Exudative pleurisy: diagnosis

The program of examination with exudative pleurisy

1. General analysis of blood, urine.
2. Biochemical analysis of blood: determination of the content of total protein, protein fractions, bilirubin, aminotransferases, cholesterol, glucose, lactate dehydrogenase, seromucoid, haptoglobin, fibrin, sialic acids, lupus cells, rheumatoid factor.
3. Radiographic examination of the lungs and computed tomography of the lungs.
4. Ultrasound of the heart.
5. ECG.
6. Pleural puncture and pleural fluid research: assessment of physical and chemical properties (determination of protein, lactate dehydrogenase, lysozyme, glucose), cytological and bacteriological studies.
7. Consultation phthisiatrician.

Laboratory data

1. The general analysis of blood - is characterized by neutrophilic leukocytosis with a shift of the leukocyte formula to the left, toxic granulocytic leukocytes, a sharp increase in ESR. In many patients, moderate anemia of normochromic or hypochromic type is found.
2. General urine analysis - in the midst of the disease, a small proteinuria (usually less than 1) is detected in a part of the patients, single fresh red blood cells, renal epithelial cells.
3. Biochemical blood analysis - the most pronounced disproteinemia (decrease in albumin level and a2- and gamma globulin increase) and "biochemical inflammation syndrome" (an increase in the content of sialic acids, seromucoid, fibrin, haptoglobin, the appearance of C-reactive protein) are most characteristic. Quite often there is a slight hyperbilirubinemia, possibly an increase in the content of alanine and aspartic aminotransferases (as a manifestation of toxic effects on the liver), lactate dehydrogenase.

Instrumental studies with exudative pleurisy

X-ray examination of the lungs

X-ray examination of the lungs is the leading accessible method that allows to reliably diagnose the presence of effusion in the pleural cavity. However, it should be noted that with the X-ray method, the amount of fluid is not less than 300-400 ml, and for lateroscopy - at least 100 ml. Most often with free exhalation in the pleural cavity, an intense homogenous obscuration with an oblique upper border going down and inside is found, the mediastinum shifts to a healthy side. Large effusions cause a darkening of a large part of the pulmonary field (2/3-3 / 4 and even almost the entire lung). With effusions of a small volume, darkening can occupy only the rib-diaphragmatic sinus, with a high position of the diaphragm dome. In the future, as the amount of fluid in the pleural cavity increases, the dome of the diaphragm drops. Small amounts of fluid in the pleural cavity are detected using the method of lateroscopy, that is, radiography performed in a horizontal position on the diseased side. In the presence of loose loose fluid, a parietal band-like shadow is found.

With the formation of pleural coalesces, there are formed effusions, which are well recognized radiographically. Depending on the localization, the isolated rib-diaphragmatic, paracostal, apical (apical), para-diastinal, supra-diaphragmatic, interlobar effusion are isolated.

The scarred pleurisy should be differentiated from focal pneumonia, lung and mediastinum tumor, pleural shvarts, less often - echinococcal cysts.

X-ray examination of the lungs should be performed before and after evacuation of the effusion from the pleural cavity, which makes it possible to ascertain the nature of the pathological process (tuberculosis, pneumonia, tumor) in the corresponding lung. For more accurate diagnosis, you often have to perform a CT scan of the lungs after evacuation of the fluid.

Computed tomography of the lung is used to detect pulmonary pathology with widespread pleural lesions: pneumonia, lung abscess, bronchogenic cancer and other diseases. With this method of investigation, pleural compaction caused by mesothelioma is well recognized . Also well-identified pleurisy pleurisy.

Ultrasonography

With ultrasound, free fluid in the pleural cavity can be detected easily. Research should be carried out not only in the position of the patient lying down, but also sitting, standing. The thorax is scanned in the longitudinal planes along the axillary, paravertebral, peri-chest lines. In the place of accumulation of pleural fluid, the sensor is deployed along the intercostal space and a transverse scan of the site of interest is performed.

VI Repik (1997) recommends starting the examination of the thorax from the basal parts in the standing position of the patient. Under the influence of gravity, the fluid first occupies the space between the lungs and the diaphragm in the posterior-lateral regions. In the position of the patient lying down, the posterior-lower parts of the pleural space should be examined through the liver, with the localization of the effusion to the right, and the spleen, when the effusion is located on the left. With the clotted pleural effusion, a thorough scan of the area of the alleged pathological process should be carried out.

The echographic pattern in the presence of pleural effusion depends on the amount of fluid. If the volume of effusion is small, it looks like wedge-shaped echo-negative areas. With an increase in the amount of fluid, the echo-negative space expands, retaining a wedge-like shape. Pleural leaflets spread apart accumulated fluid. Pulmonary tissue, which looks like a uniform echogenic formation, shifts to the root (up and toward the center of the chest).

The fibrin filaments formed in the exudate are revealed by ultrasonic examination in the form of echogenic lines of various lengths and thicknesses.

With the localization of a coherent fluid in the interlobar spaces, ultrasonic research may sometimes prove ineffective.

Examination of pleural effusion

Pleural puncture is of great importance, as it allows not only to confirm the presence of effusion, but also to conduct differential diagnosis. Considering this, one should consider performing pleural puncture as an obligatory procedure in patients with exudative pleurisy. The physical and chemical properties of the obtained liquid are evaluated, its cytological, biochemical, bacteriological study is performed and differential diagnosis is performed (see below).

Thoracoscopy

The method allows to examine the pulmonary and parietal pleura after evacuation of the fluid. Diagnostic value of the method consists, first of all, in that it allows, on the one hand, to ascertain the presence of the inflammatory process of the pleura, on the other - to establish the specific or nonspecific character of the lesion. The nonspecific inflammatory process of the pleura is characterized by hyperemia, hemorrhages, pleural fusions, fibrin deposits and, along with these signs, the preservation of airiness of the lung tissue. Specific changes in the form of grayish or yellowish tubercles suggest the presence of a tuberculosis or tumor process, refinement is performed by biopsy and analysis of clinical and laboratory data.

With thoracoscopic biopsy, a pleural biopsy can be obtained from the most altered areas of the pleura, which allows, first of all, to accurately diagnose tuberculosis or a malignant tumor and to distinguish these diseases from non-specific exudative pleurisy.

Thoracoscopic pleural biopsy is performed under anesthesia with artificial ventilation.

Surgical biopsy of the pleura is performed if thoracoscopy is not possible (with pleural adhesions). The operating biopsy of the pleura is made from a small incision in the corresponding intercostal space.

Puncture biopsy of the pleura is an effective and fairly simple method of etiological diagnosis of pleural effusions. There are practically no contraindications to this method. Characteristic manifestations of nonspecific exudative pleurisy are:

• marked lymphoid-histiocytic infiltration in the pleura and subpleural layer;
• fibrosis of the thickened pleura.

[1], [2], [3], [4], [5], [6], [7]