Pleural effusions
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There are two main types of pleural effusions - transudative and exudative. Transudative effusions have low protein levels and do not meet Light's criteria, while exudative effusions have high protein levels due to leaky capillaries around the pleura. Common causes of pleural effusions include congestive heart failure, hypoalbuminemia, subdiaphragmatic processes, infections like parapneumonic effusions, neoplasms, and inflammatory conditions. Diagnostic thoracentesis is important for analyzing pleural fluid via Light's criteria and other tests to determine the specific cause of the effusion.
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![Transudative
Effusion
Low [protein]
(NO Light’s Criteria
are met)
Exudative
effusion
High [Protein]
(Leaky membranes in
capillaries around pleura)
Entry of low protein
fluid into pleural space
from outside source
Abdominal fluid/ascites
from liver cirrhosis
urine
CSF
IV fluids
Pleural Effusions
PE: dull to percussion, ↓ breath sounds and ↓ tactile
fremitus over effusion; egophony + ↑ fremitus above level
of effusion
CXR: blunted costophrenic angles, white opacity w/
meniscus, contralateral mediastinal/tracheal shift (if large)
If costophrenic angle blunting in lateral decubitus
position >1cm diagnostic thoracentesis
Pulmonary
CHF
(high hydrostatic pressure
in pulmonary vessels
JVD + pedal edema)
Systolic dysfunction
Diastolic dysfunction
Valvular disease
Hypoproteinemia/
Hypoalbuminemia
(↓ plasma oncotic
pressure)
Nephrotic syndroms
Liver cirrhosis (↓
protein synthesis in liver)
Sub-diaphragmatic:
Esophageal rupture
Pancreatitis (high
serum amylase)
Sub-diaphragmatic
abscess
Benign ovarian tumor
Analyze fluid via Light’s
Criteria:
1. Pleural fluid [protein] /
serum [protein] > 0.5
2. Pleural fluid [LDH] /
serum [LDH] > 0.6
3. [LDH] > 2/3 upper limit
of normal serum [LDH]
(100-235 U/L)
Infectious
(Hx: age (extremes)? Diabetic? Substance
abuse? Aspiration risk + Poor dentition?
Order: Gram stain, C&S, AFB of fluid)
Parapneumonic effusion (PE: simple,
complex, empyema)
TB effusions
Neoplastic
(Ask: smoking +
asbestos Hx. Order:
thorocoscopy)
Primary
(mesothelioma)
Metastatic lung
cancer
Inflammatory
(Ask: joint pain?
Rashes? Mouth
ulcers? Alopecia?
Order: ANA)
Connective tissue
dx (RA, SLE)
Pulmonary
Embolus
Meniscus at
air-fluid level
Contralateral tracheal
+ mediastinal shift
(large effusion)
Costophrenic angle blunting
of unknown size; do lateral
decubitus CXR; pt needs
thoracocentesis if >1cm!
Hemothorax
Chylothorax
Disruption
of thoracic
duct
Lymphoma
Investigate:
• Diagnostic thoracentesis (pH, glucose,
cytology, WBCs, cultures/gram stains,
triglycerides, Hct, amylase)
• Blind needle biopsy (only 44% sensitive!)
• Thoroscopy (90% sensitive for TB + cancer)
• Additional tests for specific clinical
contexts (Liver Function Tests for
transudative effusion, etc)
1. Start Abx!
2. Diagnostic
thoracentesis!
Frank pus (empyema):
drain + abx (at least 6 wks) until resolution
No pus:
measure pH, do
gram stain + culture
- stain/culture, pH > 7.2:
Simple PE; follow clinically
+ stain/culture, pH < 7.2:
Complex PE Drain!!!
Effusion is exudative if ANY one
Light’s criteria are met. But still, 25% of
exudative effusions are undiagnosed.
](https://image.slidesharecdn.com/pleuraleffusions-181027164704/85/Pleural-effusions-1-320.jpg)
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1. PH is defined as a portal venous pressure gradient above 10 mmHg. It can be pre-sinusoidal, sinusoidal, or post-sinusoidal based on location of blockage.
2. Common causes are cirrhosis, portal or hepatic vein thrombosis, and Budd-Chiari syndrome. Cirrhosis results from fibrosis narrowing hepatic sinusoids.
3. Clinical features include splenomegaly, abdominal collaterals, ascites, gastrointestinal bleeding from varices, and hepatic encephalopathy.
Stevens–johnson syndrome
1. GI bleeding can be classified as upper GI bleeding (proximal to the ligament of Treitz) or lower GI bleeding (distal to the ligament of Treitz).
2. The document outlines the emergency resuscitation, history taking, examination, risk stratification, causes, management, and prognosis of GI bleeding.
3. Key aspects of management include fluid resuscitation, endoscopy, pharmacotherapy such as PPIs, and surgery if bleeding persists despite other treatments. Outcomes depend on severity of underlying conditions.
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Imaging of portal hypertension
This document discusses non-invasive imaging techniques for evaluating portal hypertension. Ultrasound is the most widely used initial imaging modality to assess for portal vein patency, presence of collaterals, portal blood flow, and changes of cirrhosis. CT and MRI can further evaluate the portal venous system and collateral vessels. Ultrasound Doppler is used to measure portal blood flow direction, velocity, and assess for portosystemic collaterals and changes in hepatic veins. Imaging findings of various etiologies of portal hypertension are described, including cirrhosis, non-cirrhotic portal fibrosis, portal vein thrombosis, Budd-Chiari syndrome, and extrahepatic causes.
Portal Hypertension in Children.. Dr.Malathi Sathiyasekaran
Portal Hypertension in Children by Dr.Malathi Sathiyasekaran, Pediatric Gastroenterologist, Chennai.
acutepancreatitissurgeryseminar-170509110836.pdf
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Acute pancreatitis surgery seminar
Acute pancreatitis is inflammation of the pancreas that is usually reversible. It is commonly caused by gallstones or alcoholism. Symptoms include severe abdominal pain, vomiting, and fever. Diagnosis is based on elevated serum amylase and lipase levels. Severity is assessed using scoring systems like Ranson criteria or CT severity index. Mild cases are treated conservatively with IV fluids and analgesics while severe or infected cases require intensive care monitoring, antibiotics, and possibly surgical debridement of pancreatic necrosis.
Portal hypertension
Portal hypertension occurs when pressure in the portal venous system rises, usually due to liver cirrhosis or scarring impeding blood flow into the liver. Ultrasound can detect signs of portal hypertension like ascites, splenomegaly, dilated portal veins and collateral vessels that form around the liver. Specific findings include thrombosed or narrowed portal veins, enlarged arteries supplying the liver, and reversed blood flow away from the liver.
Portal Hypertension
The portal vein is formed by the superior mesenteric and splenic veins. It drains blood from the intestines, pancreas, colon and rectum. Blood from the portal and hepatic arteries mixes in the liver sinusoids before draining into the hepatic vein and inferior vena cava. Portal hypertension occurs when pressure increases due to increased resistance in the liver from cirrhosis and increased blood flow. It can cause ascites, variceal bleeding, and other complications.
Approach to a child with hematuria
This document provides information on hematuria (blood in the urine) including causes, evaluation, diagnosis, and management. It discusses glomerular and non-glomerular causes of hematuria and lists various renal diseases that can cause hematuria such as IgA nephropathy, Alport syndrome, thin basement membrane disease, and membranoproliferative glomerulonephritis. The evaluation of hematuria involves urine analysis, urine culture, renal function tests, imaging studies, and sometimes renal biopsy. Management depends on the underlying cause and may include antibiotics, diuretics, immunosuppressive therapy, dialysis, or surgery.
466841108-1-pleural-effusion-ppt.ppt.....
Pleural effusion is the accumulation of fluid in the pleural space between the lungs and chest wall. There are two main types - exudative fluid caused by conditions like pneumonia and tuberculosis, and transudative fluid caused by conditions like heart failure and liver disease. Pleural effusions are diagnosed based on symptoms, physical exam findings like dullness on percussion, and investigations like chest x-ray and pleural fluid analysis. Treatment involves treating the underlying cause, relieving symptoms, and draining large effusions.
PORTAL HYPERTENSION & SURGERY
This document provides information on portal hypertension and its surgical management. It begins with the history of portal hypertension, describing early anatomists who studied the portal venous system. It then covers the anatomy of the portal system and pathophysiology of portal hypertension. Etiologies of portal hypertension including pre-hepatic, hepatic, and post-hepatic causes are discussed. Clinical presentation, diagnosis, evaluation, and general management approaches are summarized. The document concludes by focusing on surgical options for treating portal hypertension including devascularization procedures and liver transplantation.
Echo in pericardial diseases
This document provides an overview of echocardiography in pericardial diseases. It begins with an introduction to pericardial anatomy and pathophysiology. It then discusses various pericardial diseases that can be evaluated by echocardiography, including acute pericarditis, recurrent pericarditis, pericardial effusions, cardiac tamponade, and constrictive pericarditis. For each condition, it describes the echocardiographic findings and techniques used to evaluate the condition. It emphasizes that echocardiography is usually the initial imaging test of choice but that CT or CMR may be needed in some complex cases.
Gastrointestinal bleed overview
This document discusses gastrointestinal (GI) bleeding, including its definitions, symptoms, causes, management, and prevention. GI bleeding can occur in the upper or lower GI tract, and may present as vomiting blood, black stools, or blood in the rectum. Common causes include peptic ulcers, esophageal varices, colon polyps, and diverticulosis. Management involves stabilizing the patient, stopping the bleeding, identifying the source of bleeding, and preventing recurrence. Endoscopy allows for diagnosis and potential treatment through procedures like ligation or sclerosing of varices. Surgery may be considered for severe or recurrent bleeding. Scoring systems can help determine prognosis and appropriate care settings.
Portal Hypertension.pptx
This document provides information on portal hypertension, including:
1. It defines portal hypertension and describes types such as cirrhotic and non-cirrhotic portal hypertension.
2. It outlines the portal venous system and portosystemic circulation.
3. It discusses causes, clinical features, investigations, and management of portal hypertension including pharmacotherapy, endoscopic therapy, TIPS procedure, and surgeries.
4. Prevention of recurrent variceal hemorrhage is highlighted through long-term pharmacotherapy, endoscopic therapy, interventional procedures like TIPS, or surgical shunts if other options fail.
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Portal Hypertension in Children.. Dr.Malathi Sathiyasekaran
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Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube. It bypasses the upper airway and allows for immediate inspiration, expiration, and removal of secretions. Reasons for a tracheostomy include lung issues, airway compromise from infections or injuries, and burns to the face. Benefits are the ability to eat and talk more easily with less damage to the airways compared to an endotracheal tube. Safety tips include using the correct cannula type for ventilation and only inflating the cuff when on a ventilator. General nursing management involves always having replacement tubes and an obturator available in case of an emergency dislodgement
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- 1. Transudative Effusion Low [protein] (NO Light’s Criteria are met) Exudative effusion High [Protein] (Leaky membranes in capillaries around pleura) Entry of low protein fluid into pleural space from outside source Abdominal fluid/ascites from liver cirrhosis urine CSF IV fluids Pleural Effusions PE: dull to percussion, ↓ breath sounds and ↓ tactile fremitus over effusion; egophony + ↑ fremitus above level of effusion CXR: blunted costophrenic angles, white opacity w/ meniscus, contralateral mediastinal/tracheal shift (if large) If costophrenic angle blunting in lateral decubitus position >1cm diagnostic thoracentesis Pulmonary CHF (high hydrostatic pressure in pulmonary vessels JVD + pedal edema) Systolic dysfunction Diastolic dysfunction Valvular disease Hypoproteinemia/ Hypoalbuminemia (↓ plasma oncotic pressure) Nephrotic syndroms Liver cirrhosis (↓ protein synthesis in liver) Sub-diaphragmatic: Esophageal rupture Pancreatitis (high serum amylase) Sub-diaphragmatic abscess Benign ovarian tumor Analyze fluid via Light’s Criteria: 1. Pleural fluid [protein] / serum [protein] > 0.5 2. Pleural fluid [LDH] / serum [LDH] > 0.6 3. [LDH] > 2/3 upper limit of normal serum [LDH] (100-235 U/L) Infectious (Hx: age (extremes)? Diabetic? Substance abuse? Aspiration risk + Poor dentition? Order: Gram stain, C&S, AFB of fluid) Parapneumonic effusion (PE: simple, complex, empyema) TB effusions Neoplastic (Ask: smoking + asbestos Hx. Order: thorocoscopy) Primary (mesothelioma) Metastatic lung cancer Inflammatory (Ask: joint pain? Rashes? Mouth ulcers? Alopecia? Order: ANA) Connective tissue dx (RA, SLE) Pulmonary Embolus Meniscus at air-fluid level Contralateral tracheal + mediastinal shift (large effusion) Costophrenic angle blunting of unknown size; do lateral decubitus CXR; pt needs thoracocentesis if >1cm! Hemothorax Chylothorax Disruption of thoracic duct Lymphoma Investigate: • Diagnostic thoracentesis (pH, glucose, cytology, WBCs, cultures/gram stains, triglycerides, Hct, amylase) • Blind needle biopsy (only 44% sensitive!) • Thoroscopy (90% sensitive for TB + cancer) • Additional tests for specific clinical contexts (Liver Function Tests for transudative effusion, etc) 1. Start Abx! 2. Diagnostic thoracentesis! Frank pus (empyema): drain + abx (at least 6 wks) until resolution No pus: measure pH, do gram stain + culture - stain/culture, pH > 7.2: Simple PE; follow clinically + stain/culture, pH < 7.2: Complex PE Drain!!! Effusion is exudative if ANY one Light’s criteria are met. But still, 25% of exudative effusions are undiagnosed.