Diagnostisches Vorgehen beim Pleuraerguss

Zusammenfassung

Der Pleuraerguss ist ein häufiges pneumologisches und interdisziplinäres Problem. In Verbindung mit bildgebenden Basisuntersuchungen bleibt die Ergussprobepunktion zur Transsudat/Exsudat-Diskriminierung der Grundbaustein der Ergussdiagnostik. Die klassischen Light'schen Kriterien, bestehend aus Eiweiß und LDH (beziehungsweise ihr Serumwert-Ratio) erweisen sich hierbei mit einer Genauigkeit von 95 % am zuverlässigsten. Die Ergänzung um das Cholesterin zum Tripletttest kann in Einzelfällen zur verbesserten Identifikation der Transsudate genutzt werden. In der Regel lösen nur Exsudate als Hinweis auf direkte pleurale Krankheitsbeteiligung weiteren lokalen Klärungsbedarf aus. Die bakterielle Pleuritis, der maligne Erguss und die tuberkulöse Pleuritis sind die wichtigsten Differenzialdiagnosen. Die Thorakozentese ermöglicht mit einer Vielzahl biochemischer, zytologisch-immunologischer, mikrobiologischer und zunehmend auch innovativer zellbiologischer Marker in ca. 70 % (- 90 %) eine Diagnose oder wesentliche Einengung der Diagnose. Bei der bakteriellen Pleuritis ist die Thorakozentese in Bezug auf lokale Interventionen unmittelbar therapierelevant. Sie liefert ferner eine Plattform für weiterführende bildgebungs- oder endoskopie-gestützte bioptische Untersuchungen, in deren Mittelpunkt die internistische Thorakoskopie (Pleuroskopie) steht. Die ungezielte Stanz- oder Nadelbiopsie ist gleichermaßen bei entzündlichen wie malignen Erkrankungen zu 40 - 70 % diagnostisch, thorakoskopisch lässt sich der exsudative Pleuraerguss zu 95 % klären. Maligne Ergüsse können so in Kombination mit den weniger invasiven Untersuchungen zu 97 % spezifisch diagnostiziert werden, tuberkulöse Ergüsse zu nahezu 100 %. Zusätzliche interventionelle Möglichkeiten im Sinne der vollständigen Drainage ± Pleurodese (Talkpoudrage), ggf. auch Lösung von Kammerung und Verklebung ± Fibrinolyse charakterisieren die Thorakoskopie bei Durchführung in Lokalanästhesie auf hohem Sicherheitsniveau auch gegenüber wesentlich aufwendigeren chirurgischen Techniken als Goldstandard im Management der Pleuraergüsse.

Abstract

Pleural effusion is a common pneumologic and interdisciplinary problem. Transudate/exsudate discrimination of the pleural fluid by thoracentesis remains the diagnostic basic algorithm. Regardless of a number of new markers, classical LIGHT's criteria comprising the pleural fluid protein- and LDH-values (or their serum ratio respectively) reveal the highest potency with an overall accuracy of 95 %. Expansion to cholesterol-determination (triplet test) may be helpful to identify transudates in indeterminate cases. The need for further local diagnostic evaluation is then usually restricted to exudates. Bacterial pleurisy, malignant and tuberculous effusion are the principal differential diagnoses. With the use of a variety of conventional biochemical, cytologic, immunologic and microbiologic investigations, thoracentesis will allow- or substantially narrow-diagnosis of exudates in about 70 %, with novel cell biological markers in some conditions up to 90 %. In bacterial pleurisy thoracentesis provides information directly relevant to management in terms of local interventions. It also constitutes a platform for more invasive imaging- or endoscopy-guided investigations with a focus on medical thoracoscopy (pleuroscopy). Blind needle biopsy is diagnostic in a range of 40 - 70 % both in malignancy and inflammatory disease, thoracoscopy may clarify exudative conditions in about 95 %. Thus malignancy may be specifically diagnosed in 97 % of cases, tuberculous effusion in virtually 100 %. The value of thoracoscopy is augmented by interventional options including complete evacuation of the pleural cavity, eventually followed by talc pleurodesis (“poudrage”) in recurrent effusions or adhesiolysis, irrigation and fibrinolysis protocols in certain inflammatory conditions. These combined features as accomplished in local anesthesia on a remarkably high safety level characterise medical thoracoscopy as a gold standard tool for the management of pleural disease even in comparison to more elaborate surgical procedures.

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Bereits publizierte Beiträge zu dieser Serie:

• 01 Bildgebende Diagnostik bei Pleuraerkrankungen.  Pneumologie. 2004;  58 238-254
• 02 Pleura: Pathologie nicht-neuroplastischer Erkrankungen.  Pneumologie. 2004;  58 516-524
• 03 Pleuramesotheliom - Pathologie und Pathogenese.  Pneumologie. 2004;  58 670-679