interstitial lung disease vs. alveolar lung disease - PowerPoint PPT Presentation

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interstitial lung disease vs. alveolar lung disease

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a systemic approach to diagnose lung diseases base on a chapter in Grainger and allison's textbook of diagnostic imating – PowerPoint PPT presentation

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Title: interstitial lung disease vs. alveolar lung disease


1
Interstitial lung disease vs. alveolar lung
disease
  • A practical approach for diagnosis

Prepared by Dr. Kosar K. ahmed
2
Introduction
Lung disease can be arbitrarily divided into
Alveolar lung disease
Interstitial lung disease
3
Introduction
  • Opacities that are fluffy , cloud like or hazy
  • Tend to be confluent
  • Margins are fuzzy and indistinct
  • / - air bronchograms
  • Silhouette sign

4
Introduction
  • Discrete reticular , nodular or reticulonodular
    patterns
  • Packets of disease separated by normally
    appearing lung
  • Margins are sharp and discrete
  • May be focal or diffuse
  • No air-bronchograms

5
Interstitial lung disease
  • Pulmonary interstitium is the network that
    supports the lung , composed of
  • Alveolar walls
  • Interlobular septa
  • Peribronchiolovascular interstitium
  • In ILD pulmonary interstitium is thickened either
    by
  • Fluid
  • Cells
  • Fibrosis

6
Interstitial lung disease ( ILD )
This is a group of diseases that affect the
pulmonary interstitium and they show a various
patterns on HRCT
  • Causes
  • Idiopathic interstitial pneumonias
  • Sarcoidosis
  • Langerhans histeocytosis
  • Lymphangiomyomatosis
  • Connective tissue diseases
  • Systemic vasculitides
  • Drug-induced lung disease
  • Occupational lung disease
  • simply they can be
  • Idiopathic
  • Secondary

7
Approach to ILD
As we can see they can be caused by a lot of
disease entities and so many changes occur
giving rise to different patterns
  • The approach should combine
  • clinical data ( history , physical examination ,
    lab. Investigation )
  • radiologic findings
  • histopathologic findings .

8
Suggested form of history taking
  • Onset of the disease
  • Acute ( e.g. pulm. Edema , hypersensitivity
    pneumonitis )
  • Chronic
  • Associated illnesses
  • Connective tissue diseases ( RA, SjS ,
    scleroderma , Dermatomyocitis/ poly myositis ,
    SLE , ankylosing spondylitis )
  • Vasculitides ( wegners granulomatosis ,
    churg-strauss )
  • Any known malignancies
  • Convulsions
  • Drug consumption
  • Occupational history
  • Smoking

9
Suggested form of history taking continued
  • Drugs known to cause ILD
  • Chemotherapy
  • NSIADs ( naproxen , indomethacin )
  • Antibiotics ( ampicillin , tetracycline )
  • Cardiology ( amiodarone ,
    propranolol , captopril , simvastatin ,
    sotalol anticoagulants )
  • Anticonvulsants ( carbamazepine , phenytoin
    haloperidol )

10
Radiologic findings encountered in ILD
  • Reticular shadowing
  • Nodular shadowing
  • Reticulonodular shadowing
  • Ground glass opacification
  • Kerley lines
  • Traction bronchiactasis
  • Bronchial wall thickening
  • Honey combing
  • Cystic changes
  • In practice any combination of these findings
    could be seen
  • The rule is to see which pattern is the dominant
    one

11
Reticular shadowing
12
Nodular shadowing
13
Ground glass opacification
14
Kerley lines
15
Traction bronchiectasis
16
Bronchial wall thickening
17
Honey combing
18
Cystic changes
19
Cyst vs. Cavity
20
Approach to image interpretation
  • Patterns of opacification
  • Pattern of distribution
  • Additional features ( LAP , Pl. thickening , Pl.
    effusion , pneumothorax , cavitation
  • Cystic changes

21
Idiopathic interstitial pneumonias
This is a group of diseases that are of unknown
etiology include
Usual interstitial pneumonia
NSIP
DIP
22
Idiopathic interstitial pneumonias
  • Patches of consolidation that tend to change
    location
  • Dx. Is by histopathology

Creptogenic organizing pneumonia
23
Idiopathic interstitial pneumonias
  • Acute interstitial pneumonia
  • Areas of consolidation , GGO traction
    bronchiectasis
  • Is a grave disease and is regarded as idiopathic
    form of ARDS

24
Idiopathic interstitial pneumonias
RB-ILD
Strong association with smoking
25
Idiopathic interstitial pneumonias
  • Associated with autoimmune diseases (e.g. SjS)
  • Areas of GGO
  • Centrilobular nodules
  • Thickened septae
  • Thin walled discrete cysts

Lymphoid interstitial pneumonia
26
ILD secondary to other diseasesSarcoidosis
Sarcoidosis is a multisystem granulomatous
disorder of unknown etiology , characterized by
presence of non caseating granulomas Affecting
upper and mid zones
  • CXR staging
  • Stage 1 LAP
  • Stage 2 LAP parenchymal opacity
  • Stage 3 parenchyma opacity alone
  • Other organs affected
  • Skin
  • P. Lymph node
  • Eyes
  • Spleen
  • CNS
  • Parotid glands
  • Bones

27
Sarcoidosis
28
Radiologic findings of Sarcoidosis
Hilar LAP para tracheal
LAP egg shell calcification
29
CT findings of Sarcoidosis
30
Diagnosis is aided by
Clinical manifestations Associative features (
characteristic LAP on CXR , egg-shell
calcification If non present then
histopathology
31
Hyper sensitivity pneumonitis
These are a group of disorders caused by exposure
to organic dust ( mouldy hay , tatami mats ,
paint sprays , bird feathers and others )
Characteristically symptoms develop after
approximately 6 hours of exposure ( fever , chill
, dyspnea and cough , wheeze is not prominent )
32
Radiologic findings
  • Ground glass opacifiction
  • Centrilobular poorly defined nodules
  • Reticulonodular pattern
  • Upper lobe fibrosis

33
Langerhans cell histiocystosis
lymphangiomyomatosis
Both cause cystic pattern on HRCT
Vs.
How to differentiate ?
34
  • LCH
  • Occurs almost exclusively in smokers
  • Associated with repeated pneumothoraces

35
  • LIP
  • Occurs almost exclusively in women in child
    bearing age
  • Associated with autoimmune diseases e.g. SJS

36
Connective tissue diseases , systemic
vasculitides occupational lung disease
These cause variable disease patterns that may be
shared by two or more diseases
  • Multiple pulmonary nodules
  • Cavitary pulmonary nodule
  • Miliary pulmonary nodules
  • Lower lobe interstitial lung disease
  • Upper lobe interstitial lung disease

37
Multiple pulmonary nodules
DDx. Metastasis Granulomatous disease ( TB
fungi ) Septic emboli Wegners granulomatosis
Rheumatoid disease
38
  • Wegners granulomatosis
  • Nodules tend to cavitate
  • Associated with multiple sinus infections /-
    soft tissue mass in the upper air ways

39
  • Rheumatoid disease
  • Rheumatoid nodule in the chest occurs in those
    who have skin nodules

40
Lower lobe interstitial lung disease
  • DDx.
  • UIP
  • Collagen vascular disease( RA , SLE scleroderma
    )
  • Asbestos related
  • Drug toxicity

41
Collagen vascular disease
42
Upper lobe interstitial lung disease
  • DDx.
  • Post primary TB
  • Sarcoidosis
  • Cystic fibrosis
  • Silicosis
  • LCH

43
Drug induced ILD
  • Non specific
  • Almost any pattern

44
Alveolar lung disease
  • This is a non specific finding due to replacement
    of air in the alveoli by
  • Fluid
  • Transudate
  • Exudate
  • Blood
  • Protein
  • Cells
  • Gastric juice

45
Radiologic signs of air-space shadowing
  • Nodular pattern
  • Ground glass opacification
  • Consolidation

46
Pulmonary edema
  • This is defined as excess extra vascular lung
    water
  • It can be caused by
  • Increased hydrostatic pressure ( cardiogenic )
  • Increased vascular permeability ( non cardiogenic
    )

47
Non cadriogenic causes
Blood Fluid over load IV contrast Drugs
(narcotics , NSAID ) Brain CVA Raised ICP chest
High altitude Drowning Re-expansion of a
collapsed lung
48
CXR findings
Kerley B lines Kerley A lines Peribronchial
cuffing
49
Alveolar edema
  • The distribution of changes is variable and
    frequently random
  • in general, there is sparing of the apices and
    extreme lung bases. Typically, there is bilateral
    opacification
  • On occasion, the central lungs are more
    affected, producing the characteristic
    butterfly or bat's wing

50
Is it possible to differentiate cardiogenic from
non cardiogenic radiologicaly ?
  • Suggestive features
  • Cardiomegaly
  • Upper lobe Vs. lower lobe
  • Peripheral Vs. central
  • Width of the vascular pedicle

Differentiation of the cause of pulmonary edema
based on radiological features alone is un
reliable
51
Pulmonary hemorrhage
Diffuse This is caused by many diseases that can
non be differentiated radiologicaly
  • Localized
  • Carcinomas
  • Bronchiectasis
  • Pneumonias

52
Radiologic findings
  • Ground glass opacification
  • Consolidation

53
Thank you
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