DISEASES OF THE CHEST WALL AND PLEURA

Rib fractures

Rib fractures are caused by trauma, coughing, osteoporosis or secondary to metastatic bone disease. Pain limits chest expansion and coughing which can lead to pneumonia. Lateral and oblique X-rays may show fractures not visible on a PA chest X-ray. Treatment is with oral analgesia, local infiltration or an intercostal nerve block. Fracture of a rib in more than one place can lead to a flail segment with paradoxical movement of part of the chest wall on inspiration and inefficient ventilation; intermittent positive pressure venti-lation may be necessary.

Kyphosis and scoliosis of the spine

Kyphosis describes bowing of the thoracic spine (‘humpback') and is con-genital or secondary to osteoporosis and vertebral fractures. Scoliosis describes a curved spine ('s' shaped) and is congential or secondary to neuromuscular disease, e.g. spina bifida. Kyphoscoliosis is a combination of kyphosis and scoliosis. If severe these spinal abnormalities may diminish lung capacity. Treatment is to correct the spinal deformity if possible. Positive airway pressure ventilation through a tightly fitting nasal mask is necessary for respiratory failure.

Pleurisy

Inflammation of the pleura without an effusion results in localized sharp pain made worse on deep inspiration, coughing and bending or twisting move-ments. Common causes are pneumonia, pulmonary infarct and carcinoma. Epidemic myalgia (Bornholm disease) is due to infection with Coxsackie B virus. It is characterized by an upper respiratory tract infection followed by pleuritic pain and abdominal pain with tender muscles. The chest X-ray remains normal and the illness clears in 1 week.

Pleural effusion

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can be detected clinically when there is 500 mL or more present, and by plain chest X-ray when there is more than 300 mL. Massive effusions are most commonly malignant in origin. A pleural effusion may be asymptomatic (if small) or cause breathlessness. The typical physical signs and chest X-ray appearances are shown in Figure 11.9.

Fig. 11.9 The chest radiographic appearances of a pleural effusion. With a large effusion there is a dense homogenous shadow occupying part of the hemithorax and a meniscus visible on an erect chest X-ray.

Physical signs on the affected side:

■ Reduced chest wall movement

■ Dull (‘stony dull’) to percussion

■ Absent breath sounds

■ Reduced vocal resonance

■ Mediastinum shifted away.

Aetiology

Pleural effusions are transudates or exudates (Table 11.15). Transudates occur when the balance of hydrostatic forces in the chest favour the accu-mulation of pleural fluid; occasionally they occur because of movement of fluid from the peritoneum or retroperitoneal space. Exudates occur with damaged or altered pleura (resulting in loss of tissue fluid and protein) or from impaired lymphatic drainage of the pleural space. Differentiation of transudate from exudate is the key to subsequent management; treatment for a transudative effusion is that of the underlying disease while treatment of an exudate often requires specific pleural intervention. More rarely, effu-sions consist of blood (haemothorax), pus (empyema, p. 540) or lymph (chylothorax). Chylous effusions are caused by leakage of lymph from the thoracic duct as a result of trauma or infiltration by carcinoma.

Investigations

Diagnostic pleural fluid aspiration is the initial investigation, unless the clinical picture clearly suggests a transudate, e.g. left ventricular failure. Small effusions or where initial ‘blind' aspiration is unsuccessful require

Table 11.15 Causes of a pleural effusion

Transudate

Exudate

Pleural fluid protein <30 g/L*

Pleural fluid protein >30 g/L*

Common

Heart failure

Infection (empyema/parapneumonic effusion/TB)

Hypoalbuminaemia, e.g. nephrotic syndrome, cirrhosis

Malignancy (primary and secondary)

Constrictive pericarditis

Pulmonary embolus with infarction

Hypothyroidism

Connective tissue disease

Ovarian íibroma producing right sided effusion (Meigs’ syndrome)

Rare causes (post-myocardial infarction syndrome, acute pancreatitis, mesothelioma, sarcoidosis, chylothorax, drugs, e.g. methotrexate, amiodarone)

*if pleural fluid protein is 25–35 g/L or serum protein level is abnormal apply Light’s
criteria (for which simultaneous sampling of venous blood for protein and LDH is
required):
 pleural fluid protein/serum protein > 0.5
 pleural fluid LDH/serum LDH > 0.6
 pleural fluid LDH > two-thirds of the upper limit of normal serum LDH.
One or more of above suggest an exudate.

image guidance - usually ultrasound. Large effusions causing breathlessness are initially managed with large volume thoracocentesis (e.g. 1 L) for diag-nostic and therapeutic purposes. Appearance of the pleural fluid is noted (purulent in empyema, turbid in infected effusion, milky in chylothorax) and the sample sent for protein, lactate dehydrogenase (LDH), glucose, pH (<7.3 suggests infection), cytology (differential white cell count and malignant cells) and microbiology (Gram stain and culture after inoculating into blood culture bottles, acid-fast bacilli stain and culture) if infection is suspected. Cytology may be negative in a malignant effusion. Occasionally amylase is measured in suspected pancreatitis-associated effusion and a lipid profile in suspected chylothorax.

Contrast-enhanced thoracic CT scan is performed if diagnostic aspira-tion does not provide a diagnosis. It is most useful when pleural fluid is still present as this improves the contrast between pleural abnormality and fluid. CT scanning allows identification of pleural nodularity and image-guided needle biopsy of any focal area of abnormality.

Pleural biopsy for tissue diagnosis (TB smear, culture and histology) is obtained by CT guided biopsy, blind biopsy (via an Abram’s needle) or video assisted thoracoscopic approach that allows multiple biopsies to be taken under direct visualization.

Management

This depends on the underlying cause. Exudates are usually drained, and transudates are managed by treatment of the underlying cause. Malignant effusions usually reaccumulate after drainage. They can be treated by aspira-tion to dryness followed by instillation into the pleural space of a sclerosing agent such as talc, tetracycline or bleomycin.

Pneumothorax

Pneumothorax is air in the pleural space leading to partial or complete col-lapse of the lung and occurs spontaneously or secondary to chest trauma. A ‘tension pneumothorax’ is rare unless the patient is on a mechanical ventila-tor or nasal non-invasive ventilation. In this situation the pleural tear acts as a one-way valve through which air passes during inspiration but is unable to exit on expiration. There is a unilateral increase in intrapleural pressure with increasing respiratory distress and eventually shock and cardiorespiratory arrest. Treatment is immediate decompression by needle thoracocentesis (2nd intercostal space, mid-clavicular line) and then intercostal tube drainage.

Aetiology

Spontaneous pneumothorax typically occurs in young men (typically tall and thin) and is the result of rupture of a pleural bleb which is thought to be due

Fig. 11.10 The chest radiographic appearances of a pneumothorax.

■ The visceral-pleura line (marked by the right hand top arrowhead)

■ Loss of pulmonary markings over the left lung

■ Mediastinum is shifted away from the pneumothorax and diaphragm on the same side is pushed downwards with large pneumothoraces.

The size of a pneumothorax is estimated by measuring the distance from the lateral edge of the lung to the inner wall of the ribs. A distance >2 cm implies that the pneumothorax is at least 50%, and hence large in size. (From Henry M, Arnold T, Harvey J on behalf of the BTS Pleural Disease Group. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58 (Suppl ii): ÍÍ39-52 with permission of the BMJ Publishing Group & British Thoracic Society.)

to a congenital defect in the connective tissue of the alveolar wall. Secondary pneumothorax is associated with underlying lung disease, usually COPD.

Clinical features

There is a sudden onset of pleuritic chest pain and breathlessness. With a large pneumothorax there are reduced breath sounds and hyperresonant percussion on examination.

Investigations

A standard PA chest X-ray (Fig. 11.10) will usually confirm the diagnosis. In patients with severe bullous lung disease CT scanning will differentiate emphysematous bullae from pneumothoraces and save the patient a poten-tially dangerous needle aspiration. CT will also detect pneumothoraces too small to be visible on chest X-ray.

Management

Management of a spontaneous primary pneumothorax is shown in Figure 11.11. The management of patients with secondary pneumothoraces differs in four respects:

Fig. 11.11 Treatment of a primary spontaneous pneumothorax. All patients admitted to hospital should receive high-flow oxygen (10 L/min) to increase absorption of air from the pleural cavity.

■ Patients remain in hospital

■ Attempt aspiration only in minimally breathless patients, <50 years old with small pneumothoraces

■ Chest drain insertion indicated in all other patients

■ Oxygen given via a fixed-performance mask to patients with COPD (p. 521).

Indications for surgical referral in patients with pneumothorax include persist-ent air leaks, recurrent pneumothorax and after a first pneumothorax in professions at risk (pilots, divers). Cessation of smoking reduces the recur-rence rate. All patients are advised not to fly for 2 weeks after successful treatment of a pneumothorax.

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Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
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COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
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THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

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Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
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THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
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Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
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COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
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BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
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WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

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Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
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ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
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TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

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COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
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ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

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Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

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Intensive care medicine

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Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
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15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

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THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

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COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
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EPILEPSY AND LOSS OF CONSCIOUSNESS
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HEADACHE, MIGRAINE AND FACIAL PAIN
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DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
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Dermatology

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