Pleural effusion diagnostic study of choice: Difference between revisions
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==Overview== | ==Overview== | ||
Because the treatment of pleural effusion varies based on the cause it is important to have a good differential diagnosis. This would drive the diagnostic approach and ultimately the diagnostic study of choice based on the presentation. After determining whether the [[effusion]] is unilateral or bilateral through [[Chest X-ray|chest x-ray]], the likely cause should be considered. If the diagnosis is clearly pointing towards [[nephrotic syndrome]] or [[congestive heart failure]], then these patients do not necessarily need to have a [[ | Because the treatment of pleural effusion varies based on the cause it is important to have a good differential diagnosis. This would drive the diagnostic approach and ultimately the diagnostic study of choice based on the presentation. After determining whether the [[effusion]] is unilateral or bilateral through [[Chest X-ray|chest x-ray]], the likely cause should be considered. If the diagnosis is clearly pointing towards [[nephrotic syndrome]] or [[congestive heart failure]], then these patients do not necessarily need to have a [[thoracentesis]] performed and should be treated. However, a [[thoracentesis]] becomes the diagnostic study of choice in the following circumstances: | ||
*an unclear cause | *an unclear cause | ||
| Line 12: | Line 12: | ||
*no response to treatment | *no response to treatment | ||
The use of [[ | The use of [[thoracentesis]] becomes urgent if the patient is [[decompensating]] or the [[Pleural effusion (patient information)|pleural effusion]] is considerably large. <ref name="pmid31315808">{{cite journal| author=Jany B, Welte T| title=Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. | journal=Dtsch Arztebl Int | year= 2019 | volume= 116 | issue= 21 | pages= 377-386 | pmid=31315808 | doi=10.3238/arztebl.2019.0377 | pmc=6647819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31315808 }} </ref> | ||
==Diagnostic Study of Choice== | ==Diagnostic Study of Choice== | ||
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===Study of choice=== | ===Study of choice=== | ||
The diagnostic study of choice is a | The diagnostic study of choice is a [[thoracentesis]] that should be performed with a current [[Chest X-ray|chest x-ray]] and under [[ultrasound]] guidance. The procedure uses a 21 gauge [[needle]] with a 50 mL [[syringe]]. After the [[fluid]] is removed, it is analyzed. [[Macroscopically]], the [[fluid]] can point to differentials. If milky, consider a [[chylothorax]], [[pus]] can point to [[empyema]] and [[blood]] can indicate [[malignancy]]. [[LDH]] and [[protein]] are also measured to determine if the [[fluid]] is an [[exudate]] or [[transudate]] as per [[Light's Criteria]]. <ref name="pmid31315808">{{cite journal| author=Jany B, Welte T| title=Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. | journal=Dtsch Arztebl Int | year= 2019 | volume= 116 | issue= 21 | pages= 377-386 | pmid=31315808 | doi=10.3238/arztebl.2019.0377 | pmc=6647819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31315808 }} </ref> | ||
The Light's Criteria states that one of three of the following criteria must be met for the fluid to be considered an exudate: | The [[Light's Criteria]] states that one of three of the following criteria must be met for the [[fluid]] to be considered an [[exudate]]: | ||
*Pleural fluid protein/serum protein >0.5 or | *[[Pleural]] [[fluid]] [[protein]]/[[serum]] [[protein]] >0.5 or | ||
*Pleural fluid LDH/serum LDH >0.6, or | *[[Pleural]] [[fluid]] [[LDH]]/[[serum]] [[LDH]] >0.6, or | ||
*Pleural fluid LDH > 2/3 the upper limit of normal. | *[[Pleural]] [[fluid]] [[LDH]] > 2/3 the upper limit of normal. | ||
Exudates are caused by inflammation or impaired lymphatic drainage whereas transudates are caused by changes in the hydrostatic or | [[Exudates]] are caused by [[inflammation]] or impaired [[Lymphatic system|lymphatic]] drainage whereas [[Transudate|transudates]] are caused by changes in the [[hydrostatic]] or [[Oncotic pressure|oncotic]] pressures. | ||
<ref name="pmid4642731">{{cite journal| author=Light RW, Macgregor MI, Luchsinger PC, Ball WC| title=Pleural effusions: the diagnostic separation of transudates and exudates. | journal=Ann Intern Med | year= 1972 | volume= 77 | issue= 4 | pages= 507-13 | pmid=4642731 | doi=10.7326/0003-4819-77-4-507 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4642731 }} </ref> The initial goal of the | <ref name="pmid4642731">{{cite journal| author=Light RW, Macgregor MI, Luchsinger PC, Ball WC| title=Pleural effusions: the diagnostic separation of transudates and exudates. | journal=Ann Intern Med | year= 1972 | volume= 77 | issue= 4 | pages= 507-13 | pmid=4642731 | doi=10.7326/0003-4819-77-4-507 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4642731 }} </ref> The initial goal of the [[thoracentesis]] is to differentiate between these two and so [[Light's Criteria]] remains the guideline of choice for this [[diagnostic]] study. <ref name="pmid29530870">{{cite journal| author=Beaudoin S, Gonzalez AV| title=Evaluation of the patient with pleural effusion. | journal=CMAJ | year= 2018 | volume= 190 | issue= 10 | pages= E291-E295 | pmid=29530870 | doi=10.1503/cmaj.170420 | pmc=5849448 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29530870 }} </ref> | ||
The fluid is further analyzed for pH levels, glucose, amylase, triglycerides, biomarkers and cytology. It is recommended to check pH levels if the cause may be infectious. If the pH levels are less than 7.2, it is advised to drain the fluid immediately to decrease the risk of parapneumonic pleural effusion. Low glucose in the fluid can indicate empyema, tuberculosis, rheumatoid arthritis and malignancy. <ref name="pmid31315808">{{cite journal| author=Jany B, Welte T| title=Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. | journal=Dtsch Arztebl Int | year= 2019 | volume= 116 | issue= 21 | pages= 377-386 | pmid=31315808 | doi=10.3238/arztebl.2019.0377 | pmc=6647819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31315808 }} </ref> High amylase content can indicate acute pancreatitis, chronic pancreatitis or | The [[fluid]] is further analyzed for [[pH]] levels, [[glucose]], [[amylase]], [[triglycerides]], [[biomarkers]] and [[cytology]]. It is recommended to check [[pH]] levels if the cause may be infectious. If the [[pH]] levels are less than 7.2, it is advised to [[Drain (surgery)|drain]] the [[fluid]] immediately to decrease the risk of [[Parapneumonic effusion|parapneumonic]] pleural effusion. Low [[glucose]] in the [[fluid]] can indicate [[empyema]], [[tuberculosis]], [[rheumatoid arthritis]] and [[malignancy]]. <ref name="pmid31315808">{{cite journal| author=Jany B, Welte T| title=Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment. | journal=Dtsch Arztebl Int | year= 2019 | volume= 116 | issue= 21 | pages= 377-386 | pmid=31315808 | doi=10.3238/arztebl.2019.0377 | pmc=6647819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31315808 }} </ref> High [[amylase]] content can indicate acute [[Acute pancreatitis|pancreatitis]], [[chronic pancreatitis]] or [[esophageal rupture]]. <ref name="pmid1385051">{{cite journal| author=Joseph J, Viney S, Beck P, Strange C, Sahn SA, Basran GS| title=A prospective study of amylase-rich pleural effusions with special reference to amylase isoenzyme analysis. | journal=Chest | year= 1992 | volume= 102 | issue= 5 | pages= 1455-9 | pmid=1385051 | doi=10.1378/chest.102.5.1455 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1385051 }} </ref> Elevated levels of [[triglycerides]] (greater than 110 mg/dL) would indicate [[chylothorax]]. <ref name="pmid7442324">{{cite journal| author=Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K| title=The lipoprotein profile of chylous and nonchylous pleural effusions. | journal=Mayo Clin Proc | year= 1980 | volume= 55 | issue= 11 | pages= 700-4 | pmid=7442324 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7442324 }} </ref> | ||
==References== | ==References== | ||
Latest revision as of 23:48, 30 March 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dushka Riaz, MD
Overview
Because the treatment of pleural effusion varies based on the cause it is important to have a good differential diagnosis. This would drive the diagnostic approach and ultimately the diagnostic study of choice based on the presentation. After determining whether the effusion is unilateral or bilateral through chest x-ray, the likely cause should be considered. If the diagnosis is clearly pointing towards nephrotic syndrome or congestive heart failure, then these patients do not necessarily need to have a thoracentesis performed and should be treated. However, a thoracentesis becomes the diagnostic study of choice in the following circumstances:
- an unclear cause
- patient experiencing pleuritic chest pain
- patient experiencing symptoms out of proportion to the size of the effusion
- no response to treatment
The use of thoracentesis becomes urgent if the patient is decompensating or the pleural effusion is considerably large. [1]
Diagnostic Study of Choice
Study of choice
The diagnostic study of choice is a thoracentesis that should be performed with a current chest x-ray and under ultrasound guidance. The procedure uses a 21 gauge needle with a 50 mL syringe. After the fluid is removed, it is analyzed. Macroscopically, the fluid can point to differentials. If milky, consider a chylothorax, pus can point to empyema and blood can indicate malignancy. LDH and protein are also measured to determine if the fluid is an exudate or transudate as per Light's Criteria. [1]
The Light's Criteria states that one of three of the following criteria must be met for the fluid to be considered an exudate:
- Pleural fluid protein/serum protein >0.5 or
- Pleural fluid LDH/serum LDH >0.6, or
- Pleural fluid LDH > 2/3 the upper limit of normal.
Exudates are caused by inflammation or impaired lymphatic drainage whereas transudates are caused by changes in the hydrostatic or oncotic pressures. [2] The initial goal of the thoracentesis is to differentiate between these two and so Light's Criteria remains the guideline of choice for this diagnostic study. [3]
The fluid is further analyzed for pH levels, glucose, amylase, triglycerides, biomarkers and cytology. It is recommended to check pH levels if the cause may be infectious. If the pH levels are less than 7.2, it is advised to drain the fluid immediately to decrease the risk of parapneumonic pleural effusion. Low glucose in the fluid can indicate empyema, tuberculosis, rheumatoid arthritis and malignancy. [1] High amylase content can indicate acute pancreatitis, chronic pancreatitis or esophageal rupture. [4] Elevated levels of triglycerides (greater than 110 mg/dL) would indicate chylothorax. [5]
References
- ↑ 1.0 1.1 1.2 Jany B, Welte T (2019). "Pleural Effusion in Adults-Etiology, Diagnosis, and Treatment". Dtsch Arztebl Int. 116 (21): 377–386. doi:10.3238/arztebl.2019.0377. PMC 6647819 Check
|pmc=value (help). PMID 31315808. - ↑ Light RW, Macgregor MI, Luchsinger PC, Ball WC (1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Ann Intern Med. 77 (4): 507–13. doi:10.7326/0003-4819-77-4-507. PMID 4642731.
- ↑ Beaudoin S, Gonzalez AV (2018). "Evaluation of the patient with pleural effusion". CMAJ. 190 (10): E291–E295. doi:10.1503/cmaj.170420. PMC 5849448. PMID 29530870.
- ↑ Joseph J, Viney S, Beck P, Strange C, Sahn SA, Basran GS (1992). "A prospective study of amylase-rich pleural effusions with special reference to amylase isoenzyme analysis". Chest. 102 (5): 1455–9. doi:10.1378/chest.102.5.1455. PMID 1385051.
- ↑ Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K (1980). "The lipoprotein profile of chylous and nonchylous pleural effusions". Mayo Clin Proc. 55 (11): 700–4. PMID 7442324.