Effusion in the pericardium area: causes, examination, treatment

Scientific editor: Strokina OA, therapist, doctor of functional diagnostics.
September 2019.

Synonyms: pericardial effusion, pericardial effusion

ICD-10 code: I30, I31.3.

Effusion - fluid in the pericardial cavity. It is an acute and chronic. Acute occurs with increasing chest pain, dry cough. The chronic form is often asymptomatic. No special treatment, therapy is aimed at addressing the underlying disease.

Fluid accumulates in the form:

• transudate - exudate noninflammatory character.
  • in chronic heart failure,
  • with pulmonary hypertension,
• exudate in inflammatory processes - bacterial or viral pericarditis;
• pus (for bacterial pericarditis);
• blood (closed chest trauma).

In rare cases, pericardial detected air or other gas that results from the life activity of certain types of bacteria or open chest trauma.

Character fluid (exudate or transudate) pericardial determined via laboratory analysis by calculating its density, the amount of proteins and other elements. According to the difference of these elements physician assistant concludes inflammatory or non-inflammatory nature of the effusion.

Kinds

Pericardial effusion is classified according to:

• the degree of increase of its volume - acute or chronic (over three months);
• distribution of content in the cavity - encysted (localized) or ambient;
• number, determined by echocardiography (ultrasound heart) - a small (less than 10 mm), medium (10-20 mm) expressed in (20 mm);
• effects on hemodynamics - without influence, cardiac tamponade, constriction.

Encysted or localized pericarditis occurs in the presence of a large number of adhesions cavity (Connective tissue growths) formed due to inflammatory processes between two sheets pericardium. They just restrict fluid.

Massive effusions often encountered in neoplastic nature of the underlying disease.

Causes and risk factors for the formation of effusion

Pericardial effusion may be formed with a large list of diseases:

• infections - bacteria (pathogens of pneumonia, meningitis, syphilis, gonorrhea, tuberculosis)
• viral (Coxsackie, Epstein-Barr virus, mumps, rubella, HIV);
• noninfectious - autoimmune (systemic lupus erythematosus, systemic scleroderma, rheumatoid arthritis),
• tumor (metastatic tumors in lung cancer, breast)
• traumatic,
• metabolic (renal insufficiency - accumulation in the body of protein metabolism products, myxedema - extreme deficiency of thyroid hormones).

We should distinguish pericarditis, in which the characteristic of large volumes of effusion:

• tumor;
• tuberculosis;
• cholesterol;
• uremic (occurs in renal failure);
• myxedema (myxedema - an extreme form of hypothyroidism, thyroid disease).

Large volumes of effusion have a very high risk of cardiac tamponade followed by possible fatal outcome.

Risk factors

In addition to these causes of effusion risk factors are also separate categories of patients are:

• People with immune deficiency;
• patients with immunity to anti-inflammatory therapy (NSAID indomethacin, ibuprofen, diclofenac, etc.) within 1 week after initiation of therapy pericarditis;
• HIV-infected.

Symptoms of exudative pericarditis

Clinical pericardial effusion occurs acutely or chronically.

The acute form

Acute exudative pericarditis is characterized by the following features:

• discomfort or pain in the chest;
• palpitations;
• dyspnea;
• dry cough;
• pericardial friction is not typical.

Pain in the chest rising and usually last for a few hours. They have a clear dependence of respiration (pain worse on inspiration, especially during deep), change position body motions, which strongly resembles clinical symptoms pleuritis (inflammation of the pleura - the outer shell the lungs). It is also possible irradiation of pain in the left supraclavicular area, the shoulder and neck.

In acute pericarditis exudative fluid accumulates rapidly, the pressure grows in the pericardial cavity high rates, which dramatically increases the risk of occurrence in a matter of minutes or hours tamponade heart.

The chronic form

Chronic exudative pericarditis is often asymptomatic because the pericardium time to adapt to the accumulation of fluid - he gradually stretched. However, for such a scenario there is an endpoint, when the outer layer of the heart is no longer able to expand. In this case, vnutriperikardialnoe pressure rises and begins to show symptoms of the disease, which sooner or later turn into a cardiac tamponade.

Life-threatening symptoms

Before the development of tamponade, it is important to notice signs of hemodynamically significant effusion, which precedes life-threatening conditions. Its symptoms:

• Voiceless heart tones.
• The disappearance of pericardial friction noise when it was originally heard.
• Jugular venous distention.
• Decrease in systolic (upper) blood pressure inspiratory more than 10 mm Hg during quiet breathing.

Upon detection of these symptoms physician must act very quickly: hold echocardiography in the emergency order and designate a consultation or thoracic cardiovascular surgery for the definition of further tactics treatment.

Signs of effusion for localized pericarditis

For encysted or localized pericarditis characterized by other symptoms, which are very rarely occur:

• hiccups;
• nausea;
• violation of swallowing;
• hoarseness.

The appearance of these symptoms depends on the location of pericarditis and its pressure is near anatomical structures.

survey

Laboratory and instrumental diagnostics of exudative pericarditis does not differ from the general standard of inflammatory diseases of the pericardium.

analyzes

• General blood analysis. Possible inflammatory reaction of the blood, which is often accompanied by acute pericarditis - leukocyte level rise, The emergence them stab, young forms, high ESR (erythrocyte sedimentation rate). In chronic blood during the reaction can not be performed.
• Biochemical analysis of blood - markers of inflammation - increased C-reactive protein, Markers of myocardial damage (troponins, MB fraction kreatinfsfokinazy). In chronic course tests may be normal.

instrumental studies

• Electrocardiogram. If there is a significant effusion decreased amplitude of the waves in all leads.
• Echocardiography (ultrasound of the heart) - the most informative method of diagnosis of effusion in the pericardial cavity. Thanks to ultrasound the doctor will determine the approximate amount of liquid.
• Chest X-ray is recommended for all patients. Increased heart shadow is detected on the radiograph only when more than 300 ml of effusion. Investigation reveals signs of involvement in the inflammatory process pleura (lung outer shell).
• Magnetic resonance imaging is assigned when there is no information content, the impossibility of echocardiography or suspected encysted specific localization process.
• Needling pericardium with draining and subsequent analysis of the contents of the cavity enable alleviate the symptoms of the disease and to determine the cause of effusion.

In the absence of data on the cause of exudative pericarditis, your doctor may prescribe some of the following studies:

• intradermal tuberculin test (Mantoux test, Diaskintest);
• blood cultures in suspected infective endocarditis;
• virological testing by ELISA and PCR;
• HIV testing, Haemophilus influenzae;
• exception Chlamydia and Mycoplasma infections by ELISA and PCR;
• definition antinuclear factor, rheumatoid factor, antibodies to cardiolipin (in systemic lupus erythematosus, rheumatoid arthritis and others);
• titer antistreptolysin-O (at rheumatism);
• determination of antibody titers to miolemme and serum actomyosin (perimiokardialny suspected tuberculosis);
• determine the level of thyroid hormone (hypothyroidism).

Determining the cause of the disease is a major role for successful treatment.

Treatment

Treatment of pericardial effusion should be aimed primarily at addressing its root causes. Often it is the underlying disease (tuberculosis, tumors, renal insufficiency) patient. If the cause is not treated properly by, the chance of full recovery is reduced and the likelihood of recurrence of the disease increases many times.

When expressed in an amount of pericardial effusion, pericarditis absence of symptoms and signs of inflammation in the blood assays or ineffectiveness antiinflammatory therapy major treatment option select drainage pericardial cavity (pericardial puncture with a view to evacuate liquid).

Only to reduce effusion specific therapy exists. In the absence of inflammation in the pericardium NSAIDs, colchicine and corticosteroids does not give the desired effect. If the inflammatory changes are confirmed by blood analysis (increased leukocytes, ESR, C-reactive protein) analysis of the liquid evacuated from the pericardial cavity, the groups listed drugs designated the mandatory order.

When the process of unknown etiology should be considered invasive methods of treatment, including pericardial "window" (operation post pericardial and pleural cavities by forming a hole for a permanent draining pericardium) and perikardektomiya (by excision surgery pericardium).

Complications and prognosis

The most serious complications are constriction and cardiac tamponade. Last - is extremely dangerous for the patient's life and can develop in a matter of minutes (for example, in traumatic lesions).

Forecast effusion depends on its causes. Moderate to severe effusions are more likely to occur at a specific etiologies: bacterial and tumor.

Small or moderate effusions have a good prognosis and quickly to treat idiopathic pericarditis. Expressed chronic effusion of unknown etiology in 1/3 of the cases develop into tamponade.

Small effusion usually passes without clinical signs and becomes a random finding. The prognosis is good for him, and specific monitoring it requires. Patients with moderate to severe effusion due to the high risk of tamponade recommended seen by a cardiologist and perform echocardiogram control 1 every 6 months and 1 time in 3-6 months respectively.