Exudative pericarditis: symptoms and causes. Diagnosis and treatment

Exudative exudative pericarditis is a disease characterized by inflammation in the envelope lining the inner surface of the pericardial sac. By the nature of the flow of exudate pericarditis is acute or chronic.

The disease can be serous, hemorrhagic, purulent, fibrinous and serous-hemorrhagic. With fibrinous exudative pericarditis, filaments of fibrin are deposited on the pericardium, and some 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 fraction of the blood. It is not uncommon for the inflammatory process to pass to the subepicardial layer, which sharply worsens its function.

Cardiogenic shock

Often the sudden accumulation of fluid in the pericardial cavity can cause a cardiac tamponade that has symptomatic signs of cardiogenic shock:

• cardiopalmus;
• Violation of breathing by the type of dyspnea;
• Increased pressure in the venous system of small and large circles of circulation;
• Decrease in the level of systolic blood pressure.

Possible complications

With resorption of the exudative fluid, a scar tissue consisting of fibrin can form, which in turn can lead to partial or complete invasion of the pericardial cavity. Typically, the scar is formed in the atrial region, at the point of confluence of the upper and lower hollow veins, near the atrioventricular furrow.

With such a nature, acute exudative pericarditis can lead to a formidable complication, called the "palpable heart", as a result of calcification of the pericardium. An important moment in the pathological process of exudative pericarditis is a violation of diastolic blood return to the ventricles of the heart. The accumulated exudate in the pericardial cavity or the presence of constrictive pericarditis leads to disruption of the subepicardial and subendocardial layers in the apex region. In rare cases, with pericardial fibrosis, a stretchable area may remain, due to which the ventricular swelling during diastole ensures normal delivery of blood to the heart.

This phenomenon is called fenestration (the effect of the "open window"). The systolic phase, which is provided by the circular muscle layer, as a rule, does not suffer. With prolonged disturbance of venous return to the heart, stagnation of blood in the pulmonary artery system occurs. With venous stasis in the system of a large circle of circulation, there is a transudation of the fluid into the surrounding tissues.

Exudative pericarditis: causes (etiological factors)

One of the most common causes of development of exudative pericarditis are RNA-containing viruses (A and B), ECHO, influenza A and B, bacterial infections of various nature (pneumococci, staphylococci, streptococci, tuberculosis mycobacteria and fungi).

This ailment 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 may be a manifestation of a post-pericardial syndrome that develops after pericardiotomy, or as an early complication after a previous myocardial infarction, which is called Dressler's syndrome. Usually 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 medicines: hydralysin, phenytoin, anticoagulants, because of the frequent use of procainamide, radiation therapy. In those cases when exudative pericarditis shows a large amount of effusion, the cause should be sought in the metastasis of tumors: breast, lung, sarcoma, lymphoma. In these cases, usually exudate is 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, also with myocardial ruptures in patients who underwent myocardial infarction, or exfoliating aortic aneurysm, as a result of which the blood fills the pericardial cavity. If the disease has occurred due to incomprehensible etiological factors, then it is referred to a group of nonspecific or idiopathic.

In addition, exudative pericarditis in children, too, sometimes happens. The reasons for this are: streptococcal and staphylococcal infections, tuberculosis, HIV infection, uncontrolled drug intake, cancer, near-heart injuries, kidney failure, heart surgery.

Exudative pericarditis: diagnosis and clinical signs

The accumulated exudate in the pericardial cavity is manifested by dull and aching pain from the region of the heart, pathological breathing by the type of dyspnea, which decreases in the sitting position, palpitation. The pressure exerted by the liquid 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 bag, at a slow speed - the state is satisfactory, with fast - moderate severity and heavy.

When examining the patient, you can find the following signs of exudative pericarditis: 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 increased, this is possible only with the accumulation of exudate in a pericardial bag with a volume exceeding 1 liter. When palpation, you can detect the sign of Jardin, when the apical impulse shifts upward and toward the inside, due to the pressure exerted by the fluid that has accumulated inside.

Percussionally, one can observe the expansion of the boundaries of relative stupidity of the heart in all directions: left-bottom (in the lower sections) to the anterior or to the middle axillary line, in the second and third intercostal spaces to the middle-clavicular line, to the right in the lower regions, to the right SCL (midline -clinical line), forming thus an obtuse angle, instead of straight in norm, to transition to the border of hepatic dullness. All this may indicate that the patient has exudative pericarditis.

Auscultatory pattern: a sharp weakening of heart tones in the region of the apex of the heart, at the point of Botkin-Erba 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 exudating fluid up and back. The noise of friction of the pericardium, as a rule, does not manifest itself auscultately. The level of blood pressure goes down, against the background 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 the case of rapid accumulation of fluid in the pericardial region and the swelling, tachycardia, a clinic of heart failure with the phenomena of blood stagnation in the circulation circles (large and small) is attached.

Based on the ECG analysis data for exudative pericarditis, the following is characteristic. 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. Radiographically, there is an increase in the shadow of the cardiac region and a weakened pulsation of the contour. The vascular bundle does not shorten. Sometimes it is possible to detect an effusion in the left pleural cavity.

ECG Echo: in the pericardial cavity, the accumulation of exudate fluid is observed behind the left ventricle of the heart, in the region of its posterior wall. At large volumes of an exudate liquid, it is found out ahead of the right ventricle of heart. The amount of accumulated fluid in the pericardial bag is judged by the interval between the reflected echoes from the epicardium and pericardium.

Determination of the factor that caused the disease

To establish the etiologic factor, which leads to the exudative form of pericarditis, virologic examination, tests for the presence of certain antibodies (to HIV), the sowing of biological material (for example, blood), to exclude the infectious nature of exudative pericarditis, a cutaneous tuberculin test, serological tests for Fungal infection.

Also immunological studies are conducted with systemic connective tissue diseases, determine the presence of antinuclear antibodies, rheumatoid factors, anti-streptolysin-O titer, cold agglutinins - with mycoplasmal infection, with uraemia, serum creatinine and urea levels 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 cardiac muscle (myocardium). Pain syndrome with 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 rhythm disturbances, conduction processes in the myocardium, stagnation phenomena in the small circle (pulmonary) circulation, characteristic changes in myocardial infarction by ECG parameters. Biochemical analysis of 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 in auscultatory examination is of great importance, besides the above, it should be noted that in dry pleurisy there are no changes on the electrocardiogram film . The difference between an aortic aneurysm and an exudative pericarditis is that it is caused by a genetic disease - Marfan's syndrome or atherosclerotic lesion of its internal membrane. In some cases, chronic exudative pericarditis may form.

Symptomatically, the aortic aneurysm manifests itself as follows: pain syndrome in the upper chest, without any irradiation, dysphagia, hoarse voice, dyspnea, cough due to compression of the mediastinum. Diagnosis of an aneurysm of the aorta by X-ray examination of the thoracic cavity, echocardiography, and aortography.

With a dissecting aneurysm, the aortic pains appear suddenly in the chest, tend to be irradiated along the aorta. In this case, patients are in serious condition, often there is a disappearance of pulsations on a large artery. At auscultation, the aortic valve is inadequate. Diagnostic measures for the dissecting aortic aneurysm will be: transesophageal ultrasound and computed tomography of the thoracic cavity organs.

What to look for

It is very important to differentiate the exudative pericarditis of ICD-10 with diffuse myocarditis, which is accompanied by the expansion of the heart cavity with the phenomena of circulatory insufficiency. Symptomatically, myocarditis manifests itself as follows: it can be pain of a stenocardic character, a feeling of heaviness in the heart area, a violation of the heart rhythm.

Auscultation hears the muffling of cardiac tones, the first and fourth tone of the heart can be bifurcated, when describing the electrocardiogram, the following features can be found: the deformed tooth P, the change in the voltage of the tooth R, the T wave can be flattened. During the Echo-KG, attention is drawn to the expansion of the heart chambers and the reduction in the contractility of the walls.

Therapeutic measures in the treatment of exudative pericarditis

If suspected of acute exudative pericarditis, it is necessary to immediately hospitalize the patient in a hospital. If there is a pronounced pain syndrome, it is mandatory to prescribe aspirin in tablet form, with a dosage of one gramme inside, every three or four hours. To aspirin, you can add indomethacin tablets with a dosage of 25-50 mg, washed down with water, every six hours.

If there are indications, then additionally prescribe a solution of 50% analgin for intramuscular injection of 2 ml or narcotic analgesic (morphine) concentration of 1%, a dose of one or a half milliliters, every six hours. In case of psychomotor agitation against the background of the developed condition or insomnia, the "Sibazon" ("Relanium") is administered internally, with a dosage of 5-10 mg three or four times a day.

To eliminate inflammatory processes most often used in the practice of "Prednisolone", a dosage of 20-80 mg / day. For several tricks. Therapy with glucocorticoid hormones in high doses is carried out with a course of 7-10 days, with the feature that in the subsequent dosage it is necessary to reduce gradually, two and a half milligram every other day.

Treatment period

During what time is exudative pericarditis treated? The treatment lasts approximately two or three weeks, sometimes it is necessary to stretch up to several months, strictly according to the indications. Specificity of treatment depends on the etiologic factor that caused exudative pericarditis.

When viral etiology is detected, non-steroidal anti-inflammatory drugs are prescribed, while hormones are not prescribed. Pericarditis caused by Streptococcus pneumonia is treated differently - prescribe antibacterial drugs, 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 not less than ten days.

Additional tests

In addition, if exudative pericarditis is diagnosed, pericardiocentesis should be performed (a procedure that is of a therapeutic and diagnostic nature, in which a special needle of the pericardial bag is punctured to draw a liquid for analysis). After that, the exudate is sown to detect a specific type of pathogen of this disease, it is important to determine the analysis of its sensitivity to antibacterial drugs. If Staphylococcus aureus is found, the drug "Vancomycin" is usually prescribed in a dose of one gram intravenously, every twelve hours, the therapeutic course is 14 to 21 days.

Sometimes a fungal infection can cause exudative pericarditis. Treatment in this case is carried out by "Amphotericin". The initial dose is 1 mg, it is injected parenterally (through a vein) in a glucose solution with a percentage of 5 percent and a volume of fifty milliliters, dripping for 30 minutes. If the patient tolerates this drug well, the dosage regimen is changed as follows: 0.2 mg / kg for one hour. Subsequently, the dosage is increased gradually to one and a half or one microgram / day. For three or four hours before the onset of a positive effect.

Side effect of "Amphotericin", which is worth paying attention to - nephrotoxic, in this regard, it is necessary to monitor the functions of the kidneys. If the exudative pericarditis has arisen because of the use of medications, then the treatment tactic will be aimed at ensuring that further reception of these drugs is stopped and additionally appointing non-steroidal anti-inflammatory drugs in combination with corticosteroids, they together lead to a rapid recovery, in particular If they were prescribed from the first days of the onset of the disease.