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PostPosted: 11 Jul 2019 18:29 
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OVERVIEW
The pericardium is a thin, double layered, fluid-filled sac lining the exterior of the heart. It protects the heart from infection and importantly does not allow the heart to over-expand when there is increase in blood volume and ensures efficient heart activity

Acute pericarditis is inflammation of the pericardium that develops suddenly and may last up to several months. The membrane appears red and swollen and may be associated with buildup of fluid between the two layers (pericardial effusion).

It usually occurs in men between the ages of 20-50 but can occur at any age and in women occasionally

CAUSES OF ACUTE PERICARDITIS
• Infection (viral, bacterial, fungal or parasitic, AIDS, tuberculosis, and aspergillosis)
• Myocardial infarction
• Post heart surgery (postpericardiotomy syndrome)
• Unknown (idiopathic or nonspecific pericarditis)
• Rheumatoid arthritis
• Systemic lupus erythematosus (lupus)
• Cancer (such as leukemia, breast or lung cancer, or, in people with AIDS or Kaposi sarcoma)
• Renal failure
• Chest trauma
• Rheumatic fever
• Radiation therapy
• Drugs, including warfarin and heparin (anticoagulants), phenytoin (antiepileptic drug), penicillin, and
procainamide (an antiarrhythmic drug)

SYMPTOMS OF PERICARDITIS
Symptoms may vary in severity, occasionally being asymptomatic or pressure of the accumulating on the heart may cause cardiac tamponade, a potentially condition
• Chest pain
 Sharp and stabbing (due to heart rubbing against the pericardium)
 Can be aggravated with coughing, swallowing, lying flat and deep inspiration
 May be relieved by sitting up and leaning forward
• Pain in neck, left shoulder or back
• Shortness of breath on lying down
• Dry cough
• Anxiety and tiredness
• Compression of heart may force the fluid back up into the lungs, abdomen and legs, resulting in symptoms of pulmonary edema (breathlessness) and peripheral edema (swelling of lower limbs) due to accumulation of fluid

COMPLICATIONS OF ACUTE PERICARDITIS
• Constrictive pericarditis and cardiac tamponade
• Pericardial effusion

DIAGNOSIS OF ACUTE PERICARDITIS
Physical examination - Acute pericarditis can be diagnosed by auscultation of the chest and may reveal a crunching sound similar to the creaking of a leather shoe or a scratchy sound similar to the rustling of dry leaves (pericardial rub). It is important to rule out complication of acute pericarditis by auscultation following a heart attack
ECG changes - The electrocardiogram (ECG) is a simple and useful test to diagnose acute pericarditis. Nearly half of the patients with pericarditis show a sequence of four distinctive patterns, but all cases of pericarditis will show at least some of the changes

Image

Echocardiogram (echo) – Demonstrates heart activity function and may reveal fluid build-up or pericardial effusion around the heart. It can detect evidence of constrictive pericarditis including thickening of and stiffness of the pericardium that limits movement of heart

Cardiac MRI and CT scan – Can reveal pericardial effusion or signs of pericardial inflammation using a special imaging agent called gadolinium. Thickened pericardium and compression of heart can also be seen

Laboratory (blood) tests – Various tests may be done to identify or rule out potential causes including heart attack, infections, renal failure, rheumatic fever, autoimmune diseases and estimation of inflammatory markers erythrocytic sedimentation rate (ESR) or C reactive protein levels which will be elevated.

Pericardiocentesis - If the cause of pericarditis is still unclear, a sample of the pericardial fluid and/or pericardial tissue can be obtained using a needle inserted through the chest wall. The fluid and tissue are sent to the laboratory for analysis.

Cardiac catheterization – May be done to measure the filling pressures within the heart to confirm a suspected diagnosis of constrictive pericarditis

TREATMENT OF ACUTE PERICARDITIS
ANTI-INFLAMMATORY DRUGS
Acute pericarditis usually responds to anti-inflammatory drugs such as colchicine or NSAIDs (such as aspirin and ibuprofen). The drugs can be tapered once the patient’s symptoms improve. Colchicine also decreases the likelihood of recurrence. If pain is very severe, an opiate such as morphine may be needed. Prednisone, a corticosteroid, is prescribed in some cases to reduce inflammation. It should not be used in persons with viral infection as it can aggravate symptoms. Prednisone also increases the chances of recurrence.

TREATMENT OF UNDERLYING CONDITION
Further management of acute pericarditis varies according to the cause.
In patients with kidney failure, frequency of dialysis can be increased
Stopping any drug that might cause pericarditis
Pericarditis caused by bacterial infection is treated with antibiotics and surgical drainage of pus from the pericardium.
Treatment of underlying cancer with chemotherapy or radiation therapy.
Recurrent pericarditis caused by a virus, an injury, or an unknown cause , may respond to aspirin or ibuprofen, sometimes along with colchicine. Rarely corticosteroids may be employed as long as the cause is not a viral illness. (as long as the cause was not an infection). The corticosteroids are sometimes injected into the pericardial space.

SURGICAL TREATMENT (DRAINAGE OF FLUID OR REMOVAL OF INFLAMED PERICARDIUM)
Fluid may be drained from the pericardium by introducing a thin tube into the pericardial space (pericardiocentesis).
Sometimes a balloon-tipped catheter is inserted through the skin (percutaneous balloon pericardiotomy), which is then then inflated to create a hole (window) in the pericardium. This is usually performed as an alternative to surgery for recurrent effusions or effusions caused by cancer
In another procedure called a subxiphoid pericardiotomy, a small incision is made beneath the sternum, and a piece of the pericardium is removed. Then a tube is inserted into the pericardial cavity. This procedure is performed for effusions due to bacterial infections. Both procedures are done under local anesthetic as a bedside procedure, and allow continuous and effective drainage of fluid.
Surgery may be required in some patients with constrictive pericarditis. Pericardiectomy is the surgical removal of a portion of the pericardium. Rarely surgery is done for persistent pain due to recurrent pericarditis

PROGNOSIS
Prognosis of pericarditis depends on the etiology. Pericarditis is caused by a virus or idiopathic, usually resolves 1 to 3 weeks. Complications and recurrences can delay the recovery period. In patients with involvement of the pericardium by cancer, survival may be 12-18 months at most

KEY POINTS
• Acute pericarditis can be caused by infections, heart attack, drugs, chest trauma ,cancer and autoimmune diseases
• Typical symptoms include chest pain made worse by inspiration or lying down
• Pericardial friction rub can be heard on auscultation
• Cause of condition is confirmed by ECG, echocardiogram, and lab tests
• Complications include constrictive pericarditis and pericardial effusion
• Treatments include analgesics and anti-inflammatories, treatment of underlying cause , drainage of pericardial fluid and rarely pericardiectomy


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