Malignant pericardial effusion in the elderly
Introduction
Introduction to malignant pericardial effusion in the elderly It is not uncommon to invade the heart when the malignant tumor progresses; the primary tumor is bronchial lung cancer, and the mediastinal tumor is more common. Connective tissue disease, lupus erythematosus can also cause, recently reported that AIDS has become an important cause of pericardial effusion, such as the occurrence of cardiac tamponade is an emergency, should be urgently treated. basic knowledge Sickness ratio: 0.0001% Susceptible people: the elderly Mode of infection: non-infectious Complications: cardiac dysfunction
Cause
The cause of malignant pericardial effusion in the elderly
Cause:
Common causes of foreign reports are acute pericarditis (virus, non-specific), new organisms (bronchial, breast or lymphoma metastasis) after radiotherapy and chest trauma, tuberculous pericarditis in China was the most common cause of pericardial effusion, recent years It is rare to see and improve living standards, the widespread use of anti-tuberculosis drugs, and the popularization of BCG vaccine vaccination to reduce the incidence of tuberculosis infection. Tumorous pericarditis is mostly pericardial metastasis. The primary tumor is bronchogenic carcinoma, and mediastinal tumor is more common. Most of the pericarditis caused by connective tissue disease is caused by systemic lupus erythematosus. Most of the suppurative pericarditis is Staphylococcus aureus infection. Recently, AIDS has become an important cause of pericardial effusion.
Pathogenesis:
The amount of fluid in the normal pericardial cavity is about 30ml. As a lubricant to reduce friction, patients with malignant tumors, such as pericardial fluid more than 50ml, consider malignant pericardial effusion, usually can be divided into 2 types: 1 peripheral type: due to direct expansion of malignant tumors or Trans-lymphatic or (and) blood metastasis, the formation of tumor nodules can infiltrate the pericardium or (and) myocardium, causing its lymphatic and venous access to block the pericardial fluid retention; 2 central type: due to mediastinal lymph node metastasis impeding myocardial and The pericardial lymphatics produce pericardial effusion through the cardiac lymph nodes and/or venous return of the blood. For example, the pericardium is fibrotic for tumor infiltration and thickening, which can form constrictive pericarditis, leading to pericardial tamponade without pericardial effusion.
Prevention
Malignant pericardial effusion prevention in the elderly
In summary, it has been reported that 10 cases of malignant pericardial effusion treatment from 1975 to 1986 have proposed the preferred xiphoid pericardial fenestration; but many people still believe that the preferred conservative pericardial puncture drainage, pericardium And systemic chemotherapy is appropriate; surgical treatment should be used for severe constrictive pericarditis caused by radiotherapy, pericardial effusion growth is too fast, pericardial puncture can not control the malignant pericardial effusion, and general non-surgical treatment is invalid, the diagnosis is difficult to clear The pericardial effusion patient.
Complication
Complications of malignant pericardial effusion in the elderly Complications, heart dysfunction
The main complications are difficulty breathing, palpitations, hepatosplenomegaly and so on.
Symptom
Symptoms of malignant pericardial effusion in the elderly Common symptoms Pericardial effusion pericardial effusion constricted upper limbs and facial blood vessels...
About 15% of patients with malignant pericardial effusion develop pericardial tamponade, about 70% can not increase the symptoms of the heart before birth. The symptoms of pericardial effusion are mainly caused by decreased cardiac output and venous system congestion; It is also closely related to the onset of onset. In acute cases, the amount of pericardial effusion is less (<250ml), and heavier symptoms can occur. In chronic cases, even if the amount of pericardial effusion is large (>1000ml), the symptoms are still Can be lighter.
Examine
Examination of malignant pericardial effusion in the elderly
Pericardial puncture and pericardial effusion examination: In some cases, it is necessary to determine the nature of pericardial effusion. In anti-cancer radiation therapy, it is necessary to decide whether the effusion is caused by pericardial tumor lesions or after radiotherapy. When the primary tumor is not determined, The cytological examination of effusion is very important. In the case of bacterial infection, it is necessary to check whether it is exudate, and it is used for bacterial culture and drug susceptibility test. In some cases, it is not necessary to analyze pericardial fluid, and should not consider pericardial puncture, diagnostic pericardium. Puncture is of little significance. For example, if there is a small amount of effusion in non-specific pericarditis, pericardial puncture is often to relieve the pericardial tamponade or empty the purulent effusion.
1. General inspection
(1) Chest X-ray examination: It is very helpful for diagnosis. It often shows heart shadow, mediastinum or hilar abnormalities, and prompts or confirms the presence of malignant pericardial effusion. However, when the effusion is <250ml, it is often difficult to find abnormalities in the chest radiograph. Sometimes it can be seen that metastatic tumor nodules form irregular nodular heart shadow outline; when the fluid volume is 300ml, the heart shadow is universal, especially to both sides, the vena cava is obvious, and the palpebral angle is acute; In the case of liquid, the heart shadow is in the shape of a flask or a pear. In the short-term review of the chest radiograph, if the heart shadow is enlarged and there is no pulmonary congestion, the diagnosis of pericardial effusion can be confirmed, such as the condition allows chest fluoroscopy or recording Photography, if the pericardial effusion shows weakened heartbeat or lack of signs, cardiovascular angiography can clearly show the presence or absence of abnormal thickening and extent of the heart shadow, and has diagnostic value for suspected cancerous constrictive pericardial effusion, CT Or MRI examination is the most sensitive examination, not only can find other pericardial effusions that are difficult to clear, but also the location of metastases.
(2) Electrocardiogram: Electrocardiogram of malignant pericardial effusion or cancerous pericarditis can show tachycardia, premature contraction and alternating electrocardiogram. ECG can be used in 2/3 patients with cancerous pericarditis and massive pericardial effusion. Occurrence, a sign of poor prognosis, alternating pulse often occurs in myocardial injury, and is rare in pericardial tamponade with alternating ECG. When a large amount of pericardial effusion draws a small amount of even 50ml pericardial fluid, the ECG can disappear.
(3) Ultrasound examination: Echocardiography is the easiest and most valuable method of examination. The abnormal activity of the anterior mitral valve can be the basis for the diagnosis of cardiac tamponade. It is a rare false positive; if it is not a pericardial effusion, then May be caused by tumor infiltration wrapped in the heart, two-dimensional ultrasound shows:
1 The pericardial wall layer and epicardial layer are thickened (>3mm), and the echo is obviously enhanced;
2 There are lower or strong echoes between the two layers. With these two points, the presence of pericardial effusion can be confirmed.
2. Speciality check
Diagnostic pericardial puncture, malignant pericardial effusion is often exudative or bloody, blood positive pericardial effusion sent cells positive rate, especially lung cancer patients up to 80% to 90%, but negative can not rule out malignant pericardial effusion Injecting carbon dioxide into the pericardium is beneficial to the tumor in the pericardium when X-ray examination is performed. It is safer than other contrast agents such as air, oxygen or contrast agent (which can increase the effusion and pericardial adhesion), but the risk of pericardial puncture cannot be ignored. Can cause coronary artery, atrial, ventricular or internal mammary artery needle injury caused by pericardial ventricular tachycardia, ventricular tachycardia, ventricular fibrillation, collapse, pneumothorax and / or chest infection, even tension pneumothorax, but the risk It is closely related to the amount of fluid accumulated and the accuracy of puncture point positioning.
The puncture point is usually selected between the xiphoid process and the left rib margin. The needle tip is oriented to the left shoulder, the needle tip is inclined upward, or the left fifth intercostal clavicle is located within 2 cm of the apex of the midline of the clavicle to avoid the pleura. The tip of the needle is toward the fourth thoracic vertebra. To the midline of the sternum, it is safer to use two-dimensional ultrasound guided puncture. The puncture needle can be connected to the chest lead and sent to the nylon tube by the puncture needle before electrocardiogram monitoring and pumping, or the puncture with Teflon sheath. The needle, after withdrawing from the puncture needle, to avoid damage to the heart by the needle tip, these measures can reduce or even avoid sudden death and complications caused by puncture.
Diagnosis
Diagnosis and differential diagnosis of malignant pericardial effusion in the elderly
diagnosis
According to medical history, physical examination and laboratory examination, malignant pericardial effusion should first be associated with pericardial effusion in patients with malignant tumors, and tumor cells can be found in effusion. Bloody pericardial effusion is often easy to find tumor cells, but attention should be paid to false negatives. In some cases, sometimes it is difficult to obtain cytological diagnosis in some cases, especially in patients with lymphoma and leukemia, and some patients with lymphoma who have undergone mediastinal radiotherapy may present with late leakage constrictive pericarditis, according to Applefeld et al. (1981). In Hodgkin's lymphoma, 31% of patients with pericardial radiotherapy have pericardial effusion associated with radiotherapy; and patients with lung cancer undergoing mediastinal radiotherapy have bloody but cytologically negative pericardial effusions, which are metastases. It is often difficult to identify the radiotherapy. It must be carefully identified and followed up after treatment. Radioactive pericarditis often occurs after the heart receives 35 to 40 Gy of radiotherapy. Acute radioactive pericarditis is often self-limiting and can be improved without leaving Constriction; chronic radioactive pericarditis can lead to pericardial constriction or pericardial tamponade.
Differential diagnosis
Malignant pericardial effusion should be differentiated from infectious and non-infective pericardial effusions.
