15/min) Given Antibiotics and Supportive Treatment Oct. 7: Patient intubated and put on the ventilator

Chest Ward pH: 7.438 (>7.40 = alkalosis) Metabolic Alkalosis pH: 7.438 (>7.40 = alkalosis) HCO3: 24.6 (>24= metabolic alkalosis) pCO2: 31.7 (>40= respiratory compensation) pO2: 68.7 Hypoalkemia K: 2.9 (3.5 - 5.0 mEq/L) Hyponatremia NA: 131 (135 - 145 mEq/L ) Blood Culture Did not grow any bacteria

Chest Ward 2-D cardiac echogram Emergency subxiphoid drainage Pericardial effusion Cardiac tamponade Emergency subxiphoid drainage Serosanguineous effusion 175 c.c. Biopsy of pericardium Normal

Chest Ward Progressive hypertension Expired on 10/21

Microscopic findings B9402035陳京瑜 B9402033陳長聖 B9402030陳建佑

Duodenum Ulcer

Prostate nodular hyperplasia

Testis hyalinized seminiferous tubules

Fibrosis, Sclerosis, and Narrowing http://www.nlm.nih.gov/MEDLINEPLUS/ency/imagepages/18020.htm

Fibrosis, Sclerosis, and Narrowing http://www.uwcvb.org/schwatz_lab%20index.htm

Sclerosed Glomeruli and Arteriosclerosis http://www.unckidneycenter.org/kidneyhealthlibrary/diabetes.html

Ground Glass Hepatocytes http://en.wikipedia.org/wiki/File:Human_liver.jpg

Ground Glass Hepatocytes http://www.pathology.med.ohio-state.edu/ext/MedEd/Med2Visuals/Scripts/descall.idc?FolderNumber=10534

Caseous Necrosis with Calcification A necrotic nodule with caseous necrosis is seen in left upper apical portion.

Caseous Necrosis with Calcification No Acid Fast Bacilli Are Found.  No Recent Infection Of TB

Small Cell Carcinoma The Tumor Is Seen In The Hilum

Small Cell Carcinoma The Peripheral Fibrotic Nodule Is A Scar With SCC.

Small Cell Carcinoma The Tumor Is Seen In The Lymphatics Spreading To The Hilum.

Small Cell Carcinoma SCC Invade Into The Trachea Under The Mucosa.

Diffuse Alveolar Damage Both Lungs Show Focal Diffuse Alveolar Damage.

Pulmonary Emboli Both Lungs Also Show Pulmonary Emboli In The Distal Portion.

Pulmonary Emboli Nearly Occlusive stage

Pulmonary Emboli Occlusive Organized Thrombosis With Recanalization.

Pulmonary Emboli Pulmonary Infarct Associated With Occluded Vessel.

Gross findings B9402041 許程凱 B9402042 梁華昌

1.Aorta Mild to sever atherosclerosis

2.Myocardium Hypertrophy of left ventricle

3.Coronary arteries Marked atherosclerosis with hardening and narrowing

4.Trachea A tumor mass is attached to the left side of the trachea at the hilum

5.lung Fibrotic nodule in the peripheral portion Necrotic nodule with caseous necrosis in left upper apical portion Marked centrilobular emphysema

5.Lung Fibrotic nodule in the peripheral portion

5.lung Necrotic nodule with caseous necrosis in left upper apical portion

5.lung Marked centrilobular emphysema

6.duodenum Antrum ulcer

Final Pathological Diagnosis 醫學四 郭震亞 醫學四 陳奕廷 醫學四 陳冠豪

Lung pathology Centrilobular Emphysema, Advanced Old Tuberculous Granuloma Small Cell Carcinoma Pulmonary Emboli Aspiration Pneumonia Diffuse Alveolar Damage

Centrilobular Emphysema 定義： 肺氣腫(emphysema)的為末端細支氣管(terminal bronchioles)遠端的氣腔(air spaces)有不正常且永久的 擴張，伴隨肺泡壁的破壞和極少的纖維化。

Centrilobular Emphysema 解剖位置可分： Centrilobular emphysema 通常和吸煙者相關。 Panacinar Emphysema Distal acinar emphysema

致病機轉 Protease-antiprotease hypothesis 認為肺氣腫的肺泡壁破壞是因為肺的蛋白脢與蛋白脢抑制 物之間的不平衡所致。

抽煙與肺氣腫

History 關聯性 病患有抽煙的習慣，抽煙量為每天一包，已持續四 十年。 抽煙可能是造成肺氣腫的主要原因。

Old Tuberculous Granuloma 特殊形式的慢性發炎，其特色為活化的巨噬細胞 (epithelioid macrophages)在局部堆積，外圍包圍著淋 巴球或漿細胞，形成結節狀的肉芽腫，中心有時會有壞死 的情況。

形成原因 Foreign body granulomas Immune granulomas 由不具活性的異物所引起。 持續的抗原不斷刺激T cell所致，此型以結核桿菌引起的 肉芽腫為代表。

History 關聯性 病患說以前沒有得過任何systemic illness。 Granuloma tissue的切片沒有發現任何acid fast bacilli。 ??推測此肉芽腫可能為primary 或secondary tuberculosis痊癒後遺留的scar。

Small cell carcinoma 定義：small cell carcinoma (highly malignant carcinoma composed of small round or egg- shaped cells with little cytoplasm; lung cancers are frequently oat cell carcinomas)

Small cell carcinoma 肺癌中最惡性的一種，通常以中央(central)或是肺 門(hilar)的腫瘤來表現。與吸菸有強烈的相關。在 顯微鏡呈巢狀(nest)或是團狀(clusters)的小型似燕 麥(oat-like)細胞，細胞質很少，缺少鱗狀上皮或 腺體的分化。 在超微結構中，有神經分泌顆粒(neurosecretory granules)

Small cell carcinoma Small cell carcinoma metastasis to hilar lymph nodes Invasion to trachea

Pulmonary embolism 定義：Blood clot from another part of the body that travels to the lungs. Can cause closed passages in the lungs and decrease oxygen exchange

Pulmonary embolism 原位的栓塞(thromboses in situ)很少見 超過95%來自腳部深層靜脈(deep leg veins) 在有嚴重燒傷、外傷、骨折或癌症得住院病人，其 肺栓塞的發生率為30% 後果： 1.猝死 2.咳血 3.肺組織出現週邊楔形的出血性壞死 4.肺高壓，血管硬化

Aspiration pneumonia, mild & focal 定義：bronchopneumonia that develops due to the entrance of foreign materials that enter the bronchial tree, usually oral or gastric contents. 原因：incompetent swallowing mechanism 1. neurological disease (seizure) 2. intoxiacation 3. iatrogenic cause (during general anaesthesia for an operation) 4. alcoholism, stroke… 5. 胃酸與混合性細菌感染 通常發生在右肺中葉與下葉(視身體姿勢而定) 右肺支氣管較垂直 異物容易掉到右肺

Aspiration pneumonia, mild & focal 病史： 1.8/22,1995 肺部檢查發現雙側下肺葉coarse crackles，以RLL最嚴重 aspiration pneumonia

Aspiration pneumonia, mild & focal 2. 9/6 :移除CVP時培養發現凝固酶陰性的葡萄球菌 以及格蘭氏陰性桿菌 病人有呼吸困難的情形 呼吸速率38/min 雙側下肺葉粗糙尖銳的聲音變大 aspiration pneumonia

Aspiration pneumonia, mild & focal 3.9/7 ：痰液培養發現大量Kleb. Pneumoniae，使 用gentamicin (K. Pneumoniae為常見的肺部感染致病菌，Gram(- )，具莢膜，為院內感染常見菌種) aspiration pneumonia

4. 10/11 : 痰中發現Staph. Aureus 5. 10/16 : 痰中發現革蘭氏陽性球菌及嗜中性球 aspiration pneumonia

Diffuse alveolar damage, focal 定義：為急性呼吸窘迫症候群(ARDS)的臨床表徵。 ARDS特徵為廣泛肺泡微血管損傷，導致嚴重的肺 水腫， 呼吸衰竭及動脈血氧過少 原因：感染、物理傷害、化學傷害、吸入異物、多 次輸血及廣泛血管內凝血

Diffuse alveolar damage, focal 病史： 9/6 :移除CVP時培養發現凝固酶陰性的葡萄球菌 以及格蘭氏陰性桿菌 病人有呼吸困難的情形 呼吸速率38/min 雙側下肺葉粗糙尖銳的聲音變大  Diffuse alveolar damage

Congestion, liver, kidney, & urinary bladder 定義:組織內血流出量減少所導致的一被動變化。 肺部鬱血通常由左心衰竭引起；肝鬱血則常在右心 衰竭發生。 History: 超音波顯示pericarial effusion & cardiac tamponade(possible) Progressive hypotension liver 等器官之Congestion

Atrophy, bilateral testes 造成testis atrophy的原因有許多 病毒感染 損傷陰囊或睪丸部位 重度睪丸炎 放射性物質影響 內分泌疾病 藥物影響 年齡

Final Pathological Diagnosis B9402036 陳佑丞

(7) Atherosclerosis (Aorta & Coronary arteries) 定義 : 動脈因膽固醇的堆積而形成粥狀物 病理變化主要分三階段 : 1.Deposition of fatty streak -Foamy mΦ -SMC proliferation 2.Formation of fibrolipid plaque -Central necrosis : Cholesterol + foamy mΦ + necrosis -Fibrous cap : collagen + SMC + Φ + lymphocyte 3.Formation of thrombus -fibrin + platelet

併發症： -Arterial stenosis(動脈狹窄) -Thromboembolism(血栓性栓塞) -Aneurysm(形成動脈瘤) 危險因子： 高血脂、高血壓、糖尿病、抽菸、男性、 年齡、家族史

Final pathological diagnosis : -Gross : The entire aorta shows mild to focally severe atherosclerosis -Micro : Marked atherosclerosis

(10) Duodenal Ulcer 定義 :十二指腸上皮組織局部壞死 Ulcer可分為兩種 : (1) Peptic ulcer (消化性潰瘍) Duodenum絕大多數是這種!! (2) Malignant ulcer (腫瘤性潰瘍) 一般在Stomach才會出現

Peptic Ulcer (1) 好發處排行榜 : (1) Duodenum (2) Gastric antrum (3) Esophagus (4) Jejunum (Marginal ulcer) 胃、空腸吻合(BillrothⅡ)的空腸端

Peptic Ulcer (2) 原因 : (1) 胃酸過多(pH↓) -Duodenal ulcer通常H+↑ -Zollinger-Ellison syndrome=gastrinoma gastrin↑HCl↑Ulcer (2) 黏膜保護不足 -黏膜上皮通透性↑ H+ back-diffusion↑ (3) Helicobacter pylori(H.p.) infection -Urease, Proteinase  黏膜破壞  黏膜屏障↓ -D-cell (somatostatin)↓ G-cell (gastrin)↑ HCl↑

Peptic ulcer (3) 病理上從淺至深分四層: 1. Necrotic debis 2. Inflammatory layer 3. Granulation tissue 4. Fibrotic tissue 併發症: 1. Bleeding -好犯Duodenum第一部分後壁 -主要侵蝕gastroduodenal artery 2. Perforation -好犯Duodenum第一部分前壁

History : 【1995/8/30】panendoscopy was performed, and severe gastric atrophy with moderate bulb deformity with an A2 ulcer at anterior wall of the duodenum were noted.

Final pathological diagnosis : -Gross : An ulcer measuring 1.5 x 1.5 cm2 at antrum -Micro: A shallow ulcer

<補充> 潰瘍依其發展順序可分為三期 : 急性期(A)、癒合期(H)、瘢痕期(S)，且各 可再分為兩期 : (1) 急性期(A) 充血、水腫減輕或消失、可見再生的上皮 -H2 : 糜爛消失、潰瘍周邊輕度充血或充血、水腫消失、可見明顯的再 生上皮及輕度的黏膜集中 (3) 瘢痕期(S) -S1 :【紅色瘢痕期】潰瘍已癒合、形成紅色瘢痕、周邊無充血、水腫、 可見再生上皮及黏膜集中 -S2 :【白色瘢痕期】潰瘍部位形成白色瘢痕、黏膜集中明顯

Final Pathological Diagnosis B9402044 張智鈞

Left ventricular hypertrophy Gross Left ventricle hypertrophy Heart weight 430 g >400 g LV thickness 1.8 mm >1.2mm Micro No remarkable finding

Left ventricular hypertrophy

Arteriolar nephrosclerosis Type Benign malignant Risk factors Age People (Black >White) Hypertension Diabetes mellitus

Benign arteriolar nephrosclerosis Pathogenesis Medial and intimal thickening Hyaline deposition in arterioles Morphology Kidney size is normal or slightly reduced Average weights: 110~130 g

Benign arteriolar nephrosclerosis

Malignant arteriolar nephrosclerosis Pathogenesis Long-standing hypertension Endothelial injury and narrowing Ischemia and RAA system activation Morphology Fibrinoid necrosis of arterioles Concentrically intimal thickening (Onion-skinning)

Malignant arteriolar nephrosclerosis

Fibrinoid necrosis

Onion-skin

Final pathological diagnosis Gross Both are 110 g Arteriosclerosis in renal aa. Micro Glomerulosclerosis Arteriosclerosis congestion

Final comments 左胸有advanced centrilobular emphysema 和 an old tuberculous granuloma Small cell carcinoma從左上葉肋膜下轉移到hilar lymph nodes並侵入tracheal mucosa 其餘肺組織有pulmonary emboli, aspiration pneumonia和focal diffuse alveolar damage Die of the respiratory disease