Exudative pericardial effusion is a disease characterized by inflammation in the membrane lining the inner surface of the pericardial sac. By the nature of the course of effusion, pericarditis is acute or chronic.
The disease can be serous, hemorrhagic, purulent, fibrinous and serous-hemorrhagic. With fibrinous exudative pericarditis, fibrin filaments are deposited on the pericardium, and a certain amount of fluid accumulates in the pericardial cavity. Usually in the pericardial cavity contains about 20-40 ml of exudate.
During acute pericarditis, the cellular reaction is accompanied by increased exudation into the pericardial cavity of the liquid blood fraction. There are frequent cases when the inflammatory process can go to the subepicardial layer, which sharply worsens its function.
Cardiogenic shock
Often, sudden accumulation of fluid in the pericardial cavity can cause cardiac tamponade, which has symptomatic signs of cardiogenic shock:
- heart palpitations;
- violation of breathing by the type of shortness of breath;
- increased pressure in the venous system of the small and large circles of blood circulation;
- decrease in systolic blood pressure.
Possible complications
When resorbing the exudative fluid, a scar tissue consisting of fibrin can form, which in turn can lead to partial or complete overgrowth of the pericardial cavity. Typically, a scar forms in the atrial region, at the confluence of the superior and inferior vena cava, near the atrioventricular sulcus.
With this nature, acute exudative pericarditis can lead to a formidable complication called "armored heart", as a result of calcification of the pericardium. An important point in the pathological process of exudative pericarditis is a violation of the diastolic return of blood to the ventricles of the heart. Accumulated exudate in the pericardial cavity or the presence of constrictive pericarditis leads to disruption of the subepicardial and subendocardial layers in the apex. In rare cases, with pericardial fibrosis, a stretchable area may remain, due to which the ventricular bulging during diastole ensures normal blood delivery to the heart.
This phenomenon is called fenestration (the effect of "open window"). The systolic phase, which provides the circular muscle layer, as a rule, does not suffer. With a prolonged violation of the venous return in the heart, blood stasis occurs in the pulmonary artery system. With venous congestion in the system of a large circle of blood circulation, fluid is transudated into the surrounding tissue.
Exudative pericarditis: causes (etiological factors)
One of the most common causes of the development of pericardial effusion is RNA-containing viruses (A and B), ECHO, influenza A and B, various bacterial infections (pneumococci, staphylococci, streptococci, tuberculosis mycobacteria and fungi).
The disease in question can complicate the course of systemic diseases (SLE or Liebman-Sachs disease, rheumatic joint damage, rheumatism, systemic scleroderma) and diseases of the genitourinary system (uremic pericarditis). Exudative pericarditis of the ICD can be a manifestation of postpericardial syndrome, which develops after pericardiotomy, or as an early complication after myocardial infarction, which is called Dressler's syndrome. Typically, this complication occurs in strictly defined terms, namely from 15 days to 2 months.
Sometimes exudative-adhesive pericarditis may appear due to the use of certain drugs: hydralisin, phenytoin, anticoagulants, due to the frequent use of procainamide, radiation therapy. In cases when exudative pericarditis is found to have a high content of effusion, the cause should be sought in the metastasis of tumors: breast cancer, lung cancer, sarcoma, lymphoma. In these cases, the exudate is usually hemorrhagic, less often serous.
There is a special type of exudative pericarditis, which is called hemopericardium. This condition occurs with penetrating wounds in the chest area in the projection of the heart, as well as with myocardial ruptures in patients after myocardial infarction, or stratified aortic aneurysm, as a result of which the blood fills the pericardial cavity. If the disease arose due to incomprehensible etiological factors, then it is referred to the group of non-specific or idiopathic.
In addition, exudative pericarditis in children also sometimes happens. The reasons for this are: streptococcal and staphylococcal infections, tuberculosis, HIV infection, uncontrolled medication, cancerous tumors, injuries near the heart, kidney failure, heart surgery.
Exudative pericarditis: diagnosis and clinical signs
Accumulated exudate in the pericardial cavity is manifested by pains of a dull and aching nature from the region of the heart, pathological breathing like dyspnea, which decreases in a sitting position, heart palpitations. The pressure exerted by the fluid on the trachea and bronchi causes a dry cough.
The general condition of patients depends on the rate of formation of the liquid component in the pericardial sac, at a slow speed - the condition is satisfactory, with a fast - moderate and severe.
When examining a patient, the following signs of exudative pericarditis can be found: pale skin, cyanosis of the mucous membrane of the lips, swelling of the lower extremities, acrocyanosis.
When examining the chest area, asymmetry can be detected, the left side can be enlarged, this is possible only with the accumulation of exudate in the pericardial sac with a volume reaching more than 1 liter. On palpation, you can find the sign of Jarden, when the apical impulse is displaced upwards and inwards, due to the pressure exerted by the fluid accumulated inside.
Percussion can detect the expansion of the boundaries of the relative dullness of the heart in all directions: left-bottom (in the lower sections) to the front or to the median axillary line, in the second and third intercostal spaces to the mid-clavicular line, to the right in the lower sections, to the right SCR (midline -clavicular line), forming an obtuse angle, instead of a normal line, to the transition to the border of hepatic dullness. All this may indicate that the patient has exudative pericarditis.
Auscultatory picture: sharp weakening of heart sounds in the region of the apex of the heart, at the point of Botkin-Erb and the xiphoid process. In the area of the base of the heart, loud tones are heard due to the fact that the heart is displaced by the exudate up and back. The noise of pericardial friction, as a rule, does not manifest itself auscultatory in any way. The level of blood pressure is on the decline, with a decrease in cardiac output.
If the accumulation of exudate occurs slowly in time, then the mechanical work of the heart for a long time is not disturbed due to the fact that the pericardium stretches in this case slowly. In the case of rapid accumulation of fluid in the pericardial region and effusion, tachycardia, a clinic of heart failure with symptoms of stagnation of blood in the blood circulation (large and small), join.
Based on ECG analysis data, exudative pericarditis is characterized by the following. With the accumulation of exudative fluid, the decrease in the voltage of the QRS complex and the electrical alteration of the ventricular complexes are additionally calculated. Radiologically there is an increase in the shadow of the heart region and a weakened pulsation of the contour. The vascular bundle is not shortened. Sometimes it is possible to detect effusion in the left pleural cavity.
ECG echo: in the pericardial cavity, an accumulation of exudate fluid is observed behind the left ventricle of the heart, in the region of its posterior wall. With large volumes of effluent, it is found in front of the right ventricle of the heart. The amount of accumulated fluid in the pericardial sac is judged by the interval between the reflected echoes from the epicardium and pericardium.
Establishment of the factor that caused the disease
To establish the etiological factor that led to the exudative form of pericarditis, a virological examination is carried out, tests for the presence of certain antibodies (to HIV), inoculation of biological material (for example, blood) in order to exclude the infectious nature of exudative pericarditis, a skin tuberculin test is carried out,
serological tests for fungal infection.
Also, immunological studies are carried out with systemic connective tissue diseases, determine the presence of antinuclear antibodies, rheumatoid factors, antistreptolysin-O titer, cold agglutinins - with mycoplasma infection, with uremia, serum creatinine and urea are monitored.
Differential diagnosis of exudative pericarditis
Exudative pericarditis differentiates with the following nosological units: acute myocardial infarction, vasogenic pain, mitral valve prolapse, dry pleurisy.
In acute myocardial infarction, the pain syndrome is caused by the accumulation of metabolic products in the heart muscle (myocardium). Pain syndrome with myocardial infarction is accompanied by a number of clinical and laboratory signs that manifest themselves as a violation of central hemodynamics, cardiac arrhythmias, myocardial conduction processes, stagnation phenomena in the small circle (pulmonary) blood circulation, changes in ECG indices characteristic of myocardial infarction. Biochemical analysis for myocardial infarction indicates the activity of cardiac isoenzymes.
With dry pleurisy, the fact of the presence of pain and its characteristics associated with breathing, coughing, body position, pleural friction noise during auscultation examination is of great importance, in addition to the above, it should be noted that with dry pleurisy there are no changes on the electrocardiogram film . The difference between aortic aneurysm and exudative pericarditis is that its cause is a genetic disease - Marfan syndrome or atherosclerotic lesion of its inner membrane. In some cases, chronic pericardial effusion may form.
Symptomatically, an aortic aneurysm manifests itself as follows: pain in the upper chest, without any irradiation, dysphagia, hoarse voice, shortness of breath, cough caused by compression of the mediastinum. Aortic aneurysm is diagnosed with an X-ray examination of the chest cavity, echocardiography, and aortography.
With a stratified aortic aneurysm, pains appear suddenly in the chest, tend to irradiate along the aorta. At the same time, patients are in serious condition, often pulsation on the large artery disappears. During auscultation, aortic valve insufficiency is heard. Diagnostic measures for stratified aortic aneurysm will include: transesophageal ultrasound and computed tomography of the chest cavity.
What to look for
It is very important to differentiate exudative pericarditis ICD 10 with diffuse myocarditis, which is accompanied by an expansion of the heart cavity with symptoms of
circulatory failure. Symptomatically, myocarditis manifests itself as follows: it can be angina pectoris, a feeling of heaviness in the heart region, a violation of the heart rhythm.
During auscultation, a muffling of heart sounds is heard, the first and fourth heart sounds can be bifurcated, when describing an electrocardiogram, the following features can be detected: a deformed P wave, a change in the voltage of the R wave, T wave can be flattened. During the Echo-KG, attention is drawn to the expansion of the chambers of the heart and the reduction of contractility of the walls.
Therapeutic measures in the treatment of exudative pericarditis
If acute exudative pericarditis is suspected, it is necessary to urgently hospitalize the patient in a hospital. If there is severe pain, it is mandatory to prescribe aspirin in tablet form, with a dosage of one gram inside, at intervals of three or four hours. Indomethacin tablets with a dosage of 25-50 mg can be added to aspirin, washed down with water, at intervals every six hours.
If there are indications, an additional solution of 50% analgin for intramuscular injection of 2 ml or a narcotic analgesic (morphine) with a concentration of 1%, a dosage of one or one and a half milliliters, every six hours every six hours, is additionally prescribed. With psychomotor agitation against the background of a condition or insomnia, "Sibazon" ("Relanium") is prescribed orally, with a dosage of 5-10 mg three or four times a day.
To eliminate inflammatory processes, Prednisolone is most often used in practice, with a dosage of 20-80 mg / day. in a few tricks. Therapy with glucocorticoid hormones in high doses is carried out in a course of 7-10 days, with the peculiarity that in the subsequent dosage should be reduced gradually, two and a half milligrams every day.
Treatment period
How long is exudative pericarditis treated? Treatment lasts approximately two or three weeks, sometimes it is necessary to stretch it to several months, strictly according to indications. The specificity of treatment depends on the etiological factor that caused exudative pericarditis.
When a viral etiology is detected, non-steroidal anti-inflammatory drugs are prescribed, hormones are not prescribed. Pericarditis caused by Streptococcus pneumonia is treated differently - antibiotics are prescribed, for example, benzylpenicillin with a dosage of 200,000 units / kg / day. intravenously, this dosage is divided into six injections, the duration of treatment is at least ten days.
Additional analyzes
In addition, if exudative pericarditis is diagnosed, then pericardiocentesis should be performed (a procedure that has a medical-diagnostic nature, in which a special needle is punctured with a pericardial sac in order to collect fluid for analysis). After that, exudate is sown in order to detect a certain type of causative agent of this disease, it is important to determine the analysis of its sensitivity to antibacterial drugs. If Staphylococcus aureus is found, then the drug "Vancomycin" is usually prescribed with a dosage of one gram intravenously, every twelve hours, the therapeutic course is from 14 to 21 days.
Sometimes a fungal infection can cause pericardial effusion. The treatment in this case is carried out with Amphotericinum. The initial dose is 1 mg, it is in a glucose solution with a percentage equal to 5 percent and in the volume of fifty milliliters, administered parenterally (through a vein), dripped for 30 minutes. If the patient tolerates this drug well, then the dosage regimen is changed according to the following scheme: 0.2 mg / kg for one hour. Subsequently, the dosage is gradually increased to one and a half or one microgram / day. three or four hours before the onset of a positive effect.
A side effect of Amphotericin, which is worth paying attention to, is nephrotoxic, in connection with this, monitoring of renal function is necessary. If exudative pericarditis occurred due to medication, then the treatment tactic will be aimed at stopping further use of these drugs and additionally prescribing non-steroidal anti-inflammatory drugs in combination with corticosteroids, which together lead to a quick recovery, in particular if they were prescribed from the first days of the onset of the disease.