Wednesday, October 15, 2014


        I often see patients with the fluid around the lung or sometimes both lungs . When I try to explain my patients , i try to make it simple . I often tell them that there is always some fluid around the lungs , but it is so small that we can not see it on the plain chest X-ray.Now a days there are so many CT scans done that we see so many abnormality that need to be addressed. In past when we did only chest X-ray we did not appreciate these minor things . So as much as we can diagnose cancer at it's early stage, and can get cure , we also see things that means nothing on the long term,but we still have to do follow up and do more CT scans.The Ct scans do show more fluid as it is done when patient is lying supine and the fluid layers down and so looks worse.So many a times when I do not see much fluid on plain X-ray , I would elect to do follow up X-ray and 9 out of 10 times I don't have to do anything.(drain fluid ) I also tell patients that there is constantly fluid made and constantly absorbed.So when there is more production (as in case of infection , pleurisy or TB or cancer) or there is less absorption,(as in case of weak heart ,liver disease or kidney disease).But there are other causes of fluid too. But they are are so uncommon, that in usual ,cases I don;t mention them.Sometimes in case of patients who have had some kind of surgery, the possibility of 'blood' can be there.But today The case I am going to tell is one that is not uncommon.
      I saw this patient,who is almost 88 now. When I saw her she remembered me. She told me that I was the one who had 'drained'fluid after her heart surgery. When I checked old records, I realised that Indeed I had seen her almost 18 years ago. She had coronary artery disease and then had work up and then was advised to have a coronary bypass.She did  quite well and was discharged. She had a follow up chest X-ray.The chest X-ray showed fluid on the left side .In many cases of open heart, there is some fluid on the left side and it is simply due to the surgery. In most of the cases it is blood and the body tends to absorb it if given time. I have seen many patients that have had it and who were advised to have it drained and by just waiting , and doing follow up X-ray I have avoided the procedure in at least 9 out of 10 patients. I explained this to patient in general. But when i repeated the chest X-ray , it showed no improvement, but showed some worsening. So I decided to drain it.In past I had one or two patients , that needed to have surgery as there was significant blood.The fluid was not that worse , but I was concerned.
    So I did bring her in the ultrasound department and decided to do the drainage of the fluid. I did the ultrasound and marked the spot for insertion of the needle and then the catheter . When I inserted the needle , followed by the catheter, what came out shocked me . IT was a milky fluid . Normally the fluid is like clear water .In case of fluid with high protein , it is yellow .may be like concentrated urine.And then there is blood.But the milky fluid is very uncommon and indicates injury to or blockage of LYMPHATIC DUCT. In view of the recent heart surgery, the injury to the lymphatic duct was high. Most of the people don't know about the lymphatic system This system also drains fluid and drains to special glands, called lymph nodes.So sometimes in case of cancer of the lymph nodes, lymphoma, fluid can collect. But I have seen may be one case of the collection of such a fluid . So in this case it was related to the heart surgery. In most of the cases the leak stops automatically and nothing special needs to be done . In case of this patient I just did the follow up chest X-ray and the fluid was gone.I did not have to do anything more. 

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