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Deutsches Arzteblatt International May 2019Pleural effusion is common in routine medical practice and can be due to many different underlying diseases. Precise differential diagnostic categorization is essential,... (Review)
Review
BACKGROUND
Pleural effusion is common in routine medical practice and can be due to many different underlying diseases. Precise differential diagnostic categorization is essential, as the treatment and prognosis of pleural effusion largely depend on its cause.
METHODS
This review is based on pertinent publications retrieved by a selective search in PubMed and on the authors' personal experience.
RESULTS
The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism. Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains, at present, the foundation of the further diagnostic work-up. When a pleural effusion arises in the setting of pneumonia, the potential devel- opment of an empyema must not be overlooked. Lung cancer is the most common cause of malignant pleural effusion, followed by breast cancer. Alongside the treatment of the underlying disease, the specific treatment of pleural effusion ranges from pleurodesis, to thoracoscopy and video-assisted thoracoscopy (with early consultation of a thoracic surgeon), to the placement of a permanently indwelling pleural catheter.
CONCLUSION
The proper treatment of pleural effusion can be determined only after meticulous differential diagnosis. The range of therapeutic options has recently become much wider. More data can be expected in the near future concerning diagnostic test- ing for the etiology of the effusion, better pleurodetic agents, the development of interventional techniques, and the genetic background of the affected patients.
Topics: Adult; Exudates and Transudates; Humans; Pleural Effusion; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis
PubMed: 31315808
DOI: 10.3238/arztebl.2019.0377 -
Liver International : Official Journal... Feb 2020Ascites is the most common complication of cirrhosis, which develops in 5%-10% of patients per year. Its management is based on symptomatic measures including... (Review)
Review
Ascites is the most common complication of cirrhosis, which develops in 5%-10% of patients per year. Its management is based on symptomatic measures including restriction of sodium intake, diuretics and paracentesis. Underlying liver disease must always be treated and may improve ascites. In some patients, ascites is not controlled by medical therapies and has a major impact on quality of life and survival. TIPS placement and liver transplantation must therefore be discussed. More recently, repeated albumin infusions and Alfapump have emerged as new therapies in ascites. In this review, the current data on these different options are analysed and an algorithm to help the physician make clinical decisions is suggested.
Topics: Ascites; Diuretics; Humans; Liver Cirrhosis; Liver Transplantation; Paracentesis; Quality of Life
PubMed: 32077614
DOI: 10.1111/liv.14361 -
Clinical and Molecular Hepatology Jan 2023The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its... (Review)
Review
The development of refractory ascites in approximately 10% of patients with decompensated cirrhosis heralds the progression to a more advanced stage of cirrhosis. Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.
Topics: Humans; Ascites; Quality of Life; Liver Cirrhosis; Albumins; Hypertension, Portal; Sodium; Portasystemic Shunt, Transjugular Intrahepatic; Paracentesis
PubMed: 35676862
DOI: 10.3350/cmh.2022.0104 -
Canadian Respiratory Journal 2020Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12... (Review)
Review
Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient's preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.
Topics: Catheters, Indwelling; Drainage; Humans; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis
PubMed: 33273991
DOI: 10.1155/2020/2950751 -
European Review For Medical and... Dec 2022Pleural effusion affects gas exchange, hemodynamic stability, and respiratory movement, thereby increasing the failure rate of intensive care unit discharge and... (Review)
Review
Pleural effusion affects gas exchange, hemodynamic stability, and respiratory movement, thereby increasing the failure rate of intensive care unit discharge and mortality. Therefore, it is especially important to diagnose pleural effusion quickly to make the appropriate treatment decisions. The present review discusses the role of ultrasound in the diagnosis and puncture/drainage of pleural effusions and highlights the importance of lung ultrasound techniques in this patient population. We searched on PubMed, Embase, and Cochrane Library databases for articles from establishment to October 2022 using the following keywords: "lung ultrasound", "pulmonary ultrasound", "pleural effusion", "ultrasound-guided" and "thoracentesis". Lung ultrasound not only helps clinicians visualize pleural effusion but also to identify its different types and assess pleural effusion volume. It is also very important for thoracentesis, not only to increase safety and reduce life-threatening complications, but also to monitor the amount of fluid after drainage of pleural effusion. Lung ultrasound is a simple, noninvasive bedside technique with good sensitivity and specificity for the diagnosis and treatment of pleural effusions.
Topics: Humans; Pleural Effusion; Thoracentesis; Exudates and Transudates; Lung; Ultrasonography; Drainage
PubMed: 36524495
DOI: 10.26355/eurrev_202212_30548 -
Current Cardiology Reports Jul 2021Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to... (Review)
Review
PURPOSE OF REVIEW
Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to life-threatening cardiac tamponade. In this review, we summarize the contemporary evidence of the etiology; diagnostic work-up, with particular emphasis on the contribution of multimodality imaging; therapeutic options; and short- and long-term outcomes of these patients.
RECENT FINDINGS
In recent years, an important piece of information has contributed to put together several missing parts of the puzzle of pericardial effusion. The most recent 2015 guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases are a valuable aid for a tailored approach to this condition. Actually, current guidelines suggest a 4-step treatment algorithm depending on the presence or absence of hemodynamic impairment; the elevation of inflammatory markers; the presence of a known or first-diagnosed underlying condition, possibly related to pericardial effusion; and finally the duration and size of the effusion. In contrast to earlier perceptions, based on the most recent evidence, it seems that in the subgroup of asymptomatic patients with large (> 2-cm end-diastolic diameter), chronic (> 3 months) C-reactive protein negative, idiopathic (without an apparent cause) pericardial effusion, a conservative approach is the most reasonable option. At present there is an increasing interest in the pericardial syndromes in general and pericardial effusions in specific, which has consistently expanded our knowledge in this "hazy landscape." Apart from general recommendations applied to all cases, an individualized, etiologically driven treatment is of paramount importance.
Topics: Cardiac Tamponade; Cardiology; Hemodynamics; Humans; Pericardial Effusion; Pericardiocentesis
PubMed: 34196832
DOI: 10.1007/s11886-021-01539-7 -
Current Opinion in Pulmonary Medicine Jul 2016Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article,... (Review)
Review
PURPOSE OF REVIEW
Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema.
RECENT FINDINGS
Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study.
SUMMARY
Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.
Topics: Hematoma; Hemorrhage; Hemothorax; Humans; Incidence; Pleural Diseases; Pneumothorax; Pressure; Pulmonary Edema; Risk Factors; Thoracentesis; Thoracic Wall
PubMed: 27093476
DOI: 10.1097/MCP.0000000000000285 -
Critical Care (London, England) Dec 2017Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients.... (Review)
Review
Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.
Topics: Drainage; Humans; Intensive Care Units; Lung; Pleural Effusion; Thoracentesis; Ultrasonography
PubMed: 29282107
DOI: 10.1186/s13054-017-1897-5 -
Romanian Journal of Internal Medicine =... Dec 2021Spontaneous bacterial peritonitis (SBP) is a common complication in patients with liver cirrhosis, with an increased risk of mortality. For this reason, a diagnostic...
Spontaneous bacterial peritonitis (SBP) is a common complication in patients with liver cirrhosis, with an increased risk of mortality. For this reason, a diagnostic paracentesis should be performed in all patients with ascites and clinical features with high diagnostic suspicion. Although literature data abound in identifying new diagnostic markers in serum or ascites, they have not yet been validated. The final diagnosis requires the analysis of ascites and the presence of > 250 mm neutrophil polymorphonuclear (PMN) in ascites. If previous data showed that the most common microorganisms identified were represented by gram-negative bacteria, we are currently facing an increase in gram-positive bacteria and multidrug-resistant bacteria. Although prompt and effective treatment is required to prevent outcomes, this becomes challenging as first-line therapies may become ineffective leading to worsening prognosis and increased in-hospital mortality. In this paper we will make a brief review of existing data on the diagnosis and treatment of SBP.
Topics: Adult; Anti-Bacterial Agents; Ascites; Bacterial Infections; Female; Humans; Liver Cirrhosis; Male; Middle Aged; Neutrophils; Paracentesis; Peritonitis; Treatment Outcome
PubMed: 34182617
DOI: 10.2478/rjim-2021-0024 -
Alimentary Pharmacology & Therapeutics Jun 2015Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites. (Review)
Review
BACKGROUND
Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection in patients with cirrhosis and ascites.
AIM
To review the known and changing bacteriology, risk factors, ascitic fluid interpretation, steps in performing paracentesis, treatment, prophylaxis and evolving perspectives related to SBP.
METHODS
Information was obtained from reviewing medical literature accessible on PubMed Central. The search term 'spontaneous bacterial peritonitis' was cross-referenced with 'bacteria', 'risk factors', 'ascites', 'paracentesis', 'ascitic fluid analysis', 'diagnosis', 'treatment', 'antibiotics', 'prophylaxis', 'liver transplantation' and 'nutrition'.
RESULTS
Gram-positive cocci (GPC) such as Staphylococcus, Enterococcus as well as multi-resistant bacteria have become common pathogens and have changed the conventional approach to treatment of SBP. Health care-associated and nosocomial SBP infections should prompt greater vigilance and consideration for alternative antibiotic coverage. Acid suppressive and beta-adrenergic antagonist therapies are strongly associated with SBP in at-risk individuals.
CONCLUSIONS
Third-generation, broad-spectrum cephalosporins remain a good initial choice for SBP treatment. Levofloxacin is an acceptable alternative for patients not receiving long-term flouroquinolone prophylaxis or for those with a penicillin allergy. For uncomplicated SBP, early oral switch therapy is reasonable. Alternative antibiotics such as pipercillin-tazobactam should be considered for patients with nosocomial SBP or for patients who fail to improve on traditional antibiotic regimens. Selective albumin supplementation remains an important adjunct in SBP treatment. Withholding acid suppressive medication deserves strong consideration, and discontinuing beta-adrenergic antagonist therapy in patients with end-stage liver disease and resistant ascites is standard care. Liver transplant evaluation should be undertaken for patients who develop SBP barring contraindications.
Topics: Anti-Bacterial Agents; Ascites; Bacterial Infections; Cross Infection; Humans; Liver Cirrhosis; Liver Transplantation; Paracentesis; Peritonitis; Risk Factors
PubMed: 25819304
DOI: 10.1111/apt.13172