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Heart , which is the main organ that work to pump blood that carry oxygenated blood and deoxygenated blood to all parts of human body. It is separated or septum into two parts which are right and left compartments. Both compartments consist of atrium and ventricle. This main organ is located within the thoracic cavity and enclosed by a fluid filled sac named the pericardium. There are two events that happen when the heart beats which are diastole phase and systole phase. These two type of events are called cardiac cycle. Diastole phase is referred to the condition when the heart ventricles are relaxed and filled with blood. While systole phase is referred to the condition when the heart ventricles are contract and pumped out the blood to the arteries. (http://biology.about.com/od/humananatomybiology/ss/heart_anatomy.htm) In a normal heart, there are three layered tissues which are endocardium, myocardium, and pericardium. The innermost layer that coated to the hearts chambers is called the endocardium. Myocardium or known as the heart muscle is characterised by the thick middle layer of the heart. The last layer of the heart is known as pericardium. The pericardium is defined as a thin double-layered sac that surrounds the heart. It is functioning as protective layer that protect the heart within the thoracic cavity. The pericardium consists of two parts; the first part is the inner serous pericardium and the second part is the outer fibrous pericardium. The serous pericardium consists of two layers which are the visceral and the parietal and between these two layers has a pericardial cavity. The visceral pericardium is known as the epicardium which is the inner layer that contact with the myocardium of the heart whereas the parietal pericardium is the outer that non contact to the myocardium itself. The function of fibrous pericardium is to enclose the serous pericardium which is composed of dense connective tissues that connected to the diaphragm and the base of the great vessels.
Pericardial effusion is one of the disease that is related to the thin double-layered structure or pericardium that mentioned before. This type of disease is defined as an excessive collection of pericardial fluid that exceeds the normal level of the fluid volume. As the pericardial cavity is very limited space thus the fluid within it cannot exceeds the normal level volume. When those conditions occur, it may lead the raise of intrapericardial pressure that will give negative feedback or complication to the heart and disturb the normal function of this main organ. One of the common complications is cardiac temponade. In this condition, heart that has been compressed will avoid the blood from entering the heart. Therefore, when less volume of the blood entering the heart chambers, there is less output volume of the blood pumped to whole parts of the body. Heart failure or death can occur when a person suffered from pericardial effusion. (http://www.cardiachealth.org/your-pericardium#Top )
Description of the disease
Pericardial is the word referring to pericardium or related to the area around the heart (pericardial cavity) while effusion is defined as escaped of fluid into the body cavity. Pericardial effusion is an abnormal collection of pericardial fluid in the pericardial cavity. The normal amount of pericardial fluid is about 15 to 50 millilitres. (http://en.wikipedia.org/wiki/Pericardial_effusion) Pericardial effusion usually related to inflammation of pericardium sac that result from disease or any injury involving increases in fluid whether blood accumulation or any fluid entering the pericardial cavity. It may also occur after surgical procedure or injury. The excessive fluid or blood in the pericardial cavity can increase intrapericardial pressure thus give excessive pressure to the heart. This will disturb the physiology of the heart and if it not treated it may lead to fatality. (http://www.mayoclinic.com/health/pericardial-effusion/DS01124) The volume of the fluid in the pericardial cavity may range from a few millilitres and rises to two millilitres. There is several types of effusion and it may be a transudative, exudative, haemorrhagic and malignancy. Transudative effusion often related to myxoedema and nephritic syndrome. Exudative is usually related tuberculosis and empyema. Haemorrhagic effusion is due to trauma, rupture of aneurysms and malignant effusion. Malignant effusion is due to collection of fluid result from the metastasis process. (http://en.wikipedia.org/wiki/Pericardial_effusion)
Cause of the disease
Pericardial effusion can be categorized as inflammatory disorder. An inflammation of pericardium or also known as pericarditis is one of the causes that lead to this disease.
Pericardial effusion also can be result from disturbance of the pericardial fluid flow such as blockage or collection of blood in the pericardial cavity. However, there is still incomplete finding that shows some diseases can cause to pericardial effusion and sometimes it is idiopathic. But there are some specific causes that result to this disease which may relate to;
Infections from viral, bacterial, fungal or parasite
Inflammation of pericardium sac that result from unknown cause
Inflammation of pericardium due to previous heart surgery
An immune system disorders that result in inflammation and tissue damage, such as rheumatoid arthritis or lupus (several disease which causes lesions
Less thyroid hormone been produce from thyroid gland or known as hypothyroidism also may lead to pericardial effusion as it may build up fluid around the heart in excess volume.
Virus such as Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS)
Metastasis process of cancerous cell which may located in the lungs, breast or any adjacent structure to the heart
Cancer of pericardium or heart itself
Acute radiation dose exposed to the heart
Motor vehicle accident (trauma that cause puncture and bleeding into pericardial cavity
Drugs experience such as medication for hypertension (hydralazine) and medication for epilepsy (phenytoin)
Anatomical part involved
As stated before, pericardial effusion is a common pathology that is related to the heart organ basically and specifically related to the layer of the heart called pericardium.
Pericardium define as a double layered membrane which surrounding the heart. Pericardium has small amount of fluid that called pericardial fluid in the space between the two layered membrane and the space is called pericardial cavity. The fluid within the space basically protects the heart from any peripherals shock or jerk. Pericardium layer are characterized by two layers which are the outermost fibrous pericardium and the inner serous pericardium. The inner serous pericardium itself is consists of two other layers which are parietal pericardium and visceral pericardium. The parietal pericardium as attach together with the outermost fibrous pericardium and while the visceral pericardium is the layer that attach to the outer muscle of the heart and it is called epicardium. Pericardial cavity that mentioned before is actually situated between the parietal and visceral pericardial layers.
The physiology of the pericardium and pericardial fluid is to make sure the heart in its position and ensure there is no movement beyond the limit. Layer of pericardium also work as a barrier that protect the heart from infected by other adjacent organ. It also avoid the heart from excessively dilate if in cases of overloaded volume. Pericardial fluid function as lubricating fluid in order to reduce the friction around the heart.
( http://en.wikipedia.org/wiki/Pericardium )
Signs and symptoms
There are a few of normal signs and symptoms that occur when a person suffer from pericardial effusion which are chest pain, shortness of breath and low blood pressure (Wiki 2013).
Symptom is more associated with the patient's perception, and more on what patient's feel related to the disease. In the case of pericardial effusion according to Dr W. Halley, cited in Dr Colin Tidy (2012), the symptoms present, is rely on the speed of abnormal accumulation of the fluid in the pericardial cavity and also the size of the effusion. Almost all of small to moderate effusion and take a longer period of time to forms an effusion will appear asymptomatic or less symptoms will be exist. In the other case, even a small abnormal collection of pericardial fluid but rapidly occur may cause to tamponade and disturb the normal circulation.
The most common symptoms results from pericardial effusion are chest pain, uneasiness and feeling pressure in the chest area. This chest pain is identifying with pericardial pain. Pain caused by pericardial pain can be eliminated or relieved by lying prone or sitting and will further reduced by lying in a supine position (Dr W. Halley, cited in Dr Colin Tidy 2012).
Besides chest pain, patient will experience light-headedness. This type of symptom is a common and often unpleasant sensation of dizziness or feeling that he or she may about to faint. In some cases, the individual may feel as though his or her head is weightless. The person may also feel as the place around him or her is "spinning" or moving or known as vertigo (Dr W. Halley, cited in Dr Colin Tidy 2012).
The other symptom that may patient feel is palpitation. Palpitation is an abnormality of heartbeat that ranges from often unnoticed skipped beats or increased heart rate to very noticeable changes accompanied by dizziness or difficulty in breathing. Cough, shortness of breath and hoarseness are other common symptoms that occur when patient suffer from pericardial effusion. Hoarseness or roughness is defined as disorder of voice or other sound (Dr W. Halley, cited in Dr Colin Tidy 2012).
Patient may also experience anxiety and confusion. These kinds feeling sometimes accompanied with patient consciousness. Sometimes patient loss of ability to place him or herself correctly in the world by time, location and personal identity (Dr W. Halley, cited in Dr Colin Tidy 2012).
According to Dr W. Halley, cited in Dr Colin Tidy (2012) describe that hiccoughs is also the symptom that will presents due to pericardial effusion. A hiccough or hiccup is defined as involuntary spasm of the diaphragm and throat muscles accompanied by an abrupt sound of "hic".
The treatment for pericardial effusion is depending on the volume of abnormal collection of the fluid within the pericardial cavity, the causes of pericardial effusion and what kind of complication will occur if patient suffer from pericardial effusion (Mayo Clinic staff 2010).
According to Wiki (2013), the treatment used for pericardial effusion is based on the cause and the seriousness of the heart defect. If the effusion is due to the infection of virus, it often disappeared without any treatment within a week. There is a few of effusions have no progression in it severity and they never need any treatment at all.
There are many methods in treating effusions as according to Mayo Clinic staff (2010) such as using anti inflammatory medications and also via invasive procedure. According to Mayo Clinic staff (2010) describe that there is no urgent treatment if the individual not having any disturbance physiology of the heart such as tamponade, and doctor or experts will order for treatment for inflammation of pericardium that may result in pericardial effusion. The used of drug such as aspirin or known as acetylsalicylic asid can reduce the inflammation that can caused pericardial effusion. Aspirin is also the medication used to relieve pain (Mayo Clinic staff 2010).
Nonsteroidal anti inflammatory drugs (NSAIDs) are drugs with analgesic and antipyretic that can give anti inflammatory effect such as indomethacin or ibuprofen. Another anti inflammatory drugs used for treating pericardial effusion is colchicines (colcrys), that is usually used to treat gout, familial Mediterranean fever, pericarditis and also use as anticancer drug (Mayo Clinic staff 2010).
Beside the used of anti inflammatory drugs, according to Mayo Clinic staff (2010) an invasive procedure is use to draw out the effusion and the last choice method use if anti inflammatory drugs cannot cure the effusion because it is too large or the effusion still repeating after it had been successfully cured.
Pericardiocentesis is one of the invasive procedures used. Through this procedure, the experts will use a needle and catheter to draw out the effusion from the pericardial cavity under fluoroscopic or echocardiography as the imaging modalities and guidance to make the procedure possible (Mayo Clinic staff 2010). During this procedure is conducted, the patient's heart is observe with the ECG machine. In some cases, the catheter that had been inserted into the pericardial cavity is left inside in order to drain the effusion if there is reaccumulation occur (Mayo Clinic staff 2010).
Pericardial effusion also can be cure with open-heart surgery. According to Mayo Clinic staff (2010), open heart surgery commonly done to the patients who suffer effusion due to the accumulation of blood which may be caused by previous heart surgery or other factor. This procedure surgery is used to drain out the blood accumulation and repair the damage to the pericardium such as rupture of pericardium.
Imaging modalities used
According to Vibhuti N Singh (2011) describe that, in imaging of pericardial effusion, there are many types of method approached in order to produce the most accurate and most sensitive outcome about this disease. In order to achieve that particular reason echocardiography, computed tomography (CT scan), and also magnetic resonance imaging (MRI) had been used to evaluate pericardial effusion. Those of imaging modalities are very sensitive to recognize the appearance of effusion even the effusion is at the normal level of volume.
The normal pericardial fluid is been considered when there is not presence of any pericardial disease. In echocardiography, normal volume of pericardial fluid will appear as free space between visceral layer and parietal layer during the heart ventricles contract and pump blood to the arteries (systole phase) and during the heart ventricles are relaxed and the heart fills with blood (diastole phase) less than 1 millimetre division will be visualise between those pericardial layer. However echocardiography will have a positive effusion as the result when there is fat between the pericardial layers but there is otherwise for MRI and CT scan (Vibhuti N singh 2011).
According to Vibhuti N Singh (2011) describe that, with the used of plain x-ray nor fluoroscopy, they have not really play an important role in order to diagnose pericardial effusion disease. These kinds of modalities are only recommended when there is patient suffering with large effusion (Vibhuti N Singh 2011). They usually produce a questionable outcome as they produce a low degree of diagnostic information. There may produce false positive information and sometimes false negative information. The images produce by fluoroscopy or plain x-ray may have the possibility to be misdiagnose by radiologist whether it is pericardial effusion or cardiomegaly due to the difficulty to distinguish between two of them (Vibhuti N Singh 2011).
Changes required and imaging considerations