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Overview of Pleural Effusion in Adults: Upul Pathirana
Overview of Pleural Effusion in Adults: Upul Pathirana
UPUL PATHIRANA
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Mechanisms of pleural liquid accumulation in disease
DECREASED
FLUID EXIT
an abnormal
accumulation of
fluid in the pleural
space.
INCREASED
FLUID ENTRY Pleural effusion
6/2/2011 3
Making the diagnosis
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Conventional radiography
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Conventional radiography
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Conventional radiography
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Conventional radiography
“meniscoid arc ‘’
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Conventional radiography
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Conventional radiography
“pseudotumors or vanishing
tumors”
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Conventional radiography
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Ultrasonography
AnechoicNormal
area (transudative
appearance effusion)
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Ultrasonography
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Computed tomography
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Diagnostic evaluation of a pleural effusion :
Initial testing
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Example 01
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Is it transudate or exudate?
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Is it transudate or exudate?
Acute diuresis in heart failure can elevate protein levels into the exudative range
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Is it transudate or exudate?
Acute diuresis in heart failure can elevate protein levels into the exudative
range
serum to pleural fluid albumin gradient greater than 1.2 g/dL (12 g/L)
elevated blood N-terminal pro-brain natriuretic peptide (NT-proBNP)
Example 01
Serum albumin 3.5 g/dL and pleural fluid albumin 1.8 g/dL
serum to pleural fluid albumin gradient 3.5-2.0=1.7 (transudative)
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Example 02
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Gross appearance
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Parapneumonic effusion
Uncomplicated parapneumonic
effusion
pH <7.20
Complicated parapneumonic glucose <60 mg/dL
LDH>1000 IU/L
effusion
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Thoracic empyema
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Example 03
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Sub pleural focus
of disease Cavity rupture into pleural space
Leakage or rupture
Thoracic lymph node
Antigen and organism
Subdiaphragamatic
focus
Delayed hypersensitivity
Hematogenous
Tuberculous pleural effusion
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Example 03
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Tuberculous pleural effusion
“Even when the AFB smear and culture are negative, compatible routine
studies along with an elevated ADA level may establish a presumptive
diagnosis of tuberculous pleuritis in the right clinical setting”
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Tuberculous pleural effusion
Diagnostic work up
Pleural biopsy
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Tuberculous pleural effusion
Diagnostic work up
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Tuberculous pleural effusion
Treatment
Antituberculous chemotherapy
Treatment response
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Example 04
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Malignancy related pleural effusions
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Example 03
Exudative
Lymphocytic
Mesothelial cells >5% (tuberculosis unlikely)
Adenosine deaminase 18 IU/L
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Evaluation of malignant pleural effusion
Pleural biopsy
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Management of malignant pleural effusions
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Example 05
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Example 05
Exudative
Lymphocytic
Mesothelial cells >5% (tuberculosis unlikely)
Adenosine deaminase 11 IU/L
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Left side pleural effusion with high amylase
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Management of pancreatic pleural effusion
Treatment
repeated aspiration
diuretics, octreotide
parenteral nutrition to decrease pancreatic secretion
endoscopically-placed stents
surgery
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Example 04
Referred to GI surgeon
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Thank you
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