Pericardial effusion pathophysiology: Difference between revisions
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{{pericardial effusion}} | {{pericardial effusion}} | ||
{{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S. | {{CMG}}; '''Associate Editor-In-Chief:''' {{AIA}}, [[Varun Kumar]], M.B.B.S. | ||
==Overview== | ==Overview== | ||
Pericardial effusion usually results from a disturbed equilibrium between the production and | [[Pericardial effusion]] usually results from a disturbed equilibrium between the production and reabsorption of [[pericardial fluid]]. This can occur in infections and inflammations where there is increased production of pericardial fluid, increased microvascular pressure as in [[cardiac failure]] and [[renal failure ]]cause, decreased plasma oncotic pressure as in [[cirrhosis]] and [[nephrotic syndrome]], or in [[malignancy]] and [[hypothyroidism]] where there is inadequate drainage of the fluid. | ||
==Pathophysiology== | ==Pathophysiology== | ||
=== Physiology === | |||
=== | * [[Pericardium]] surrounds the heart and it consists of two layers, [[parietal]] and [[visceral]] layers <ref name="pmid29025540">{{cite journal| author=Hoit BD| title=Anatomy and Physiology of the Pericardium. | journal=Cardiol Clin | year= 2017 | volume= 35 | issue= 4 | pages= 481-490 | pmid=29025540 | doi=10.1016/j.ccl.2017.07.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29025540 }} </ref>. | ||
* The space between the layers is known as the [[pericardial cavity]]. | |||
* It usually contains small amount of fluid, approximately 15-50ml, which acts as a lubricating agent between the layers. | |||
* This fluid enters the pericardial space from the capillaries into the visceral pericardium. | |||
* This fluid is drained by [[lymphatics]] <ref name="pmid28062264">{{cite journal| author=Rodriguez ER, Tan CD| title=Structure and Anatomy of the Human Pericardium. | journal=Prog Cardiovasc Dis | year= 2017 | volume= 59 | issue= 4 | pages= 327-340 | pmid=28062264 | doi=10.1016/j.pcad.2016.12.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28062264 }} </ref>. | |||
* When this fluid production-drainage mechanism is altered, excess fluid accumulates in the pericardial cavity and this is referred to as [[pericardial effusion]]. | |||
[[File:New.jpg|center|thumb|Normal gross anatomy of the pericardium space and fluid. Credit: Anatomist90 <ref>https://commons.wikimedia.org/wiki/File:Slide14gggg.JPG/</ref>]] | |||
: | <br /> | ||
: | === Pathogenesis === | ||
Therefore, [[pericardial effusion]] occurs when there is: | |||
: | |||
: | * Increased capillary membrane permeability: [[Infection]] or [[inflammation]] may lead to [[exudative]] fluid or hemorrhagic effusion which have high protein levels. The pericardial effusion observed in the following conditions results from increased permeability of the capillary membrane <ref name="pmid28062268">{{cite journal| author=Vakamudi S, Ho N, Cremer PC| title=Pericardial Effusions: Causes, Diagnosis, and Management. | journal=Prog Cardiovasc Dis | year= 2017 | volume= 59 | issue= 4 | pages= 380-388 | pmid=28062268 | doi=10.1016/j.pcad.2016.12.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28062268 }} </ref>. | ||
**[[Viral]]/[[Bacteria|bacterial]] infections such as [[adenovirus]] infection and [[tuberculosis]] | |||
**[[Autoimmune disease]]s such as [[sarcoidosis]], [[SLE]] and [[rheumatoid arthritis]] | |||
**[[Penetrating trauma]] which injure the [[blood vessels]] and cause [[hemorrhage]] into the pericardial space | |||
**[[Malignancies]] such as [[pulmonary carcinoma]] may metastasize to the [[pericardium]] and can disrupt pericardial anatomy and vasculature | |||
* Increased microvascular pressure: Hypervolemic states like [[cardiac failure]] and [[renal failure ]]cause pericardial effusion due to increased microvascular pressure <ref name="pmid29580632">{{cite journal| author=Patel Y, Agarwal V, Argulian E| title=Relation of Blood Pressure to Severity of Pericardial Effusion. | journal=Am J Cardiol | year= 2018 | volume= 121 | issue= 11 | pages= 1409-1412 | pmid=29580632 | doi=10.1016/j.amjcard.2018.02.023 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29580632 }} </ref>. | |||
* Decreased plasma oncotic pressure: [[Pericardial effusion]] seen in [[cirrhosis]] and [[nephrotic syndrome]] is due to decreased plasma [[oncotic pressure]] secondary to [[hypoalbuminemia]]. | |||
* Decreased drainage of [[pericardial fluid]]: [[Pericardial effusion]] may occur in [[malignancies]] and [[hypothyroidism]] due to decreased drainage of the [[pericardial fluid]] by the [[lymphatics]] <ref name="pmid25833996">{{cite journal| author=Scardulla F, Rinaudo A, Pasta S, Scardulla C| title=Mechanics of pericardial effusion: a simulation study. | journal=Proc Inst Mech Eng H | year= 2015 | volume= 229 | issue= 3 | pages= 205-14 | pmid=25833996 | doi=10.1177/0954411915574012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25833996 }} </ref><ref name="pmid21928406">{{cite journal| author=Refaat MM, Katz WE| title=Neoplastic pericardial effusion. | journal=Clin Cardiol | year= 2011 | volume= 34 | issue= 10 | pages= 593-8 | pmid=21928406 | doi=10.1002/clc.20936 | pmc=6652358 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21928406 }} </ref>. | |||
== Genetics == | |||
There are no known genetic causes of [[pericardial effusion]]. | |||
== Associated Conditions == | |||
Conditions associated with [[pericardial effusion]] include: | |||
* Other pericardial diseases e.g. [[pericarditis]]. | |||
*[[Parapneumonic effusion|Parapneumonic effusion.]] | |||
*[[Autoimmune disorders]], such as [[rheumatoid arthritis]] or [[Systemic lupus erythematosus|lupus]]. | |||
*[[Malignancy]] | |||
== Gross Pathology == | |||
On [[gross pathology]], enlarged cardiac cavity, compressed [[cardiac chambers]] (with large effusions), heart swinging within the effusion fluid are characteristic findings of [[pericardial effusion]]. Further, the color of the effusion fluid may give an insight into the possible effusion cause. | |||
== Microscopic Pathology == | |||
On microscopic histopathological analysis, there are no characteristic features of [[pericardial effusion]]. However, analysis of the pericardial fluid itself may give insights into the underlying cause e.g. numerous pus cells would indicate a [[pyogenic]]/[[inflammatory]] cause, [[Lymphocyte|lymphocytes]] indicate [[viral infection]], and [[malignant]] cells indicate malignant seeding into the [[pericardium]]. | |||
==References== | ==References== | ||
Latest revision as of 13:17, 9 March 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Abdelrahman Ibrahim Abushouk, MD[2], Varun Kumar, M.B.B.S.
Overview
Pericardial effusion usually results from a disturbed equilibrium between the production and reabsorption of pericardial fluid. This can occur in infections and inflammations where there is increased production of pericardial fluid, increased microvascular pressure as in cardiac failure and renal failure cause, decreased plasma oncotic pressure as in cirrhosis and nephrotic syndrome, or in malignancy and hypothyroidism where there is inadequate drainage of the fluid.
Pathophysiology
Physiology
- Pericardium surrounds the heart and it consists of two layers, parietal and visceral layers [1].
- The space between the layers is known as the pericardial cavity.
- It usually contains small amount of fluid, approximately 15-50ml, which acts as a lubricating agent between the layers.
- This fluid enters the pericardial space from the capillaries into the visceral pericardium.
- This fluid is drained by lymphatics [2].
- When this fluid production-drainage mechanism is altered, excess fluid accumulates in the pericardial cavity and this is referred to as pericardial effusion.
Pathogenesis
Therefore, pericardial effusion occurs when there is:
- Increased capillary membrane permeability: Infection or inflammation may lead to exudative fluid or hemorrhagic effusion which have high protein levels. The pericardial effusion observed in the following conditions results from increased permeability of the capillary membrane [4].
- Viral/bacterial infections such as adenovirus infection and tuberculosis
- Autoimmune diseases such as sarcoidosis, SLE and rheumatoid arthritis
- Penetrating trauma which injure the blood vessels and cause hemorrhage into the pericardial space
- Malignancies such as pulmonary carcinoma may metastasize to the pericardium and can disrupt pericardial anatomy and vasculature
- Increased microvascular pressure: Hypervolemic states like cardiac failure and renal failure cause pericardial effusion due to increased microvascular pressure [5].
- Decreased plasma oncotic pressure: Pericardial effusion seen in cirrhosis and nephrotic syndrome is due to decreased plasma oncotic pressure secondary to hypoalbuminemia.
- Decreased drainage of pericardial fluid: Pericardial effusion may occur in malignancies and hypothyroidism due to decreased drainage of the pericardial fluid by the lymphatics [6][7].
Genetics
There are no known genetic causes of pericardial effusion.
Associated Conditions
Conditions associated with pericardial effusion include:
- Other pericardial diseases e.g. pericarditis.
- Parapneumonic effusion.
- Autoimmune disorders, such as rheumatoid arthritis or lupus.
- Malignancy
Gross Pathology
On gross pathology, enlarged cardiac cavity, compressed cardiac chambers (with large effusions), heart swinging within the effusion fluid are characteristic findings of pericardial effusion. Further, the color of the effusion fluid may give an insight into the possible effusion cause.
Microscopic Pathology
On microscopic histopathological analysis, there are no characteristic features of pericardial effusion. However, analysis of the pericardial fluid itself may give insights into the underlying cause e.g. numerous pus cells would indicate a pyogenic/inflammatory cause, lymphocytes indicate viral infection, and malignant cells indicate malignant seeding into the pericardium.
References
- ↑ Hoit BD (2017). "Anatomy and Physiology of the Pericardium". Cardiol Clin. 35 (4): 481–490. doi:10.1016/j.ccl.2017.07.002. PMID 29025540.
- ↑ Rodriguez ER, Tan CD (2017). "Structure and Anatomy of the Human Pericardium". Prog Cardiovasc Dis. 59 (4): 327–340. doi:10.1016/j.pcad.2016.12.010. PMID 28062264.
- ↑ https://commons.wikimedia.org/wiki/File:Slide14gggg.JPG/
- ↑ Vakamudi S, Ho N, Cremer PC (2017). "Pericardial Effusions: Causes, Diagnosis, and Management". Prog Cardiovasc Dis. 59 (4): 380–388. doi:10.1016/j.pcad.2016.12.009. PMID 28062268.
- ↑ Patel Y, Agarwal V, Argulian E (2018). "Relation of Blood Pressure to Severity of Pericardial Effusion". Am J Cardiol. 121 (11): 1409–1412. doi:10.1016/j.amjcard.2018.02.023. PMID 29580632.
- ↑ Scardulla F, Rinaudo A, Pasta S, Scardulla C (2015). "Mechanics of pericardial effusion: a simulation study". Proc Inst Mech Eng H. 229 (3): 205–14. doi:10.1177/0954411915574012. PMID 25833996.
- ↑ Refaat MM, Katz WE (2011). "Neoplastic pericardial effusion". Clin Cardiol. 34 (10): 593–8. doi:10.1002/clc.20936. PMC 6652358 Check
|pmc=value (help). PMID 21928406.
