81yearoldmalewithhistoryoftypeIIdiabetes,hyperlipidemia,andcongesAveheartfailurepresentsastransferfromextendedcarefacilityforevaluaAonofacute,progressiveshortnessofbreathandincreasingabdominalgirth.
Pulmonaryexamsignificantfortachypnea.Abdomenwasdistendedonphysicalexam.2+LEedemabilaterally.
CXRobtainedfordyspneashowedbilateralpleuraleffusions.
U/Sofabdomenwasperformed,whichalsodemonstratedlargebilateralpleuraleffusionsaswellasascites.
OverviewofPleuralEffusions• AbnormalcollecAonoffluidinthepleuralspace• Transudatevs.exudate• Normalpleuralfluid:pH7.60‐7.64,protein<1‐2g/dL,<1000
WBCs/mm3,glucose~plasmaglucose,LDH<50%plasmaLDH• Light’scriteriaforexudates:
– Pleuralfluidprotein/serumprotein>0.5– PleuralfluidLDH/serumLDH>0.6– PleuralfluidLDH>200IU/Lor2/3normalupperlimitforserum
• Exudate*– Pleuralfluidtotalprotein>2.9g/dL– Pleuralfluidprotein/serumprotein>0.5– Pleuralfluidcholesterol>45mg/dL– PleuralfluidLDH/serumLDH>0.6
*HeffnerJ,BrownL,BarbieriC(1997)."DiagnosAcvalueofteststhatdiscriminatebetweenexudaAveandtransudaAvepleuraleffusions.PrimaryStudyInvesAgators".Chest111(4):970–80.doi:10.1378/chest.111.4.970.PMID9106577.
OverviewofPleuralEffusions
• Transudates– CHF(asinthispaAent)– Cirrhosis– NephroAcsyndrome– Others‐urinothorax,myxedema,peritonealdialysis
• Exudates– InfecAon– Malignancy– PE– Chylothorax– Hemothorax– Others‐druginduced,SLE,RA,vasculiAs(Wegener’s,Churg‐
Strauss),GI(pancreaAAs,esophagealrupture)
DiagnosisandTreatmentofPleuralEffusions
• DiagnosActhoracentesis• TherapeuActhoracentesisforsymptomaAceffusions
• Tubethoracostomyforhemothorax
• Tubethoracostomyempyemas±tPA– pusonthoracentesis,aposiAveGramstain,glucose<60mg/dL,pH<7.20,orelevatedLDH
• Treatunderlyingdisorder
OverviewofAscites
• Theoriesonpathophysiology– Underfilling‐insufficientsequestraAonoffluidsecondarytoportalhypertensionleadingtoacAvaAonofrenin‐angiotensin‐aldosteronesystem
– Overflow‐inappropriateretenAonofNaandH2Obyrenalsystem,hepatorenalreflex
– PeripheralarterialvasodilaAonhypothesis‐vasodilaAonsecondarytoportalhypertensionleadingtodecreasedeffecAvearterialvolumeandrenalNaretenAon
– DecreasedoncoAcpressuresecondarytohypoalbuminemia
EAologyofAscites
Serumascitesalbumingradient SAAG(g/dL)=SerumAlbumin‐AscitesAlbumin
Runyonetal(1992)
>=1.1g/dL <1.1g/dL
CirrhosisAlcoholichepa77sCHFMassivehepa7cmetastasesVascularocclusionFaAyliverdiseaseofpregnancyMyxedema
PeritonealcarcinomatosisPeritonealTBPancrea77sSerosi7sNephro7csyndromeBowelobstruc7on/infarc7on/perfora7on
Treatment
• SodiumrestricAon• DiureAcs
– Spironolactone(25‐200mg/dPOqdordividedbid)±furosemide(40‐120mg/dayPOdividedqd‐bid;start20‐80mgPOx1,increase20‐40mgq6‐8hrsor20‐40mgmgIV/IM;Atrateup20mgq2hrs;Max:600mg/day)
• TherapeuAcparacentesis– Largevolume>4‐6Lwithalbuminreplacement
• 5gofalbumin/LofasciAcfluid(over5L)todecreaserateofcomplicaAons
• TIPS– FordiureAc‐refractoryascites– Stentispercutaneouslyplacedfromtherightjugularveininto
thehepaAcvein.ConnectsportalandsystemiccirculaAons.
PaAent’shospitalcourseCHFexacerbaAon‐paAentwasiniAallydiuresedwithIVLasixforsevere
volumeoverloadandthentransiAonedtoPODemadex.HewasondobutamineforincreasedcreaAnine,whichwasbrieflyswitchedtomilrinoneforhiselevatedwedgeandPApressuresbyrightheartcath.LeNheartcathshowednewnon‐obstrucAvecoronaryarterydisease.StaAnACEinhibitorandaspirinwereaddedtohismedicaAonregiment.Cardiacechofinding:severetricuspidvalveregurgitaAon,moderatetoseveremitralvalveregurgitaAon,moderateaorAcregurgitaAon,andanEFof25%.PaAentwasinatrialfib/fluterduringhospitalizaAon.Coumadinwasheldduetorisks.
AtAmeofdischargepaAentremainedsignificantlyvolumeoverloadeddespitediuresisofasignificantvolume,howeverthepaAenthadimprovedshortnessofbreathandwasabletoambulatewithassistance.BUNandcreaAninehadincreasedfromadmissionandDemadexdosewasdecrease.