In terms of making a specific diagnosis, we’ve got to find out what’s in the fluid. Now, if the patient
is only mildly ill, you probably would not do a pericardiocentesis. But if the patient is substantially ill,
you’ve got to get some of that fluid for stains and culture. Once again, you wouldn’t put a patient
through such a procedure without getting the maximum yield from the procedure. So, simply to culture it
for routine bacteria would hurt the patient. If you’re going to do such an invasive procedure,
you’re going to do stains and cultures, I like to say for everything known to man, for routine, AFB, and fungi.
While you’re at it, to rule out malignancy, you would want to get cytology on the fluid.
Sometimes when the fluid is substantial and a pericardial window must be placed to drain the fluid
by the cardiac and chest surgeons, you want to go ahead and get a pericardial biopsy
because actually having a large amount of tissue increases the yield for determining the cause.
So, pericardiectomy with biopsy and drainage when there’s need for doing an invasive procedure.
It’s going to produce higher yield and fewer complications than sticking the pericardium.
A specific diagnosis can generally be made in at least half the patients. Keep in mind that many of these
are caused by viruses which we are unable to identify. So, how do you treat pericarditis?
Well, if you’re pretty convinced that you’re talking about a viral problem, nonsteroidal anti-inflammatory drugs
are given to relieve pain and decrease the inflammation. You only resort to corticosteroids
if it’s refractory to that treatment. For bacterial pericarditis, obviously you have to find out
what bacterium is causing it and target your antibiotics to stains and cultures. Bacterial pericarditis
must be drained. With respect to tuberculosis, if you diagnose that, it’s 4-drug therapy per usual
for active tuberculosis. But because of the likelihood of constrictive pericarditis, we add steroids
to the treatment to prevent constriction. For cardiac tamponade, we certainly need to do pericardiocentesis
emergently if it’s an emergent problem or put an intrapericardial catheter for one to two days
for acute infectious pericarditis and then withdrawing the catheter should be able to do something with that.
For healed pericarditis, you can get a plaque-like, fibrous thickening of the serosal surface,
so called soldier’s plaque. That doesn’t usually have any effect on cardiac function. For the treatment
of adhesive mediastinopericarditis, the pericardial sac is often completely obliterated.
That could compromise cardiac contraction. For the treatment of constrictive pericarditis,
this can produce a dense, fibrous or fibrocalcific scar. You can actually have calcium deposits
in the pericardial sac. That will unquestionably limit diastolic filling. For this, a pericardiectomy
is required. This requires painstaking surgery. Of course, that brings me to the end
of my discussion of pericarditis. I hope it helped.