Internal illnesses. Pericarditis (lecture notes)

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Internal illnesses. Pericarditis (lecture notes)

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LECTURE No. 6. Pericarditis

Pericarditis is an inflammatory disease of the pericardium, which is more often a local manifestation of a certain disease (tuberculosis, rheumatism, diffuse connective tissue diseases) or a concomitant disease of the myocardium and endocardium.

Etiology. The disease is caused by various pathogens (bacteria, viruses, fungi, rickettsiae, mycobacteria, typhoid and dysenteric bacillus).

It is possible to develop aseptic pericarditis with allergies, systemic connective tissue lesions, traumatic injuries, autoimmune processes (post-infarction, post-commissurotomy, blood diseases, hemorrhagic diathesis, radiation injuries, hemodialysis, malignant tumors, deep metabolic disorders (uremic, gouty).

There is a group of idiopathic pericarditis.

Pathogenesis. The infection penetrates into the pericardial cavity by the hematogenous or lymphogenous route. Ex-sudative processes intensify in the pericardium. In the pericardial cavity, fibrinogen is released, fibrin is formed. Fibrous pericarditis develops. Under the fibrin layer, the mesothelium is destroyed, the fibrinous masses fuse with the underlying tissue. With the total involvement of the pericardium in the inflammatory process, the development of exudative pericarditis is possible.

The accumulation of a large amount of exudate in the pericardial cavity is manifested by the syndrome of cardiac tamponade. Diastolic filling of the cavities of the heart with blood is difficult with the development of congestive insufficiency of the right ventricular type.

Pathological anatomy. Pericarditis are fibrinous, serous, serous-fibrinous, serous-hemorrhagic, hemorrhagic, purulent, putrefactive.

The adhesive process is not limited to the pericardial cavity, it can go beyond it, lead to the formation of adhesions with the pleura, mediastinum, diaphragm, with the anterior chest wall, the vena cava and hepatic veins can be affected.

Clinic. Dry (fibrinous) pericarditis there are pains in the region of the heart of varying strength. The pains are usually localized in the lower sternum or in the region of the apex of the heart, radiating to the left shoulder blade, neck, epigastrium, to the left arm.

Borders and heart sounds are not changed. A pericardial friction rub is heard, which is more often determined on the sternum and to the left of the parasternal line. Noise is heard in any phase of the cardiac cycle, sometimes it can be heard only in the sitting position or in the knee-elbow position. The murmur is heard better on inspiration, has a scratchy tone, higher than other heart murmurs. It may last for several hours or months.

With effusion (exudative) pericarditis, which develops after the stage of dry pericarditis or without it, appear: shortness of breath, decreasing in the sitting position, when the torso is tilted forward; cough (usually dry), vomiting possible. The body temperature rises, the boundaries of the heart increase in all directions, the apical impulse decreases or disappears, the cervical veins swell (pulsation is not visually determined). Heart sounds are sharply muffled, sinus tachycardia is possible, pericardial friction rub (with a small amount of exudate), which weakens with the accumulation of exudate.

With a large effusion, the pulse decreases, especially on inspiration (paradoxical pulse), blood pressure decreases, especially systolic.

With cardiac tamponade there are severe pain behind the sternum, collapse, tachycardia, paradoxical pulse. With compression of the superior vena cava, the formation of a "consular" head, Stokes collar, is possible. With compression of the inferior vena cava appear: hepatomegaly, premature ascites, Breitman's position, periodic disturbance of consciousness.

With adhesive (adhesive) pericarditis an adhesive process develops due to purulent, tuberculous and hemorrhagic pericarditis and may be asymptomatic. Pain in the region of the heart, dry cough, aggravated by physical exertion, are more often noted. Perhaps the retraction of the apex beat (symptom of Saly-Chudnovsky), its combination with Friedreich's diastolic venous collapse and the prodiastolic tone of the throw, obliteration of the cavities and fusion of the pericardium with the anterior abdominal wall) the boundaries of relative and absolute dullness merge. During auscultation, the three-term nature of the rhythm is determined (an additional click at the end of systole, which does not change from inhalation or exhalation). Perhaps the appearance of systolic non-conductive noise over the anterior surface of the heart.

With constrictive (compressive) pericarditis in the early stages, shortness of breath develops, which occurs first during exertion, then at rest, a slight cyanosis of the lips and the tip of the nose. In the extended stage, Beck's triad appears: high venous pressure, ascites, "small quiet heart".

The cervical veins swell, puffiness of the face, cyanosis appears. The position of the patient in orthopnea. Trophic disorders develop. The apex beat disappears, is not detected by palpation. The pulse is rapid, small amplitude, atrial fibrillation, blood pressure is reduced, especially systolic, venous pressure is increased. The size of the heart may not be increased, the heart sounds are muffled. There may be a low systolic murmur, anasarca, hydrothorax, ascites are noted.

This variant of pericarditis is more often observed in men, the main cause of its development is tuberculosis.

Additional diagnostic study. A general blood test is performed, in which leukocytosis is detected with a shift of the formula to the left, an increase in ESR. The severity of the indicators depends on the inflammatory manifestations.

To detect changes in the configuration of the heart shadow, effusion, pulsation of the contours of the heart in chronic pericarditis, thickening of the pericardium, lime deposits, an X-ray examination is performed.

An ECG study is required. With dry pericarditis in all leads, the ST segment is elevated above the isoline with gradual normalization, a negative T wave may appear. The ECG picture resembles an acute myocardial infarction, since the Q wave and the QRS complex do not change, ST segment changes are never discordant.

With exudative pericarditis, there is a decrease in the voltage of all teeth, extrasystole, atrial fibrillation.

EchoCG study visualizes changes in the heart, while probing the heart, the pressure in the cavities is measured. A diagnostic puncture is carried out with a mandatory subsequent cytological, bacteriological, biochemical, immunological study of the punctate.

Differential diagnostics. Should be carried out with nonspecific myocarditis, myocardial infarction, dry pleurisy, cardialgia of various origins.

Treatment. In the acute period, bed rest, a diet with enough protein, vitamins C and K, and salt restriction are prescribed. The underlying disease is being treated - etiotropic therapy.

Of the means of pathogenetic therapy, NSAIDs are used (not indicated for secondary pericarditis, with myocardial infarction), glucocorticoids for 1-1,5 months (with a tumor nature not prescribed), antihistamines, vitamin C.

If necessary, symptomatic therapy is used.

With squeezing pericarditis, surgical treatment (pericardectomy) is indicated. The consequences of operations are serious. For the treatment of heart failure, diuretics are used for a long time (sometimes years) in small doses.

Flow. The course can be acute (pass within 1-2 months), long-term, progressive.

Forecast. determined by the underlying disease. In acute forms, the prognosis is often favorable, in chronic forms it is serious.

Author: Myshkina A.A.

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