小小医生之有趣的医学
云南省一院孙丹雄
前言 外科会诊遇到好几次，主动脉夹层、咯血，我一直认为咯血是主动脉夹层引起，但是一直没有时间查阅文献。今天查阅文献，证实一下，学习一下，确定一下我的想法。
主动脉夹层 大咯血
case01
The patient
A 76 year old hypertensive woman presented with massive haemoptysis and right-sided pleuritic chest pain.
76岁女性，有高血压，表现为大咯血，右侧胸膜炎性胸痛。
Investigations
A chest radiograph and computed tomography (CT) were performed.
做了CT。
Comment
In the majority of cases of thoracic aortic dissection, the predominant presenting symptom is chest pain, occurring in over 90% of cases. Haemoptysis is a rare but well-documented complication, occurring in 6% of cases. It may rarely be the sole presenting feature and may occur in association with a mediastinal haematoma.
胸主动脉夹层，主要表现为胸痛（>90%）。咯血少见（6%）。咯血在少数情况下可能是唯一的症状，可合并纵隔血肿。
In this case the mass lesion on the chest radiograph was accompanied by the typical mediastinal widening seen in aortic dissection. Bronchoscopy did not reveal an endobronchial lesion. The CT scan with contrast enhancement demonstrates the dissection involving the ascending aorta with the adjacent mediastinal haematoma. There was no aorto-bronchial fistula present. The case also illustrates the value of CT scanning prior to attempting a needle biopsy of a mass lesion.
支气管镜检查，没有发现支气管损伤。也没有主动脉-支气管瘘形成。这个病例显示，增强CT非常重要，价值巨大。
为什么会咯血？
参考文献：Prasad A , Shotliff K . Aortic dissection complicated by a mediastinal haematoma and haemoptysis.[J]. Postgraduate Medical Journal, 1994, 70(829):821-822.
上面是这篇文献的全文，牛皮吧？
外？崴？歪？and why？
查了一些文献，没有解释为神马！
先看看主动脉夹层的典型CT。
主动脉与肺，是连在一起的，就像红楼梦四大家族：有可能一荣俱荣，一损俱损！
解剖
The patient was a 58-year-old male, who sought medical care at InCor complaining of dyspnea and fever.
病人58岁男性，因为呼吸困难、发热来院就诊。
He knew he had arterial hypertension, ischemic heart disease, renal failure (undergoing renal replacement therapy) and aortic dissection. He had myocardial infarction in January 1999, being referred to InCor.
既往有高血压、缺血性心脏病、尿毒症、主动脉夹层。1999年心肌梗塞。
The patient had back pain and massive hemoptysis, with cardiopulmonary arrest in asystole, did not respond to resuscitation maneuvers, and died (February 24th, ).
病人诉背痛，大咯血，后心跳骤停，心肺复苏失败。
The patient’s main disease was chronic aortic dissection,DeBakey type III (Stanford type B), extending from the aorticarch to the iliac bifurcation. The entrance orifice had 2 cm ofextension. There was aortic rupture to the left lung and pleuralcavity, with massive pulmonary hemorrhage , whichwas the final factor triggering death.
遗体解剖：慢性主动脉夹层，从主动脉弓撕裂到髂动脉分叉，撕裂口2cm。主动脉撕裂到左肺及胸膜腔，大量肺泡出血，这是死亡原因。
咯血原因
综上所述，可以推测：肺组织和主动脉的关系，可谓“天涯若比邻”，肺组织和主动脉相邻，主动脉撕裂，血液破入肺组织，或者顺便撕裂肺组织，导致咯血。
I think so！
参考文献：Desiderio F , Sampaio G P . Case 3/ - 58 Year-Old Hypertensive Male with End-Stage Renal Disease, Aortic Dissection, Fever and Hemoptysis:[J]. Arquivos Brasileiros De Cardiologia, , 107(1):71-76.
大咯血的病因
参考文献：中国医师协会整合医学分会呼吸专业委员会.大咯血诊疗规范[J].中华肺部疾病杂志（电子版）,,12(1):1-8.
类风湿关节炎，都会大咯血！这样真的好吗？
莫名其妙的大咯血
大医院经常不知道咯血的原因。
为什么？
尽管医学飞速发展，仍有高达20％的患者未发现明显病因，被归类为隐源性大咯血。
病因简单的，基层医院就明确诊断了（结核、支气管扩张、肺癌等）。
转到大医院的，很多是复杂的病人，很多查不到明确的病因，专家们一脸茫然，或者装洋！
主动脉夹层撕裂支气管
主动脉夹层，非常鸡贼！
城门失火，殃及池鱼！
主动脉可以撕裂支气管，然后主动脉的血液飙到支气管（主动脉-支气管瘘），引起咯血。
A 38-year-old man presented with massive hemoptysis followed by hemorrhage shock. The patient"s history revealed a Dacron patch repair for aortic coarctation and recoarctation carried out twice, once 23 and once 10 years ago. Diagnosis of a ruptured descending aortic aneurysm with an aortobronchial fistula into the left lower lobe was established using CT scan. Emergency surgery consisted of left pneumonectomy and descending aortic graft replacement during deep hypothermic circulatory arrest. The patient was discharged 12 days later.
一位38岁男性表现为大咯血合，随后失血性休克。
病人的病史显示，在前和前，进行了两次主动脉缩窄和再缩的涤纶补片修复术。
应用CT扫描发现主动脉降主动脉瘤破裂，左下叶主动脉-支气管瘘形成。
急诊手术包括深低温体外循环下的的左肺切除术和降主动脉移植物置换术。病人12天后出院。
从鬼门关走了3次！
参考文献：Kamler M , Tuengerthal S , Rauch H , et al. Near-Fatal Hemoptysis and Emergency Surgical Repair after Aortic Patch-Plasty[J]. The Thoracic and Cardiovascular Surgeon, 2001, 49(5):310-311.
术后也咯血
Mercedes SuárezRodríguez, Leirofernandez V , José Luis GarcíaTejedor, et al. Hemoptysis after surgical repair of aortic thoracic dissection[J]. Case Reports & Clinical Practice Review, (1).
胸主动脉夹层，外科修补术后咯血。
肺癌和主动脉夹层：狼狈为奸？
A 70-year-old woman with a known chronic dissecting aneurysm of the descending thoracic aorta presented with new-onset back pain and hemoptysis. The hemoptysis was thought to be the result of invasion of the bronchial tree by the aneurysm. During surgical repair, a lesion that appeared to be a pulmonary abscess was discovered to be adhering to the aortic tissue, and the patient underwent a localized pulmonary resection. The pathology report of the surgical specimens revealed squamous cell carcinoma of the lung with infiltration of the aortic wall. The patient died of lung cancer 6 months later. Hemoptysis was an unusual presentation in a case of lung cancer that had invaded a stable chronic aortic aneurysm.
一名70岁女性，患有胸降主动脉慢性夹层动脉瘤，最近诉背痛和咯血。咯血被认为是动脉瘤侵袭支气管树的结果。 在外科手术修复过程中，发现一个似乎是肺脓肿的病灶粘附在主动脉组织上，患者接受了局部肺切除术。手术标本的病理报告显示肺鳞状细胞癌伴主动脉壁浸润。该患者在六个月后死于肺癌。咯血是侵犯稳定的慢性主动脉瘤的肺癌病例中的不常见表现。
Tsui P , Lee J H , Maclennan G , et al. Hemoptysis as an unusual presenting symptom of invasion of a descending thoracic aortic aneurysmal dissection by lung cancer[J]. Texas Heart Institute journal / from the Texas Heart Institute of St. Luke"s Episcopal Hospital, Texas Children"s Hospital, 2002, 29(2):136-139.
中国《大咯血诊疗规范》
大咯血可被定义为任何危及生命的咯血量以及可能导致气道阻塞和窒息的任何咯血量。
支气管镜检查：对大咯血病因诊断不清，或经内科保守治疗止血效果不佳者，目前多主张在咯血期间及早施行支气管镜检查。
大咯血，以前的观点是：支气管镜相对禁忌症。
若疑诊DAH（弥漫性肺泡出血），应积极使用大剂量甲泼尼龙冲击治疗，连用3天后每天口服甲泼尼龙1mg/kg，同时应给予环磷酰胺1—2 mg/kg。若疑诊Goodpasture综合征应及时进行血浆置换，避免因等待血清学检验结果而错过治疗时机。
很多疾病都会引起弥漫性肺泡出血，不是免疫性疾病，也可以甲强龙冲击？甲强龙充饥？
138例儿童弥漫性肺泡出血临床特点及病因分析：基础疾病分别为特发性肺含铁血黄素沉着症65例,血液系统疾病22例,血管炎性疾病15例,感染性疾病14例,心血管疾病5例。
王维.138例儿童弥漫性肺泡出血临床特点及病因分析[D].重庆医科大学,:1-33.
诗
杜鹃啼血猿哀鸣——唐 · 白居易《琵琶行 / 琵琶引》诗诗
君王掩面救不得，回看血泪相和流 —— 唐 · 白居易《长恨歌》
诗诗
子规夜半犹啼血，不信东风唤不回 —— 宋 · 王令《送春》
杨柳岸，晓风残月。
视频
《武林外传》十大高手排行榜
