CR Pleural Effusion Ec Hepatoma

8/10/2019 CR Pleural Effusion Ec Hepatoma

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I. PATIENT STATUS

PATIENT IDENTITY

Initial Name : Mrs. D

Sex : Female

Age : 48 years old

Nationally : Indonesia (Javanese)

Marital Status : Married

Religion : Islam

Occupation : Housewife

Educational Background : Elementary School

Address : Talang padang, Tanggamus

ANAMNESIS

Taken from : Autoanamnesis

Date : May 29th, 2014

Time : 14.00

Chief Complain : Shortness of breath since 2 month ago

Additional Complaint : The patient felt abdominal bloating and hard, liquid bowel movements

since 2 months ago, cough with phlegm, thrush, tongue dirty.

History of The Present Illness :

Patients present with shortness of breath since 2 months ago and became heavier since 1 week

ago. Patients complain of difficulty breathing while being crowded. Patients feel better when

you're in a sitting position or by using a high pillow. Shortness of breath arise every day and

compounded with moderate activity. Patients complain when it is relapse can reach 1-2 hours.

The patient also complained of cough with phlegm since 2 months ago. The patient admitted that

he had been undergoing treatment at the general hospital Pringsewu for 1 week. But in reference



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to Abdul Moeloek Bandar Hospital. Patients also complain of poor appetite since 6 months ago.

Patients admitted to having obtained an ultrasound examination of the abdomen and liver

irritation.

The History of Illness :

(-) Small pox (-) Malaria (-) Kidney stone

(-) Chicken pox (-) Disentri (-) Hernia

(-) Difthery (+) Hepatitis (-) Prostat

(-) Pertusis (-) TifusAbdominalis (-) Melena

(-) Measles (-) Skirofula (+) Diabetic

(+) Influenza (-) Siphilis (-) Alergy

(-) Tonsilitis (-) Gonore (-) T u m o r

(-) Kholera (-) Hipertension. (-) Vaskular Disease

(-) Acute Rheumatoid Fever (-) Ventrikuli Ulcer (-) Operation(-) Pneumonia (-) Duodeni Ulcer

(-) Pleuritic (-) Gastritis

Family’s diseases History :

Patient didn’t know about his Family’s Disease History

Is there any family who suffer :

Patient said that one of the family members of the patient's husband has been sick TB and has

been dead several years ago

SYSTEM ANAMNESE

Note of Positive Complaints beside the title

Skin

(-) Boil (-) Hair (-) Night sweat

(-) Nail (-) Yellow /Werus (-) Cyanotic

(-) Others

Head

(-) Trauma (+) Headache

(-) Syncope (-) Pain of the sinus



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Ear

(-) Pain (-) Tinitus

(-) Secret (-) Ear disorders

(-) Deafness

Nose

(-) Trauma (-) Clogging

(-) Pain (-) Nose disorders

(-) Sekret (-) common cold

(-) Epistaksis

Mouth

(-) Lip (+) Dirty Tongue

(-) Gums (-) Mouth disorders

(-) Membrane (+) Stomatitis

Throat

(+) Throat Pain (-) Voice Change

Neck

(-) Protruding (-) Neck Pain

Cor/ Lung

(+) Chest pain (+) Dyspneu

(-) Pulse (-) Hemoptoe

(-) Ortopneu (+) Cough

Abdomen (Gaster/ Intestine)

(-) Puffing (+) Acites

(-) Nausea (-) Hemoroid(-) Emesis (+) Diarrhea

(-) Hematemesis (-) Melena

(-) Disfagi (-) Pale colour of feses

(-) Colic (-) Black colour of feses

(-) Nodul



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Urogenital

(-) Dysuria (-) Pyuria

(-) Stranguria (-) Kolik

(-) Polyuria (-) Oliguria

(-) Polakysuria (-) Anuria(-) Hematuria (-) Urine retention

(-) Kidney stone (-) Drip urine

(-) Wet the bed (-) Prostat

Katamenis

(-) Leukorhoe (-) Bleeding

(-) Other

Muscle and Neuron

(-) Anestesi (-) Hard to bite

(-) Parestesi (-) Ataksia

(-) Weak muscle (-) Hipo/hiper-estesi

(-) Afasia (-) Tick

(-) Amnesis (-) Vertigo

(-) Others (-) Disartri

(-) Convultion (-) Syncope

Extremities

(+) Edema (-) Deformitas

(-) Hinge pain (-) Cyanotic

Weight

Average weight (kg) : 50kg

Height (cm) : 155cm

Present Weight : 44kg

(if the patient doesn’t know certainly)

(-) steady

(+) down

(-) up



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THE HISTORY OF LIFE

Birth place

(+) in home (-) matrinity (-) matrinity hospital

Helped by:

(+) Traditional matrinity (-) Doctor (-) Nurse (-) Others

Imunitation History (Unknown)

(-) Hepatitis (-) BCG (-) Campak (-) DPT (-) Polio Tetanus

Food History

Frequency/day : 3x/day

Amount/day : 1 place/eat (health)

Variation/day : Rice, vegetables, fish

Appetite : Decrease

Educational

(+) SD (-) SMP (-) SMA (-)SMK (-) Course Academy

Problem

Financial : low

Works : -

Family : normal

Others : -

Body Check Up

General Check Up

Height : 144 cm

Weight : 42 kg

Blood Pressure : 100/60 mmHg



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Pulse : 104 x/minute

Temperature : 36,10C

Breath (Frequence&type) : 28 x/minute

Nutrition Condition : Normal,

Consciousness : Compos Mentis

Cyanotic : (-)

General Edema : pitting oedem

The way of walk : normal

Mobility : Passive

The age predicyion based on check up : 45 years old

Mentality Aspects

Behavior : Normal

Nature of Feeling : Normal

The thinking of process : Normal

Skin

Color : Olive

Keloid : (-)

Pigmentasi : (-)

Hair Growth : Normal

Arteries : Touchable

Touch temperature : Afrebris

Humid/dry : Dry

Sweat : Normal

Turgor : Normal

Icterus : Icteric

Fat Layers : Enough

Efloresensi : (-)

Edema : (+)

Others : (-)



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Lymphatic Gland

Submandibula : no enlargement

Neck : no enlargement

Supraclavicula : no enlargement

Armpit : no enlargement

Head

Face Expression : Normal

Face Symmetric : Symmetric

Hair : Black

Temporal artery : Normal

Eye

Exopthalmus : (-)

Enopthalmus : (-)

Palpebra : edema (-)/(-)

Lens : Clear/Clear

Conjunctiva : Anemis +/+

Visus : Normal

Sklera : Icteric +/+

Ear

Deafnes : (-)

Foramen : (-)

Membrane tymphani : intact

Obstruction : (-)

Serumen : (-)

Bleeding : (-)

Liquid : (-)



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Mouth

Lip : (-)

Tonsil : (-)

Palatal : Normal

Halibsts : No

Teeth : (-)

Trismus : (-)

Farings : Unhiperemis

Liquid Layers : (-)

Tongue : Dirty

Neck

JVP : Normal

Tiroid Gland : no enlargement

Limfe Gland : no enlargement

Chest

Shape : Simetric

Artery : Normal

Breast : Normal

Lung

Inspection : Left : simetric, no lession, normochest

Right : simetric, no lession, normochest

Palpation : Left : vokal fremitus decreased, pain (-)

Right : vokal fremitus decreased, pain (-)

Percussion : Left : flatness

Right : flatness

Auscultation : Left : vesiculer decrease, wheezing expiration (-), ronkhi (+)

Right : vesiculer decrease, wheezing expiration (-), ronkhi (+)



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Cor

Inspection : Ictus cordis not visible

Palpation : Ictus Cordis no palpable

Percussion : difficult to essess

Auscultation : Heart Sound 1 & 2 Regular

Artery

Temporalic artery : No aberration

Caritic artery : No aberration

Brachial artery : No aberration

Radial artery : No aberration

Femoral artery : No aberration

Poplitea artery : No aberration

Posterior tibialis artery : No aberration

Stomach

Inspection : convex

Palpation : Stomach Wall : undulation (-), pain (+)

Heart : Hepatomegali (+)

Limfe : Splenomegali (+)

Kidney : Ballotement (-)

Percussion : Shifting Dullness (+)

Auscultation : Intestine Sounds (+)

Genital (no indication)

Movement Joint

Arm Right Left

Muscle Normal Normal

Tones Normal Normal

Mass Normal Normal



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Joint Normal Normal

Movement Normal Normal

Strength Normal Normal

Heel and Leg

Wound/injury : not found

Varices : (-)

Muscle (tones&mass) : Normal

Joint : Normal

Movement : Normal

Strength/Power : Normal

Edema : (+) (pitting edema)

Others : (-)

Reflexs

Right Left

Tendon Reflex Normal Normal

Bisep Normal Normal

Trisep Normal Normal

Pattela Normal Normal

Achiles Normal Normal

Cremaster Normal Normal

Skin Reflex Normal Normal

Patologic Reflex Not Found Not Found

Laboratory

Routine Blood

- Hb : 7,0 gr/dl

- Leukosit : 19400/ mikroliter

- LED : 110 mm/jam



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- Trombosit : 316.000

- Diff. Count

o Basofil : 0%

o Eosinofil : 2%

o Stem : 0%

o Segment : 86%

o Limfosit : 6%

o Monosit : 6%

USG

Impression : Hepatomegaly, according hepatoma picture

Ascites and bilateral pleural effusion

Ren, spleen, bladder and uterus normal

Resume

Patient came to hospital and told

Patients present with shortness of breath since 2 months ago and became heavier since 1 week

ago. Patients complain of difficulty breathing while doing activity. Patients feel better when in a

sitting position or by using a high pillow. Shortness of breath arise every day and compounded

with moderate activity. Patients complain when it is relapse can reach 1-2 hours. The patient also

complained of cough with sputum since 2 months ago. Patients also complain of poor appetite

since 6 months ago. Patients admitted to having obtained an ultrasound examination of the

abdomen and liver irritation. Ultrasound examination : Hepatomegaly, according hepatoma

picture, ascites and bilateral pleural effusion, dan ren, spleen, bladder and uterus normal.

Radiology chest X-Ray : meniscus sign that blunts the costophrenic angle on the PA projection.

Working Diagnose

- PE with Hepatoma

Basic Diagnose

Anamnesis



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- shortness of breath Smoking history

Physics Examination

- flatness percussion

- Rhonki (+)

Support Radiology

- Chest X-Ray : meniscus sign that blunts the costophrenic angle on the PA projection

Ultrasound

- Hepatomegaly, according hepatoma picture, ascites and bilateral pleural effusion

Differential Diagnose

- TB

-

Cor abnormality

Basic Differential Diagnose

Anamnesis

- Shortness of breath

- Recurrent Dyspneu

- Chough with sputum

- Member of family has been diagnosed TB

Physics Examination

- Symetrics

- Flatness percussion

- Rhonki (+)

Support Examination

- Chest X ray : meniscus sign that blunts the costophrenic angle

Support Check Up

- Laboratory

o Ureum Creatinin

o Electrolite

o GDS



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o Lipid Profile

o Uric Acid

o Albumin

- Rivalta test

- Sitology

Treatment Plan

(1) General Treatment

- Bed Rest

- Nutrition (high calory, high protein)

(2) Special Treatment

-

Medicamentosa

o IVFD RL : D5 gtt X/minute

o Cetirizin ½ tab 2x1

o Ranitidin 2x1 amp

o Ciprofloxacine 200mg/12 jam

o Dexamethasone 3x1 amp

o Curcuma 3x1 tab

o Antasid tab 3x1

- Non Medicamentosa

o Therapeutic thoracentesis

o Activity adjustment

o Go to doctor immedietly if appear any symptoms

Prognose

Quo ad Vitam : Dubia ad bonam

Quo ad Functonam : Dubia

Quo ad Sanationam : Dubia ad malam



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II. REFERENCE

A. Definition

Pleural effusion means the collection of large amounts of free fluid in the pleural space.The

effusion is analogous to edema fluid in the tissues and can be called “edema of the pleural

cavity.” The causes of the effusion are the same as the causes of edema in other tissues,

including (1) blockage of lymphatic drainage from the pleural cavity; (2) cardiac failure, which

causes excessively high peripheral and pulmonary capillary pressures, leading to excessive

transudation of fluid into the pleural cavity (3) greatly reduced plasma colloid osmotic pressure,

thus allowing excessive transudation of fluid; and (4) infection or any other cause of

inflammation of the surfaces of the pleural cavity, which breaks down the capillary membranes

and allows rapid dumping of both plasma proteins and fluid into the cavity.

The pleural space lies between the lung and the chest wall and normally contains a very thin

layer of fluid, which serves as a coupling system. A pleural effusion is present when there is an

excess quantity of fluid in the pleural space. Pleural effusions seen in patients with increased

pulmonary venous pressure represent another reservoir for edema fluid, one that may

compromise respiratory function less than would having the same fluid in the lung parenchyma.

B.

Etiology

Pleural fluid accumulates when pleural fluid formation exceeds pleural fluid absorption.

Normally, fluid enters the pleural space from the capillaries in the parietal pleura and is removed

via the lymphatics in the parietal pleura. Fluid also can enter the pleural space from the

interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity via small holes

in the diaphragm. The lymphatics have the capacity to absorb 20 times more fluid than is formed

normally. Accordingly, a pleural effusion may develop when there is excess pleural fluid

formation (from the interstitial spaces of the lung, the parietal pleura, or the peritoneal cavity) or

when there is decreased fluid removal by the lymphatics.



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C. Radiological Investigations

Most pleural effusions are detected on plain chest radiography, although lateral (and specifically

lateral decubitus) radiographs increase sensitivity. About 200 ml of pleural fluid must be present

before any change is evident on the plain posteroanterior (PA) chest radiograph. The classical

appearance of pleural effusion is easily recognised. However, loculated fluid may appear

atypically and encysted fluid within the lung fissure may give the appearance of an

intraparenchymal mass.

D. Pleural fluid diagnostic tests

When a patient is found to have a pleural effusion, an effort should be made to determine the

cause. The first step is to determine whether the effusion is a transudate or an exudate. A

transudative pleural effusion occurs when systemic factors that influence the formation and

absorption of pleural fluid are altered. The leading causes of transudative pleural effusions in the

United States are left-ventricular failure and cirrhosis. An exudative pleural effusion occurs

when local factors that influence the formation and absorption of pleural fluid are altered. The

leading causes of exudative pleural effusions are bacterial pneumonia, malignancy, viral

infection, and pulmonary embolism. The primary reason for making this differentiation is that

additional diagnostic procedures are indicated with exudative effusions to define the cause of the

local disease. Transudative and exudative pleural effusions are distinguished by measuring the

lactate dehydrogenase (LDH) and protein levels in the pleural fluid. Exudative pleural effusions

meet at least one ofthe following criteria, whereas transudative pleural effusions meet none:

1. Pleural fluid protein/serum protein >0.5

2. Pleural fluid LDH/serum LDH >0.6

3. Pleural fluid LDH more than two-thirds normal upper limit for serum

These criteria misidentify ~25% of transudates as exudates. If one or more of the exudative

criteria are met and the patient is clinically thought to have a condition producing a transudative

effusion, the difference between the protein levels in the serum and the pleural fluid should be

measured. If this gradient is >31 g/L (3.1 g/dL), the exudative categorization by these criteria can

be ignored because almost all such patients have a transudative pleural effusion. If a patient has

an exudative pleural effusion, the following testson the pleural fluid should be obtained:



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description of the appearance of the fluid, glucose level, differential cell count, microbiologic

studies, and cytology.

Figure 1 Approach to the diagnosis of pleural effusions. CHF, congestive heart failure; CT, computedtomography; LDH, lactate dehydrogenase;PE, pulmonary embolism; TB, tuberculosis; PF, pleural fluid.

E. Differential Diagnoses of Pleural Effusions

Transudative Pleural Ef fusions

1. Congestive heart failure

2. Cirrhosis

3. Pulmonary embolization

4. Nephrotic syndrome

5. Peritoneal dialysis

6. Superior vena cava obstruction

7. Myxedema

8. Urinothorax



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Exudative Pleural Ef fusions

1. Neoplastic diseases

a. Metastatic disease

b. Mesothelioma

2. Infectious diseases

a. Bacterial infections

b. Tuberculosis

c. Fungal infections

d. Viral infections

e. Parasitic infections

3. Pulmonary embolization

4. Gastrointestinal disease

a. Esophageal perforation

b. Pancreatic disease

c. Intraabdominal abscesses

d. Diaphragmatic hernia

e. After abdominal surgery

f. Endoscopic variceal sclerotherapy

g. After liver transplant

5. Collagen vascular diseases

a. Rheumatoid pleuritis

b. Systemic lupus erythematosus

c. Drug-induced lupus

d. Immunoblastic lymphadenopathy

e. Sjögren’s syndrome

f. Granulomatosis with polyangiitis

(Wegener’s)

g. Churg-Strauss syndrome

6. Post-coronary artery bypass surgery

7. Asbestos exposure

8. Sarcoidosis

9. Uremia

10. Meigs’ syndrome

11. Yellow nail syndrome

12. Drug-induced pleural disease

a. Nitrofurantoin

b. Dantrolene

c. Methysergide

d. Bromocriptine

e. Procarbazine

f. Amiodarone

g. Dasatinib

13. Trapped lung

14. Radiation therapy

15. Post-cardiac injury syndrome

16. Hemothorax

17. Iatrogenic injury

18. Ovarian hyperstimulation syndrome

19. Pericardial disease

20. Chylothorax



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1. Effusion due to heart failure

The most common cause of pleural effusion is left-ventricular failure. The effusion occurs

because the increased amounts of fluid in the lung interstitial spaces exit in part across the

visceral pleura; this overwhelms the capacity of the lymphatics in the parietal pleura to

remove fluid. In patients with heart failure, a diagnostic thoracentesis should be performed

if the effusions are not bilateral and comparable in size, if the patient is febrile, or if the

patient has pleuritic chest pain to verify that the patient has a transudative effusion.

Otherwise the patient’s heart failure is treated. If the effusion persists despite therapy, a

diagnostic thoracentesis should be performed. A pleural fluid N-terminal pro-brain

natriuretic peptide (NT-proBNP) >1500 pg/mL is virtually diagnostic of an effusion

secondary to congestive heart failure.

2. Hepatic hydrothorax

Pleural effusions occur in ~5% of patients with cirrhosis and ascites. The predominant

mechanism is the direct movement of peritoneal fluid through small openings in the

diaphragm into the pleural space. The effusion is usually right-sided and frequently is

large enough to produce severe dyspnea.

3. Parapneumonic effusion

Parapneumonic effusions are associated with bacterial pneumonia, lung abscess, or

bronchiectasis and are probably the most common cause of exudative pleural effusion in

the United States. Empyema refers to a grossly purulent effusion. Patients with aerobic

bacterial pneumonia and pleural effusion present with an acute febrile illness consisting of

chest pain, sputum production, and leukocytosis. Patients with anaerobic infections present

with a subacute illness with weight loss, a brisk leukocytosis, mild anemia, and a history

of some factor that predisposes them to aspiration. The possibility of a parapneumonic

effusion should be considered whenever a patient with bacterial pneumonia is initially

evaluated. The presence of free pleural fluid can be demonstrated with a lateral decubitus

radiograph, computed tomography (CT) of the chest, or ultrasound. If the free fluid

separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be

performed. Factors indicating the likely need for a procedure more invasive than a

thoracentesis (in increasing order of importance) include the following:

Loculated pleural fluid



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Pleural fluid pH <7.20

Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)

Positive Gram stain or culture of the pleural fluid

Presence of gross pus in the pleural space

If the fluid recurs after the initial therapeutic thoracentesis and if any of these

characteristics are present, a repeat thoracentesis should be performed. If the fluid cannot

be completely removed with the therapeutic thoracentesis, consideration should be given

to inserting a chest tube and instilling a fibrinolytic agent (e.g., tissue plasminogen

activator, 10 mg) or performing a thoracoscopy with the breakdown of adhesions.

Decortication should be considered when these measures are ineffective.

4. Effusion secondary to malignancy

Malignant pleural effusions secondary to metastatic disease are the second most common

type of exudative pleural effusion. The three tumors that cause ~75% of all malignant

pleural effusions are lung carcinoma, breast carcinoma, and lymphoma. Most patients

complain of dyspnea, which is frequently out of proportion to the size of the effusion. The

pleural fluid is an exudate, and its glucose level may be reduced if the tumor burden in the

pleural space is high. The diagnosis usually is made via cytology of the pleural fluid. If the

initial cytologic examination is negative, thoracoscopy is the best next procedure if

malignancy is strongly suspected. At the time of thoracoscopy, a procedure such as pleural

abrasion should be performed to effect a pleurodesis. An alternative to thoracoscopy is

CT- or ultrasound-guided needle biopsy of pleural thickening or nodules. Patients with a

malignant pleural effusion are treated symptomatically for the most part, since the

presence of the effusion indicates disseminated disease and most malignancies associated

with pleural effusion are not curable with chemotherapy. The only symptom that can be

attributed to the effusion itself is dyspnea. If the patient’s lifestyle is compromised by

dyspnea and if the dyspnea is relieved with a therapeutic thoracentesis, one of the

following procedures should be considered: (1) insertion of a small indwelling catheter or

(2) tube thoracostomy with the instillation of a sclerosing agent such as doxycycline, 500

mg.



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5. Mesothelioma

Malignant mesotheliomas are primary tumors that arise from the mesothelial cells that line

the pleural cavities; most are related to asbestos exposure. Patients with mesothelioma

present with chest pain and shortness of breath. The chest radiograph reveals a pleural

effusion, generalized pleural thickening, and a shrunken hemithorax. Thoracoscopy or

open pleural biopsy is usually necessary to establish the diagnosis. Chest pain should be

treated with opiates, and shortness of breath with oxygen and/or opiates.

6. Effusion secondary to pulmonary embolization

The diagnosis most commonly overlooked in the differential diagnosis of a patient with an

undiagnosed pleural effusion is pulmonary embolism. Dyspnea is the most common

symptom. The pleural fluid is almost always an exudate. The diagnosis is established by

spiral CT scan or pulmonary arteriography. Treatment of a patient with a pleural effusion

secondary to pulmonary embolism is the same as it is for any patient with pulmonary

emboli. If the pleural effusion increases in size after anticoagulation, the patient probably

has recurrent emboli or another complication, such as a hemothorax or a pleural infection.

7. Tuberculous pleuritis

In many parts of the world, the most common cause of an exudative pleural effusion is

tuberculosis (TB). Tuberculous pleural effusions usually are associated with primary TB

and are thought to be due primarily to a hypersensitivity reaction to tuberculous protein in

the pleural space. Patients with tuberculous pleuritis present with fever, weight loss,

dyspnea, and/or pleuritic chest pain. The pleural fluid is an exudate with predominantly

small lymphocytes. The diagnosis is established by demonstrating high levels of TB

markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL).

Alternatively, the diagnosis can be established by culture of the pleural fluid, needle

biopsy of the pleura, or thoracoscopy. The recommended treatments of pleural and

pulmonary TB are identical.

8. Effusion secondary to viral infection

Viral infections are probably responsible for a sizable percentage of undiagnosed

exudative pleural effusions. In many series, no diagnosis is established for ~20% of

exudative effusions, and these effusions resolve spontaneously with no long-term residua.

The importance of these effusions is that one should not be too aggressive in trying to



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establish a diagnosis for the undiagnosed effusion, particularly if the patient is improving

clinically.

9. Chylothorax

A chylothorax occurs when the thoracic duct is disrupted and chyle accumulates in the

pleural space. The most common cause of chylothorax is trauma (most frequently thoracic

surgery), but it also may result from tumors in the mediastinum. Patients with chylothorax

present with dyspnea, and a large pleural effusion is present on the chest radiograph.

Thoracentesis reveals milky fluid, and biochemical analysis reveals a triglyceride level

that exceeds 1.2 mmol/L (110 mg/dL). Patients with chylothorax and no obvious trauma

should have a lymphangiogram and a mediastinal CT scan to assess the mediastinum for

lymph nodes. The treatment of choice for most chylothoraxes is insertion of a chest tube

plus the administration of octreotide. If these modalities fail, a pleuroperitoneal shunt

should be placed unless the patient has chylous ascites. An alternative treatment is ligation

of the thoracic duct. Patients with chylothoraxes should not undergo prolonged tube

thoracostomy with chest tube drainage because this will lead to malnutrition and

immunologic incompetence.

10.

Hemothorax

When a diagnostic thoracentesis reveals bloody pleural fluid, a hematocrit should be

obtained on the pleural fluid. If the hematocrit is more than one-half of that in the

peripheral blood, the patient is considered to have a hemothorax. Most hemothoraxes are

the result of trauma; other causes include rupture of a blood vessel or tumor. Most

patients with hemothorax should be treated with tube thoracostomy, which allows

continuous quantification of bleeding. If the bleeding emanates from a laceration of the

pleura, apposition of the two pleural surfaces is likely to stop the bleeding. If the pleural

hemorrhage exceeds 200 mL/h, consideration should be given to thoracoscopy or

thoracotomy.

11. Miscellaneous causes of pleural effusion.

There are many other causes of pleural effusion. Key features of some of these conditions

are as follows: If the pleural fluid amylase level is elevated, the diagnosis of esophageal

rupture or pancreatic disease is likely. If the patient is febrile, has predominantly

polymorphonuclear cells in the pleural fluid, and has no pulmonary parenchymal



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abnormalities, an intraabdominal abscess should be considered. The diagnosis of an

asbestos pleural effusion is one of exclusion. Benign ovarian tumors can produce ascites

and a pleural effusion (Meigs’ syndrome), as can the ovarian hyperstimulation syndrome.

Several drugs can cause pleural effusion; the associated fluid is usually eosinophilic.

Pleural effusions commonly occur after coronary artery bypass surgery. Effusions

occurring within the first weeks are typically left-sided and bloody, with large numbers of

eosinophils, and respond to one or two therapeutic thoracenteses. Effusions occurring

after the first few weeks are typically left-sided and clear yellow, with predominantly

small lymphocytes, and tend to recur. Other medical manipulations that induce pleural

effusions include abdominal surgery; radiation therapy; liver, lung, or heart

transplantation; and the intravascular insertion of central lines.

F. Therapy

1. Medicamentosa

Pharmacologic management of pleural effusion depends on the condition’s etiology. For

example, medical management includes nitrates and diuretics for congestive heart failure

and pulmonary edema, antibiotics for parapneumonic effusion and empyema, and

anticoagulation for pulmonary embolism. In patients with parapneumonic effusions,

empyemas, and effusions associated with esophageal perforation and intra-abdominal

abscesses, antibiotics should be administered early when these conditions are suspected.

Antibiotic selection should be based on the suspected causative microorganisms and the

overall clinical picture. Considerations include the patient's age, comorbidities, duration of

the illness, setting (community vs nursing home), and local organism sensitivities. Various

effective single agents and combination antimicrobial therapies exist. Coverage should

generally include anaerobic organisms. Options may include clindamycin, extended-

spectrum penicillins, and imipenem. Depending on the patient's clinical condition,

infectious disease consultation may be appropriate. Particular attention must be given to

potential drug interactions, adverse effects, and preexisting conditions.

2. Therapeutic Thoracentesis

Therapeutic thoracentesis to remove larger amounts of pleural fluid is used to alleviate

dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusions. In



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addition to the precautions listed previously for diagnostic thoracentesis, note 3 additional

considerations when performing therapeutic thoracentesis.

First, to avoid producing a pneumothorax during the removal of large quantities of fluid,

remove fluid during therapeutic thoracentesis with a catheter, rather than with a sharp

needle, introduced into the pleural space. Various specially designed thoracentesis trays

are available for introducing small catheters into the pleural space. Alternatively, newer

systems using spring-loaded, blunt-tip needles that avoid lung puncture are also available.

Second, monitor oxygenation closely during and after thoracentesis because arterial

oxygen tension paradoxically might worsen after pleural fluid drainage due to shifts in

perfusion and ventilation in the reexpanding lung. Consider use of empiric supplementaloxygen during the procedure.

Third, remove only moderate amounts of pleural fluid to avoid reexpansion pulmonary

edema and to avoid causing a pneumothorax. Removal of 400-500 mL of pleural fluid is

often sufficient to alleviate shortness of breath. The recommended limit is 1000-1500 mL

in a single thoracentesis procedure.

3. Tube Thoracostomy

Although small, freely flowing parapneumonic effusions can be drained by therapeutic

thoracentesis, most larger effusions and complicated parapneumonic effusions or

empyemas require drainage by tube thoracostomy.

Traditionally, large-bore chest tubes (20-36F) have been used to drain thick pleural fluid

and to break up loculations in empyemas. However, such tubes are not always well

tolerated by patients and are difficult to direct correctly into the pleural space. However,

small-bore tubes (7-14F) inserted at the bedside or under radiographic guidance have been

shown to provide adequate drainage, even when empyema is present. These tubes cause

less discomfort and are more likely to be placed successfully within a pocket of pleural

fluid. Using 20-cm water suction and flushing the tube with normal saline every 6-8 hours

may prevent occlusion of small-bore catheters.



Documents

CR Pleural Effusion Ec Hepatoma