Pleural effusion secondary to diseases of GIT.pptx

Pleural effusion secondary to diseases of GIT

1. Pleural effusion secondary to diseases of GIT Dr. Sathish Kumar M

2. Pancreatic diseases Subphrenic abscess Intrahepatic abscess Esophageal perforation Abdominal surgical procedures Diaphragmatic Hernia Endoscopic variceal sclerotherapy Bilious pleural effusion Pleural effusion after liver transplantation Pleural effusion as complications of therapy for tumours of the liver

3. Pancreatic diseases. 4 types of non malignant pancreatic diseases associated with pleural effusion 1. Acute pancreatitis 2. Chronic pancreatitis with Pseudocyst 3. Pancreatic abscess 4. Pancreatic ascites

4. Acute pancreatitis Left sided - Indication of severe pancreatiti s Mechanism – Trans diaphragmatic transfer of exudative fluid, Diaphragmatic inflammation Numerous lymphatic networks join on the peritoneal and pleural aspects of the diaphragm. Anatomically, the tail of the pancreas is in direct contact with the diaphragm. Hence, the exudate resulting from acute pancreatic inflammation, which is rich in pancreatic enzymes , enters the lymphatic vessels on the peritoneal side of the diaphragm and is conveyed to the pleural side of the diaphragm.

5. Because this fluid contains high levels of pancreatic enzymes, the permeability of the lymphatic vessels is increased and fluid leaks from the pleural lymphatic vessels into the pleural space. The high enzymatic content of the pancreatic exudate may also cause partial or complete obstruction of the pleural lymphatic vessels that leads to more pleural fluid accumulation T he diaphragm itself may be inflamed from the adjacent inflammatory process , and this inflammation may increase the permeability of the capillaries in the diaphragmatic pleura

6. Clinical features : abdominal and respiratory symptoms Pleuritic chest pain and dyspnea Abdominal pain, nausea, and vomiting

7. In Acute pancreatitis… CXR Small – moderate pleural effusion Basilar infiltrates Fluid analysis Exudate Polymorphonuclear leukocytosis Amylase elevated Management No Thoracocentesis Resolves spontaneously by 2 weeks

8. Pancreatic abscess: Pancreatic abscess usually follows an episode of acute pancreatitis Acute pancreatitis initially responds to therapy, but 10 to 21 days later, the patient becomes febrile with abdominal pain and leukocytosis The diagnosis is also suggested if a patient with acute pancreatitis does not respond to the usual therapy within several days mortality rate approaches 100% if the abscess is not drained surgically INV – USG, Abdominal CT The other complication that can cause a pleural effusion to persist in patients with acute pancreatitis is a pancreatic pseudocyst

9. Pancreatic pseudocyst P ancreatic pseudocyst is not a true cyst but rather a collection of fluid and debris rich in pancreatic enzymes near or within the pancreas. The walls consist of granulation tissue without an epithelial lining Approximately 5% of patients with a pancreatic pseudocyst have a pleural effusion Mechanism: Pancreatico pleural fistula – development of a direct sinus tract between the pancreas and the pleural space

10. Clinical features abdominal and respiratory symptoms Pleuritic chest pain and dyspnea Abdominal pain, nausea, and vomiting – lack of abdominal symptoms – since pancreaticopleural fistula decompresses th e pseudocyst Unilateral – left sided, Large Diagnosis: Fluid analysis: Amylase >1000 – best screening test CT abdomen and chest / ERCP to trace the tract

11. In pancreatic pseudocyst… Elevated amylase Pancreatic pleural effusion Malignancy -Amylase >1000 - Not so high -Pancreatic amylase is elevated - Salivary amylase is elevated

12. In pancreatic pseudocyst… Treatment: Non operative: Conservative management Nasogastric tube – intravenous hyperalimentation. Somatatostatin or octreotide – inhibitory effect on pancreatic exocrine secreation Pancreatic secretions are minimized  tract closes

13. If after 2 weeks – remains symptomatic – surgical intervention needed ERCP and abdominal CT – leak from distal end – distal pancreatectomy Leak from proximal portion – Roux-en-Y jejunal loop or Whipple resection Alternative- percutaneous drainage under CT guidance Non resolution after 6 months – Decortication

14. Subphrenic abcscess : Pleural effusion is present in approximately 80% of cases. Causes: Follow intraabdominal surgical procedures – gastrectomy, exploratory laporatomy for trauma G astric, duodenal, or appendiceal perforation; diverticulitis; cholecystitis; pancreatitis; or trauma Mechanism: Diaphragmatic inflammation from adjacent abscess increases the permeability of capillaries of diaphragmatic pleura

15. Clinical manifestations: Abdominal and respiratory symptoms CXR – pleural effusion, basal pneumonitis , compression atelectasis, and an elevated diaphragm on the affected side. Pleural effusions occur in 60% to 80% of patients and are usually small to moderate in size, but may be large, occupying more than 50% of the hemithorax

16. Most patients with postoperative subphrenic abscesses have fever, leukocytosis, and abdominal pain The interval between the surgical procedure and the development of the subphrenic abscess is usually 1 to 3 weeks but can be as long as 5 months Exudate with predominantly polymorphonuclear leukocytes . Although the pleural fluid WBC may approach or even exceed 50,000/mm3 , the pleural fluid pH and glucose level remain above 7.20 and 60 mg/dL , respectively.

17. Investigations : CXR – air fluid level below the diaphragm outside the GI tract – best demonstrated in heavily exposed abdominal films USG abdomen CT chest/ abdomen Gallium scan

18. Treatment: Administration of appropriate antibiotics(broad spectrum antibiotics with anaerobic coverage) and drainage. Drainange by percutaneous approach or surgically

19. Intrahepatic abscess: Pleural effusions accompany intrahepatic abscesses in approximately 50% of patients Because the mortality rate of patients with untreated liver abscesses approaches 100%, the diagnosis of intrahepatic abscess should be considered in every patient with a right-sided exudative pleural effusion with predominantly polymorphonuclear leukocytes on the pleural fl uid differential. Clinical manifestations: Fever Anorexia Chills Abdominal pain Tender hepatomegaly Leukocytosis Anemia Elevated alkaline phosphatase hyperbilirubinemia

20. Investigation USG abdomen CT abdomen Definitive diagnosis by percutaneous aspiration guided by CT scanning or ultrasound Treatment: Administration of appropriate antibiotics and drainage. Image guided aspiration with or without catheter drainage Emergency laporatomy in case of signs of peritonitis or persistent abscess

21. Intrasplenic abscess: 20%to 50% patients with splenic abscess had a left sided Pleural effusion splenic suppuration arises from primary hematogenous seeding such as with endocarditis . Splenic abscess appears to be more common in individuals with diseases producing splenic abnormalities, such as chronic hemolytic anemia or sickle cell anemia Localised pain in left upper quadrant, Left pleural effusion and thrombocytosis should raise suspicion of intrasplenic abscess INV- CT abdomen Treatment – surgical – splenectomy and antibiotics, some pts cured with catheter drainage

22. Esophageal perforation: Esophageal perforation most commonly arises as a complication of esophagoscopic examination Causes: esophagoscopy when one has attempted to remove a foreign body or to dilate an esophageal stricture insertion of a Blakemore tube for esophageal varices can also be complicated by esophageal rupture may also arise from foreign bodies themselves, carcinomas, gastric intubation, chest trauma, and chest operations. may occur as a complication of vomiting ( Boerhaave syndrome) Spontaneous rupture almost always involves the lower esophagus, just above the diaphragm.

23. Clinical presentation: The clinical symptoms of esophageal perforation are due to contamination of the mediastinum by oropharyngeal contents, which produces an acute mediastinitis persistent chest or epigastric pain within several hours of the procedure history of vomiting, followed by chest pain, and they frequently describe a sensation of tearing or bursting in the lower part of the chest or the epigastrium The chest pain is characteristically excruciating and is often unrelieved by opiates, sometimes associated with hematemesis Dyspnoea , subcutaneous emphysema – first appears in substernal notch

24. Investigation: CXR - The pleural effusion is usually left sided, but it may be right sided or bilateral. Other radiographic findings may include widening of the mediastinum and air visible within the mediastinal compartments. The chest CT scan is useful in suggesting the diagnosis of esophageal perforation because it demonstrates periesophageal air tracks suggestive of esophageal perforation in most cases

25. Pleural fluid analysis - exudative pleural effusion a high amylase level – within 2 hours of rupture low pH – leucocyte metabolism the presence of squamous epithelial cells – wright ’s stain Low glucose ingested food particles, multiple pathogens on smear or culture.

26. Contrast studies of esophagus – diagnostic of esophageal perforation The contrast agent of choice is probably meglumine and ioxaglate sodium ( Hexabrix , 320 mg/mL), diatrizoate sodium ( Gastrografin ) Hexabrix or meglumine and diatrizoate sodium ( Gastrografin ) , are injected in the pleural space, they are almost completely absorbed after 24 hours and neither creates much of an inflammatory response Hexabrix is considered the agent of choice because Gastrografin creates marked bronchospasm CT chest – may also facilitate the diagnosis

27. Treatment: Because the mortality rate approaches 60% when treatment is delayed for more than 24 hours, the diagnosis of esophageal rupture should be mede as early as possible Exploration of the mediastinum with primary repair of the esophageal tear and drainage of the pleural space and mediastinum If primary repair is not possible because the damaged tissue cannot hold the sutures, the patient can be managed with T-tube intubation of the esophageal defect

28. Abdominal surgical procedures: The incidence of small pleural effusions after abdominal operations is high bilateral decubitus chest radiographs 48 to 72 hours following abdominal surgical procedures may show pleural effusion Most mild pleural effusion Larger left-sided pleural effusions are particularly common after splenectomy. Postoperative pleural effusions are more common in patients undergoing upper abdominal surgical procedures, in patients with postoperative atelectasis, and in those with free abdominal fluid at the time of operation Mechanism – diaphragmatic irritation INV – CXR , CT chest Mostly resolve spontaneously, pleural effusion measures more than 10 mm in thickness on the decubitus film, a diagnostic thoracentesis should be performed to rule out pleural infection

29. Diaphragmatic Hernia: Hernias through the diaphragm are important in th e differential diagnosis of pleural effusions - mimic a pleural effusion and pleural effusions are usually present in patients with a strangulated diaphragmatic hernia pleural effusion has an atypical shape or location Air in the herniated intestine is usually the clue t o this diagnosis strangulated diaphragmatic hernia should always be considered in patients with a left pleural effusion and signs of an acute abdominal catastrophe MC site – left, rt side protected by liver Serosanguinous exudative pleural fluid, neutrophilic CXR – multiple air fluid fluid levels, CT chest and contrast studies Immediate surgical treatment in case strangulation

30. Poste roa nte r i o r chest ra d i o g r a p h from a 3 1 -ye a r- o l d m a n who p resented with i ncrea s i n g dys p n e a . H e was in a n a utom o b i l e accident 1 5 yea rs previ o u s l y a n d w a s t o l d t h a t h e h a d i nj u red h i s r i g ht d i a p h ra g m . N ote t h e co l l ecti o n s o f a i r i n t h e u p p e r p a rt of the a p p a rent mass. At s u rg e ry , both the l iver a n d co l o n h a d h e r n i ated t h rou g h t h e d i a p h ra g m .

31. Endoscopic variceal sclerotherapy: EVS is followed by the development of a pleural effusion 5% sodium morrhuate Left, right, and bilateral effusions Most of the effusions are small and resolve within a week

32. Bilious pleural effusion: Bilious pleural effusions are a rare complication of biliary tract disorders fistula from the biliary tree to the pleural space Cause: thoracoabdominal trauma Other causes have included parasitic liver disease, Suppurative complications of biliary tract obstruction, and postoperative strictures of bile ducts. Bilious pleural effusions have also been reported to occur after percutaneous biliary drainage

33. The diagnosis of a bilious pleural effusion should be suspected in any patient with an obstructed biliary system the ratio of the pleural fluid to serum bilirubin is greater than 1 .0 The appropriate treatment for this condition is the reestablishment of the biliary drainage . Most patients who have a bilious pleural effusion after trauma require decortication and diaphragmatic repair

34. Pleural effusion after liver transplantation: The pleural effusion after liver transplantation may be large The pathogenesis of the pleural effusions after liver transplantation is not definitely known. It has been suggested that the effusion is due to injury or irritation of the right hemidiaphragm caused by the extensive right upper quadrant dissection and retraction The pleural effusion that occurs after liver transplantation can be largely prevented if a fibrin sealant is sprayed on the undersurface of the diaphragm around the insertion of the liver ligaments at the time of transplantation.

35. Thank you