Constrictive pericarditis presenting as chylous ascites.

The patient presented by Dr Patricia Campbell1 from the Advanced Heart Disease Section of Brigham and Women's Hospital exemplifies challenges that surround the possible diagnosis of constrictive pericarditis. Constrictive pericarditis is a pericardial compressive syndrome due to fibrosis, scarring, and occasionally calcification of the pericardium. The primary pathophysiological consequence is impairment of ventricular filling. The hemodynamic abnormalities are characterized by elevation of both right and left ventricular filling pressures and equalization of right and left ventricular diastolic pressures. It should be appreciated, however, that there are a number of pathological conditions that can be associated with equalization of ventricular diastolic pressures (Table). View this table: Table. Examples of Conditions That Can Cause Equalization of Ventricular Diastolic Pressures The best-recognized differential diagnosis for equalization of ventricular diastolic pressures is presented by the pair of constrictive pericarditis and restrictive cardiomyopathy. Cardiac catheterization and measurements of intracardiac pressures frequently are performed to distinguish between these 2 conditions. Constrictive pericarditis can be caused by infection, such as tuberculosis, noninfectious inflammatory disorders, and collagen vascular diseases such as systemic lupus erythematosus. It can also occur as a complication of radiation therapy or traumatic hemorrhagic pericardial effusion. In the patient under discussion, there was no history suggesting tuberculosis, collagen vascular disease, or previous symptomatic pericarditis and no prior radiation or chest trauma. Constrictive pericarditis, however, is being increasingly encountered after open heart surgery. In ≈2% of patients after coronary artery bypass surgery, constrictive pericarditis develops. The patient under discussion had previous triple-vessel coronary artery bypass surgery, and thus, constrictive pericarditis needs to be considered in his differential diagnosis, which was particularly relevant in this patient referred to a cardiac surgeon for consideration of a pericardial stripping procedure. Presentation of constrictive pericarditis within 6 months of cardiac surgery would be unusual, however, and some exertional dyspnea had preceded surgery. …

Introduction: Contemporary data on clinical presentation and outcomes of constrictive pericarditis (CP) in a community setting is lacking. We investigated the clinical spectrum of CP in a real-world setting. Hypothesis: Diagnosis of CP in contemporary clinical practice is difficult and frequently requires multimodality testing, with possible impact on clinical outcomes. Methods: A retrospective cohort of patients with surgically proven CP from January 2000 to December 2009 was studied. Baseline characteristics, clinical presentation, radiological imaging, cardiac catheterization and echocardiographic examinations were reviewed. Results: A total of 43 patients (median age 67; 76.7% male) were identified during the 10-year period. The majority presented with dyspnea (91%) and peripheral edema (72%), while anasarca and ascites were present in 33% of patients. Calcification on chest X-ray was present in 17% (5 of 29 cases), while catheterization hemodynamics suggested CP in 81% (25 of 31 cases). Computed tomography and/or magnetic resonance imaging showed pericardial thickening in 67% (20 of 30 studies). A specific etiology was found in 67% of the cohort (figure). Combined pericardiectomy with other cardiac surgery was undertaken in 35%. The perioperative 30-day mortality rate was 16%. At a median follow-up of 9 months, survival rate excluding perioperative mortality was 72%. Depressed ejection fraction (<40%) was a predictor of perioperative mortality (odds ratio: 8.27, 95% confidence interval [CI]: 1.41-48.54; p=0.019), while prior cardiac surgery was associated with reduced long-term survival (odds ratio: 6.82, 95% CI: 1.47-31.61; p=0.014). Conclusions: Our findings reaffirm the complexity of diagnosing constrictive pericarditis in contemporary medical practice. Early suspicion in clinical groups at risk for constrictive pericarditis and prompt surgical intervention prior to systolic dysfunction may improve outcomes.

An 18-year-old Romanian man with no known history of cardiac disease was admitted to the hospital for the management of right heart failure and bilateral pleural eff usions. Further investigations revealed mediastinal lymph nodes and a constrictive cardiac haemodynamic pattern. Lymph node biopsy demonstrated a purulent liquid from which cultures were positive for Mycobacterium tuberculosis. The patient improved rapidly with conservative medical management involving antituberculous therapy and diuretics.Tuberculous constrictive pericarditis is rare in Western countries but may still present in migrant populations. As shown in this case, the possibility of atypical and reversible presentations with neither calcifi cations nor thickening of the pericardium must not be forgotten.

The role of laparoscopy in the evaluation of ascites of unknown origin

Purpose: Heart failure (HF) is, after cirrhosis, the second most common cause of ascites. Serum B-type natriuretic peptide (BNP) plays an important role in the diagnosis of HF. We therefore hypothesized that BNP would be useful in the differential diagnosis of ascites. Methods: Consecutive patients with new onset ascites were prospectively enrolled in this cross-sectional study. All patients had measurements of serum-ascites albumin gradient (SAAG), total protein concentration in ascitic fluid, serum and ascites BNP. We enrolled 218 consecutive patients with ascites due to HF (n=44), cirrhosis (n=162), peritoneal disease (n=10) and constrictive pericarditis (n=2). Results: Compared to SAAG and/or total protein concentration in ascitic fluid, the test that best discriminated HF-related ascites from other causes of ascites was serum BNP. A cutoff of >364 pg/mL (sensitivity 98%, specificity 99%, diagnostic accuracy 99%) had the highest positive likelihood ratio (168.1), that is, it was the best to rule-in HF-related ascites. Conversely, a cutoff ≤182 pg/mL had the lowest negative likelihood ratio (0.0) and was the best to rule-out HF-related ascites. These findings were confirmed in a 60-patient validation cohort. Conclusions: Serum BNP is more accurate than ascites analyses in the diagnosis of HF-related ascites. The workup of patients with new onset ascites could be streamlined by obtaining serum BNP as an initial test. A positive test would forego the need for a diagnostic paracentesis.

From March 1975 to June 1987 twelve eases of constrietive pericarditis were hospitalized.It accounts for 0.7%of thoracic and cardiovacular surgical patients in this period of time.Among the 11 operated cases there were ten boys and two girls,aged between thirteen months and twelve years.The pathological diagnosis were:chronic idiopathic pericarditis in 6,tuberculosis in 1 and acute pericarditis with effusion in 4.Partial pericardiectomy through median sternotomy is the treatment of choice.Preoperative preparations including improvement of the nutritional status and correction of ascites and hypokalemia are important.The result is satisfactory without mortality.

Constrictive pericarditis represents a rare cause of protein-losing enteropathy resulting from intestinal lymphangiectasia. We report the case of a patient with an atypical clinical presentation of constrictive pericarditis and protein-losing enteropathy as its principal manifestation; he was successfully treated with pericardiectomy. We conclude that constrictive pericarditis should be considered in the presence of protein-losing enteropathy and also, protein-losing enteropathy should be considered in the differential diagnosis of hypoalbuminemia.

Reports of chronic constrictive pericarditis presenting with hepatomegaly, cirrhosis and ascites but no cardiac symptoms are rare. A 10 year old child presented with refractory ascites and firm hepatomegaly of 2 years duration which partially responded to diuretics. Doppler study showed dilated hepatic veins and inferior vena cava and ruled out hepatic venous outflow tract obstruction. Chest X ray showed pericardial calcification and 2D Echo was suggestive of chronic constrictive pericarditis. A diagnosis of chronic calcified constrictive pericarditis with cirrhosis and refractory ascites was made. Based on previous series which showed that tuberculosis is the most common cause of constrictive pericarditis, tuberculosis as the cause of constrictive pericarditis was kept. Anti tuberculous treatment as per Revised National Tuberculosis Control Program guidelines was started along with oral steroids and diuretics. Child showed response to the treatment and was later referred to cardiac surgery department for further management (pericardectomy).

We present the first well-documented case of a patient with chylous ascites secondary to constrictive pericarditis in whom complete resolution of the ascites followed anterior pericardiectomy. We postulate that persistently elevated central venous pressure, leading to lymphatic hypertension, resulted in engorgement of the peritoneal serosal lymphatic system and formation of chylous ascites.

Constrictive pericarditis represents a rare cause of protein-losing enteropathy in children. Reported is an 11-year-old girl with protein-losing enteropathy (PLE) as the principal manifestations of constrictive pericarditis. After total pericardiectomy, symptoms and signs of PLE disappeared. Doppler echocardiography including tissue Doppler imaging is a useful noninvasive initial diagnostic tool for differential diagnosis of diastolic heart failure

The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition.

BackgroundPulmonary hypertension in young children can be due to a myriad of conditions. Few aetiologies of pulmonary hypertension are potentially reversible. An extensive workup for the cause of pulmonary hypertension is a must before attributing it to idiopathic pulmonary hypertension. We describe an uncommon aetiology of pulmonary hypertension in a young boy.Case presentationA 12-year-old child, with past history of tubercular pleural effusion, presented with dyspnoea on exertion and easy fatiguability for 2 years. He was evaluated elsewhere and was being treated as primary pulmonary hypertension with pulmonary vasodilators. The child was revaluated since the clinical features were not completely favouring the diagnosis. On detailed evaluation, a diagnosis of constrictive pericarditis was made. He was referred for pericardiectomy.ConclusionsConstrictive pericarditis presenting with severe pulmonary hypertension without congestive symptoms is very rare. In patients presenting with pulmonary hypertension, always look for a reversible cause before labeling them as idiopathic PAH.

Exercise syncope: An unusual presentation of a constrictive pericarditis in a young patient

Of 47 patients with tuberculous peritonitis followed for an average of three years x-ray examination showed a parenchymal pulmonary lesion in only 6 per cent. Barium-enema and barium-meal studies, intravenous pyelography and salpingography revealed no tuberculous lesion in the adjacent organs in this series. With the use of about 1 liter of ascitic fluid, acid-fast bacilli were cultured in 83 per cent of the patients. Percutaneous peritoneal biopsy proved to be a simple and useful method of arriving at a quick diagnosis, and a caseating granuloma was demonstrated by this technic in 64 per cent. Other serous membranes were often involved in patients with tuberculous peritonitis. Pleural effusion was present in 32 per cent and cryptic pericarditis characterized by electrocardiographic changes only in 13 per cent. Antituberculous drugs were highly effective, and concomitant use of steroids prevented the late fibrotic complications of tuberculosis in the form of constrictive pericarditis and intestinal obstruction from adhesive bands.

We present an interesting case of mycobacterial tuberculosis pericarditis presenting as effusive constrictive pericarditis with early cardiac tamponade in a young Mexican migrant of Haitian descent. The patient underwent a pericardial window and was treated with rifampin, isoniazid, pyrazinamide, ethambutol, and vitamin B6. After further receiving steroids, the patient was doing well and was discharged home safely.