Unilateral Left Pleural Effusion among Patients

with Liver Cirrhosis ,Congestive Heart Failure and

Nephrotic Syndrome

Gamal Rabie Agmy, MD, FCCP

Professor of Chest Diseases, Assiut University

Distinguishing an exudate from a

transudate is the first step in the

diagnostic approach of a patient

with pleural effusion.

Introduction

This study included 320 patient with

congestive heart failure, 214 with liver

cirrhosis and 94 with nephrotic

syndrome. All patients had pleural

effusion. Out of these, 35 patients with

congestive heart failure, 38 with liver

cirrhosis and 24 with nephrotic

syndrome had unilateral left sided

pleural effusion. .

Patients and Methods

All patients were subjected to:

1-Detailed history taking.

2-Complete clinical examination.

3-Chest X-ray both posteroanterior and

lateral views.

4-Chest and abdominal sonography.

Patients and Methods

5-Diagnostic thoracentesis

6-Serum sample:

7-All investigations for detection of aetiology of pleural effusions among cases suspected to have exudative effusion.

Patients and Methods

The criteria analyzed for discrimination

between transudates and exudates were: 1-Classical, Abbreviated and modified Light’s

criteria.

2-Pleural fluid cholesterol.

3-P/S cholesterol ratio.

4-Pleural cholinesterase.

5-P/S cholinesterase ratio.

6-P/S bilirubin ratio.

7-Serum-pleural albumin gradient (SPAG).

Table1:Type and side of pleural effusion among patients with

congestive heart failure during the period of this study

Type of effusion

Congestive heart failure No of %

patients Right Left Bilateral

Transudative 130 (40.6%) 3 (0.9%) 82(25.6%) 215 67.1%

Exudative 56 (17.5%) 32 (10%) 17(5.4%) 105 32.9%

Total no of %

patients

186 (58%) 35 (11%) 99(31%) 320 100%

Table2:Type and side of pleural effusion among patients with

liver cirrhosis during the course of this study

Type of effusion

Liver cirrhosis No of %

patients

Right Left Bilateral

Transudative 110(51.4%) 4(1.9%) 35(16.4%) 149 69.6%

Exudative 17(7.9%) 34(15.9%) 14(6.5%) 65 30.4%

Total no of

patients (%)

127(59.3%) 38(17.8) 49(22.9%) 214 100%

Table3:Type and side of pleural effusion among cases with

nephrotic syndrome during the period of this work

Type of effusion

Nephrotic syndrome No of %

Patients

Right Left Bilateral

Transudative 22 (23.4%) 2 (2.1%) 40 (42.6%) 64 68.1%

Exudative 8 (8.5%) 22 (23.4%) 0 (0%) 30 31.9%

Total no of %

patients

30 (31.9%) 24 (25.5) 40 (42.6%) 94 100%

Aims of the Work and Results

The first objective was:

1-to assess the diagnostic value of

the new biochemical criteria

proposed to discriminate pleural

transudates from exudates.

Figure1:Sensitivity, specificity and accuracy of different

biochemical parameters in identifying exudates:

0 20 40 60 80 100 120

Light criteria

SPAG

Clolesterol ratio

Cholinesterase ratio

Bilirubin ratio

Sensitivity Specificty Accuracy

2-to evaluate the effect of diuretic

therapy on different biochemical

parameters among transudative

pleural effusion.

The second Aim

Diuretics had a significant action on

light’s criteria that leaded to

misclassification of trasudates into

pseudoexudates in 50 cases of congestive

heart failure,44 cases of liver cirrhosis and

30 cases of nephrotic syndrome. On the

other hand, diuretics had insignificant

action on other parameters.

The Third Aim

3- to identify the aetiology of left

exudative pleural effusion among

patients with liver cirrhosis, heart

failure and nephrotic syndrome.

Figure2:Etiology of unilateral left pleural effusion

among cases of congestive heart failure:

0 10 20 30 40 50 60 70

Transudative effusion

Pulmonary embolism

Pneumonia

Malignancy

Collagen disease

Figure3:Etiology of unilateral left pleural

effusion among patients with liver cirrhosis:

0 10 20 30 40 50 60

Transudative effusion

Tuberculosis

Malignancy

Pneumonia

Collagen disease

Figure 4:Etiology of unilateral left pleural

effusion among patients with nephrotic

syndrome:

0 10 20 30 40

Transudative effusion

pulmonary embolism

Pneumonia

Malignancy

Tuberculosis

Conclusions 1-SPAG is the most sensitive and

specific parameter in separation

between exudates and transudates.

2-Light’s criteria should not be used

for differentiation between exudates

and transudates in patients under

diuretic therapy.

3-Classical , abbreviated and modified Light’s

criteria have the same sensitivity and

specificity in segregating exudates from

transudates.

4-Cholinesterase had a poor diagnostic yield

in detection of transudates in liver cirrhosis.

5-Unilateral left trasudative pleural effusion is

rare among cases of congestive heart failure,

liver cirrhosis and nephrotic syndrome.

6-The most common cause for unilateral left

exudative pleural effusion is pulmonary

embolism among cases of congestive heart failure

and nephrotic syndrome, while, TB is the major

contributory disease in liver cirrhosis.

7-Ultrasonography is more sensitive in detection of

pleural effusion than plain chest radiograph

especially in small sized and subpulmonic

effusions.