|A 2D transthoracic echocardiogram of pericardial effusion. The "swinging" heart|
|Symptoms||Chest pain, shortness of breath, tiredness|
|Usual onset||Sudden, gradual|
|Types||Transudate, exudate, bloody|
|Diagnostic method||Ultrasound of the heart|
|Differential diagnosis||Pericarditis, pulmonary edema, dilated cardiomyopathy, constrictive pericarditis, pulmonary embolism|
|Treatment||Conservative management, pericardiocentesis|
Pericardial effusion is an abnormal accumulation of fluid in the pericardial space around the heart. Symptoms may include chest pain, shortness of breath, and tiredness. Onset may be sudden or gradual. Complications may include cardiac tamponade with low blood pressure, fast heart rate, jugular venous distension, and distant heart sounds.
Causes include infections, autoimmune disorders, cancer, trauma, following a heart attack, thoracic aortic dissection, kidney failure, low thyroid, and cirrhosis. In the developed world the most common cause is viral pericarditis. Diagnosis is confirmed by ultrasound of the heart. Normal levels of pericardial fluid are from 15 to 50 ml.
Treatment depends on the underlying cause, size of the effusion, and a person's symptoms. Small effusions may be managed conservatively while large effusions may be treated with pericardiocentesis. Pericardial effusions are relatively common. Pericardial effusions were first described around 200 AD by Galen.
Signs and symptoms
Chest pain or pressure are common symptoms. A small effusion may be asymptomatic. Larger effusions may cause cardiac tamponade, a life-threatening complication; signs of impending tamponade include dyspnea, low blood pressure, and distant heart sounds.
- Viral infection (coxsackie virus)
- Infection including tuberculosis
- Drug eluting stents
- Inflammatory disorders, such as lupus, rheumatoid arthritis and post myocardial infarction pericarditis (Dressler's syndrome)
- Cancer that has spread to the pericardium such as breast and lung cancer. Pericardial irregular thickening and/or nodularity, focal, or diffuse FDG uptake on PET scan and lack of preserved fat plane with an adjacent tumor are strongly suggestive of cancer spread from other parts of the body.
- Kidney failure with excessive blood levels of urea nitrogen
- Heart surgery (Postpericardiotomy syndrome)
- Primary tumor - The most common primary pericardial tumour is mesothelioma. Various imaging appearances such as solid and cystic components could be encountered on CT scan on those with mesothelioma. Other less common primary tumours are sarcoma, ly,phoma, and primitive neuroectodermal tumour.
It may be:
- transudative (congestive heart failure, myxoedema, nephrotic syndrome),
- exudative (tuberculosis, spread from empyema)
- bloody (trauma, rupture of aneurysms, malignant effusion).
- malignant (due to fluid accumulation caused by metastasis)
The most common causes of pericardial effusion have changed over time and vary depending on geography and the population in question. When pericardial effusion is suspected, echocardiography usually confirms the diagnosis and allows assessment for signs of hemodynamic instability. Cross-sectional imaging with computed tomography (CT) can help to localize and quantify (as in a loculated effusion) or assess for pericardial pathology (pericardial thickening, constrictive pericarditis).
The so-called "water-bottle heart" is a radiographic sign of pericardial effusion, in which the cardiopericardial silhouette is enlarged and assumes the shape of a flask or water bottle.
A CT scan image showing a pericardial effusion
An ECG showing sinus tachycardia and electrical alternans in a person with a pericardial effusion.
Loculated pericardial effusion
Treatment depends on the underlying cause and the severity of the heart impairment. Pericardial effusion due to a viral infection usually goes away within a few weeks without the treatment. Some pericardial effusions remain small and never need treatment. If the pericardial effusion is due to a condition such as lupus, treatment with anti-inflammatory medications may help. If the effusion is compromising heart function and causing cardiac tamponade, it will need to be drained, most commonly by a needle inserted through the chest wall and into the pericardial space called pericardiocentesis. A drainage tube is often left in place for several days. In some cases, surgical drainage may be required by cutting through the pericardium creating a pericardial window.
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