Pericardial effusion

1. Gastroepato
2. Cardiology
3. Pericarditis
4. The patient swollen
5.  Pulmonary heart

• #Definition
• #Etiology_of_the_causes_of-_pericardial_effusion
• #Types_of_pericarditis
• #Pathophysiology
• #Features
• #Symptomatology
• #Pathological_conditions_related-to_pericarditis

notes by  dr Claudio Italiano

The pericardium is a fibrous sac that contains the heart and the large blood vessels, divided into 2 sheets, with 20 ml of liquid between the visceral and parietal laminae, smooth and shiny, used to allow the heart to move freely, reducing frictions. In the case of pericarditis, ie inflammation of the pericardium, plaque opacification, calcification and fibrosis can be appreciated. Other times, in the condition of "adipositas cordis" the heart is surrounded by fatty tissue, adipose tissue. We also describe dry pericarditis with fibrin deposition, of reddish color, or of uric acid crystals and it is called "cor villosus". Pericardium may also have neoplasms: we have primary tumors, mesothelioma, as with the pleura, but it is more common than secondary lesions.

Definition

Definition: we talk about pericardial effusion when between the pericardial sheets it is clear liquid that exceeds 200-300 ml. It can be randomly highlighted with echocardiography or chest radiography. At the X-ray examination the heart appears with a "boot" appearance, like a balloon, with implemented profiles. The echocardiographic survey shows a thickness around the heart defined in clinical practice as "disconnection", which generally can only be posterior or extended. The patient also has retorseral pains, sometimes feverish or high fever, fatigue, dyspnoea, but more rarely, there are changes in the electrocardiographic pattern, characterized by low QRS complexes.

Etiology of the causes of pericardial effusion

-Trauma: pericardiotomy, injection of m.d.c., perforations of the right ventricle from the catheter, pacemarker implantation, stroke on the thorax;
- Viral infections: coxackie virus, adenovirus, coxsakie virus, infectious mononucleosis, influenza, venereal lymphogranuloma, mycoplasma, AIDS;
- bacterial infections: TBC, - staphylococcus, pneumococcus, meningococcus, streptococcus, from haemophilus - influenzae, chlamydia,
- rickettia,
- Radiation
- Primitive neoplasms: mesothelioma, teratoma, fibroma, leiomyofibroma, lipoma
- Metastasis: bronchogenic carcinoma, breast cancer, lymphoma, leukemia, melanoma.
- Granulomatosis: collagen diseases, rheumatic fever, SLE, vasculitis, scleroderma;
- Anticoagulants: heparin and dicumarolics
- Myocardial infarction or Dressler's syndrome
- Drugs: procainamide, disodiocromoglicate, hydralazine, dantrolene
- Dissection of the aneurysm
- haemopericardium
- Idropericardium.
- Chilopericardium

Types of pericarditis

- Purulent bacterial infection due to infection in sepsis, trauma
-Viral, from viruses
- From tbc
-In course of rheumatic illness
-epistenocardica during Dressler's post-infarct syndrome
Uremic uric acid of the patient with chronic renal failure at the advanced stages


It may be:

- transudative (congestive heart failure, myxoedema, nephrotic syndrome),
- exudative (tuberculosis, spread from empyema)
- hemorrhagic (trauma, rupture of aneurysms, malignant effusion).
- malignant (due to fluid accumulation caused by metastasis)

Pathophysiology

Mechanism with which the liquid is formed: a) for increased capillary hydrostatic pressure; b) for non-reabsorption, c) for increased vessel permeability.

Pericardiocentesis technique

The liquid is aspirated by pericardiocentesis; the elective points for this maneuver must be extraperitoneal and extrapleural and are located at the costosternal corner with direction towards the left nipple or 4 -5th intercostal space, one finger beyond the breastbone.

Features

The liquid may have the characteristics of exudate or transudate. The transudate will have a serous yellow color, with a specific gravity <1015, not coagulated, the protein content is <25%, the cellular content is low and the Rivalta reaction is negative. In the case of exudate, its color will be bright yellow, haemorrhagic, purulent or chilose, sublime or frankly turbid, specific gravity> 1015, spontaneous coagulation, different cellular content depending on the etiology of the same effusion (neoplastic cells, LE, RA, CD8 + lymphocytes, PMN, lymphocytes). In the case of neoplasms it will be possible to find invasion of the pericardium and to demonstrate the primary and secondary nature of the cells through the cytological investigation; in case of bacterial infections it will be possible to carry out culture tests; the presence of red blood cells will orientate towards viral pericarditis but also in uremic forms

Symptomatology

This may vary depending on whether the effusion is massive and rapid onset, up to the established cardiac tamponade picture, which requires urgent evacuation pericardiocentesis. Examples are the victims of thoracic traumas, myocardial infarction with cardiac rupture, dissecting aneurysm, which have severe dyspnea, chest tightness, vertigo, paradoxical pulse, which falls by 10-20 mmHg in the inspiratory phase, hypotension and shock. The patient with an important effusion presents a painful symptomatology that depends on the algogenic sensibility of the inferioralateral parietal pericardium (fibers of the phrenic nerve) due to the involvement of the phrenic nerve; the pain is precordial, irradiated to the left arm, and to the neck, exacerbated by the breath and the decubitus, sometimes similar in all to an acute infarct, some other bearable. Fever, dysphagia and dyspnea also appear. Objectively, the diagnosis is made at the auscultation for signs of pericardial rubbing, a superficial, scratchy, strident noise, like the rough leather or the trampled snow, the cardiac tones are weakened, the cardiac atria increases at the thoracic percussion, and later on large effusions of dullness of the left shoulder blade. To the ECG, QRS complexes of low voltage with elevation of ST matching saddle. Rx with a heart image of a flask or pear heart, echocardiography: it shows 2 echoes of the posterior wall of the heart: one from the left ventricular wall and the other from the pericardium, from which there are two echoes; if it is abundant we will have the image of the "swining heart", in the tamponade we can deduce a severe compression of the right ventricle and of the right atrium.

Pathological conditions related to pericarditis

Uremic effusion

In subjects undergoing peritoneal dialysis, hemorrhagic dithesis predisposes to blood effusion, which initially begins as serum-fibrinic pericarditis.
Post-infarct or S. of Dressler. It is a serum-fibrinous, seroematic effusion, as it resolves with steroid treatment and recognizes an immune-type reaction consequent to myocardial damage.
Payment in neoplastic diseases. Some primary or secondary neoplasms can evolve involving the myocardium and the pericardium, in particular the metastases in the course of carcinoma of the breast, of the lung, of the lymphomas, of the leukemia. The liquid is usually blood and in its context there are neoplastic cells, and give rise to constrictive pericarditis.

Effusion into radiation

Radiation mediastinal exposure carries the risk of damage to the myocardium, eg in Hodgkin disease, probably due to damage of pericardial lymphatics, especially in patients undergoing chemotherapy. This is for exposures of at least 4000 rads.

Effusion of rheumatoid arthritis, scleroderma and LES

In 30% of cases there is a chronic exudative effusion, sometimes fibrinous, or frankly hemorrhagic, or opalescent and containing crystals of cholesterol, with lymphocytic cells of the CD8 + type; in the course of LES it is possible to find LE cells, reduced level of complement and reduced glucose level.

Effusion into tuberculous pericarditis

In patients with AIDS, due to the extension of the process from contiguous lung areas, a serofibrinose exudate with a serofibrinose or, more often, hematic effusion can occur. In the liquid it is possible to demonstrate Koch's bacilli and a typical caseous necrosis. The evolution will be towards adhesive-constrictive pericarditis.

Effusion of bacterial infections

Purulent discharge is less frequent due to the effectiveness of antibiotics; we have meningococcus, staphylococcus, Klebsiella, Haemophilus Influenzae, with an effusion that is initially serofibrinose, therefore serum, therefore frankly purulent, especially in children; it may originate from contiguous structures, e.g. pneumonia, empyema, and propagate to the pericardial serosa. It will have been toxic, high fever and pronounced leukocytosis, with cardiac tamponade.

Transudative effusion (hydropericardium)

It is given by an excessive content of transudate in the pericardial cavity, by generalized anasarcatic state; this occurs due to the resorption of the pericardial fluid in the following conditions: congestive heart failure, glomerulonephrosis, mixedema, beriberi, cachectizing diseases with severe dysrotidemia, carcinomatosis and cirrhosis of the liver. It also depends on conditions of impeding the outflow of the venous pericardial fluid, as in mediastinal, pulmonary tumors of the thymus and medistine lymph nodes.

Frankly blood supply or hemopericardium

Hemopericardium is called the collection of blood in the pericardial cavity, not due to inflammatory process, but from the wall break of a cardiac cavity, e.g. in the course of IMA and / or rupture of heart due to trauma or rupture of the aorta in its intrapericardial tract by dissecting aneurysm.
 

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