Exudative exudative pericarditis is a disease characterized by inflammation in the membrane lining the inner surface of the pericardial sac. By the nature of the course, effusion pericarditis is acute or chronic.
The disease can be serous, hemorrhagic, purulent, fibrinous and serous-hemorrhagic. With fibrinous exudative pericarditis, fibrin strands are deposited on the pericardium, and some fluid accumulates in the pericardial cavity. Typically, the pericardial cavity contains about 20-40 ml of exudate.
During acute pericarditis, the cellular reaction is accompanied by increased exudation of the liquid fraction of blood into the pericardial cavity. There are frequent cases when the inflammatory process can move 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:
- palpitations;
- impaired breathing by type of shortness of breath;
- increased pressure in the venous system of small and large circulation;
- decrease in systolic blood pressure.
Possible Complications
When the exudative fluid is resorbed, scar tissue consisting of fibrin can form, which in turn can lead to partial or complete infection of the pericardial cavity. Usually the scar is formed in the atrial region, at the confluence of the superior and inferior vena cava, near the atrioventricular sulcus.
With this character, acute exudative pericarditis can lead to a formidable complication, which is called "shell 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, pericardial fibrosis may leave a distensible area, due to which the bulging of the ventricle during diastole allows normal delivery of blood to the heart.
This phenomenon is called fenestration ("open window" effect). The systolic phase, which is provided by the circular muscle layer, as a rule, does not suffer. With a prolonged violation of venous return to the heart, blood stagnation occurs in the pulmonary artery system. With venous stasis in the system of a large circle of blood circulationthere is an extravasation of fluid into the surrounding tissues.
Exudative pericarditis: causes (etiological factors)
One of the most common causes of exudative pericarditis are RNA-containing viruses (A and B), ECHO, influenza A and B, bacterial infections of various nature (pneumococci, staphylococci, streptococci, mycobacterium tuberculosis 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 KSD can be a manifestation of postpericardial syndrome that develops after pericardiotomy, or as an early complication after myocardial infarction, which is called Dressler's syndrome. Usually this complication occurs within a strictly defined time frame, namely from 15 days to 2 months.
Sometimes, exudative-adhesive pericarditis can occur due to the intake of certain drugs: hydralizine, phenytoin, anticoagulants, due to the frequent use of procainamide, radiation therapy. In those cases when a large amount of effusion is found in exudative pericarditis, the cause should be sought in the metastasis of tumors: breast cancer, lung cancer, sarcomas, lymphomas. In these cases, the exudate is usually hemorrhagic, rarely serous.
There is a special kind of exudative pericarditis called hemopericardium. This state occurswith penetrating wounds in the chest area in the projection of the heart, also with myocardial ruptures in patients who have had a myocardial infarction, or with dissecting aortic aneurysms, as a result of which blood fills the pericardial cavity. If the disease has arisen due to incomprehensible etiological factors, then it is classified as nonspecific 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
The accumulated exudate in the pericardial cavity is manifested by pains of a dull and aching nature from the region of the heart, pathological breathing by the type of shortness of breath, which decreases in a sitting position, 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, with a slow rate - the condition is satisfactory, with a fast rate - moderate and severe.
When examining a patient, the following signs of exudative pericarditis can be detected: pale skin, cyanosis of the mucous membrane of the lips, swelling of the lower extremities, acrocyanosis.
When examining the chest area, asymmetry can be found, the left side maybe increased, this is possible only with the accumulation of exudate in the pericardial sac with a volume reaching more than 1 liter. On palpation, Jardin's sign can be detected, when the apical impulse moves up and inward, due to pressure exerted by the fluid accumulated inside.
Percussion can detect the expansion of the boundaries of relative dullness of the heart in all directions: to the left-bottom (in the lower sections) to the anterior 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 SCL (mid-clavicular line), while forming an obtuse angle, instead of a straight one in the norm, to the transition to the border of hepatic dullness. All this may indicate that the patient has exudative pericarditis.
Auscultatory picture: a sharp weakening of the heart sounds in the region of the apex of the heart, at the Botkin-Erb point and the xiphoid process. Loud tones are heard in the region of the base of the heart due to the fact that the heart is displaced by the exudative fluid upwards and backwards. The pericardial friction rub, as a rule, does not manifest itself in any way on auscultation. The level of blood pressure is on the decline, against the backdrop of a decrease in cardiac output.
If the accumulation of exudate occurs slowly in time, then the mechanical work of the heart is not disturbed for a long time due to the fact that the pericardium stretches slowly in this case. In case of rapid accumulation of fluid in the pericardial region and effusion, tachycardia joins, a heart failure clinic with symptoms of blood stagnation in the circulation (large and small).
OnBased on the ECG analysis data for exudative pericarditis, the following is typical. With the accumulation of exudative fluid, a decrease in the voltage of the QRS complex and electrical alteration of the ventricular complexes are additionally calculated. Radiologically, there is an increase in the shadow of the cardiac region and a weakened pulsation of the contour. The vascular bundle is not shortened. Sometimes an effusion can be found in the left pleural cavity.
ECG echo: in the pericardial cavity, the accumulation of effusion fluid is observed behind the left ventricle of the heart, in the region of its posterior wall. With large volumes of effusive fluid, 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 echoes reflected from the epicardium and pericardium.
Identification 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), sowing of biological material (for example, blood) in order to exclude the infectious nature of exudative pericarditis, skin tuberculin sample, serological tests for fungal infection.
Also, immunological studies are carried out in case of systemic connective tissue diseases, they determine the presence of antinuclear antibodies, rheumatoid factors, antistreptolysin-O titer, cold agglutinins - with mycoplasma infection, with uremia, they look at the level of serum creatinine andurea.
Differential diagnosis of exudative pericarditis
Exudative pericarditis is differentiated 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 in myocardial infarction is accompanied by a number of clinical and laboratory signs that manifest themselves as a violation of the processes of central hemodynamics, cardiac arrhythmias, conduction processes in the myocardium, stagnation in the pulmonary circulation, changes in ECG parameters characteristic of myocardial infarction. Biochemical analysis in myocardial infarction indicates the activity of cardiac isoenzymes.
With dry pleurisy, the fact of the presence of pain syndrome and its features associated with breathing, coughing, body position, pleural friction noise during auscultatory examination is of great importance, in addition to the above, it should be noted that with dry pleurisy there is no no changes on the electrocardiogram film. The difference between aortic aneurysm and exudative pericarditis is that it is caused by a genetic disease - Marfan's syndrome or an atherosclerotic lesion of its inner membrane. In some cases, chronic exudative pericarditis may form.
Symptomatically, an aortic aneurysm manifests itself as follows: painsyndrome in the upper chest, without any irradiation, dysphagia, hoarse voice, shortness of breath, cough, caused by compression of the mediastinum. An aortic aneurysm is diagnosed using a chest X-ray, echocardiography, and aortography.
With a dissecting aortic aneurysm, pain appears suddenly in the chest, tends to radiate along the aorta. In this case, the patients are in a serious condition, often there is a disappearance of pulsation on a large artery. Auscultation reveals insufficiency of the aortic valve. Diagnostic measures for dissecting aortic aneurysm will be: transesophageal ultrasound and computed tomography of the chest organs.
What to look out 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 pain, a feeling of heaviness in the heart area, and heart rhythm disturbance.
During auscultation, muffled heart sounds are heard, the first and fourth heart sounds can be bifurcated, when describing the electrocardiogram, the following features can be detected: deformed P wave, change in R wave voltage, T wave may be flattened. During the echocardiography, attention is drawn to the expansion of the chambers of the heart and a decrease in the contractility of the walls.
Therapeutic measures in the treatment of exudative pericarditis
If acute exudative pericarditis is suspected, the patient must be urgently hospitalized in a hospital. If there is a pronounced pain syndrome, it is mandatory to prescribe aspirin in tablet form, a dosage of one gram orally, every three or four hours. Indomethacin 25-50 mg tablets can be added to aspirin with water at intervals of every six hours.
If there are indications, then additionally prescribe a 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. In case of psychomotor agitation against the background of the condition that has arisen or insomnia, "Sibazon" ("Relanium") is prescribed orally, at 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. over several steps. Therapy with glucocorticoid hormones in high doses is carried out in a course of 7-10 days, with the peculiarity that subsequently the dosage should be reduced gradually, two and a half milligrams every day.
Treatment period
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How long is exudative pericarditis treated? Treatment lasts approximately two or three weeks, sometimes it has to be extended up to several months, strictly according totestimony. The specifics 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 - antibacterial drugs are prescribed, for example, benzylpenicillin at 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 tests
Among other things, if exudative pericarditis is diagnosed, then pericardiocentesis should be performed (a procedure of a therapeutic and diagnostic nature, in which a special needle is punctured into the pericardial sac in order to take fluid for analysis). After that, the 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 at a dosage of one gram intravenously, every twelve hours, the therapeutic course is from 14 to 21 days.
Sometimes a fungal infection can cause exudative pericarditis. Treatment in this case is carried out with "Amphotericin". The initial dose is 1 mg, it is administered parenterally (through a vein) in a glucose solution with a percentage of 5 percent and in a volume of fifty milliliters, dripping for 30 minutes. If the patient is given the drugtolerates well, then the dosing regimen is changed according to the following scheme: 0.2 mg / kg for one hour. Subsequently, the dosage is increased gradually 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 kidney function is necessary. If exudative pericarditis has arisen due to taking medications, then in this case, the treatment tactics will be aimed at ensuring that further use of these drugs is stopped and additionally prescribe non-steroidal anti-inflammatory drugs in combination with corticosteroids, they together lead to a quick recovery, especially if they were prescribed from the first days of the onset of the disease.
