PERICARDIUM

From Big Medical Encyclopedia

PERICARDIUM [pericardium (PNA, JNA, BNA); outdated synonym pericardiac bag] — the fabric cover surrounding heart, an aorta, a pulmonary trunk, mouths of hollow and pulmonary veins. Distinguish fibrous P. (pericardium fibrosum) covering heart and the listed vessels, and serous P. (pericardium serosum) which the parietal plate (lamina parietalis) covers fibrous P. from within, and visceral (lamina visceralis), t. e. an epicardium (epicardium) — an outer surface of heart. Between parietal and visceral plates there is a slit-like space — a pericardiac cavity (cavitas pericardialis).

The item at vertebrate animals develops in connection with formation of heart and primary perigastriums. Already fishes and amphibians have P. consisting of two serous plates: parietal and visceral. In more high-organized classes, especially the highest vertebrata, have a complication of structure of P. and its cavity, in particular at the expense of a reduction of primary arterial arches, formation of a pulmonary trunk, hollow and pulmonary veins, and also formation of a diaphragm and pleural cavities.

Embryology

Fig. 1. Diagrammatic representation of development of a pericardium in Broman: and — cross-section of an embryo 5 mm long; 1,3 — cordial bubbles, 2 — a ventral mesentery of heart; — cross-section of an embryo 7 mm long; 1 — a dorsal mesentery of heart, 2 — a cordial tube, 3 — a plevroperikardialny cavity.

Formation of a pericardiac cavity happens at the end of the 3rd and on the 4th week of embryonic development. Pair rudiments of heart in the form of two cordial tubules gradually approach and, growing together, create a cordial tube. The visceral mesoderm covering a cordial tube upon transition to a parietal mesoderm forms mesenteries of a cordial tube (mesocardia), to-rye together with plates of a mesoderm limit two primary pericardiac cavities (fig. 1). The parietal mesoderm gives rise actually to a pericardium. The epicardium develops from the site of a visceral mesoderm which is a part of a myoepicardial plate of heart. At an embryo 7 mm long the ventral mesentery is reduced owing to what there is a uniform secondary plevroperikardialny cavity. Then the cordial tube is displaced down in a thorax, the cross partition and a plevroperikardialny plate are formed, to-rye divide the general perigastrium into a chest and belly, and plevroperikardialny cavity on pericardiac and pleural cavities. Disturbance of an embryogenesis of P. leads to inborn malformations of P. (partial or total absence of P., its diverticulums).

The topography and anatomy

P. is in a lower part of front mediastinums (see), in space between a diaphragm (from below), mediastinal pleurae (on the parties), a chest wall (in front) both a backbone and bodies of a postmediastinum (behind). In relation to the sagittal plane P. it is located asymmetrically: apprx. 2/3 it is to the left of this plane, 1/3 — on the right.

The skeletopia and P.'s syntopy correspond to topography hearts (see).

At newborns and children of early children's age of P. has almost spherical shape that corresponds to a round shape of heart. In further P. gets a cone-shaped form and at adults reminds the truncated cone turned by a top up, and the basis (fig. 2) from top to bottom. In a pericardium heart, the ascending aorta, a pulmonary trunk, mouths of hollow and pulmonary veins are located. P.'s cavity contains from 20 to 30 ml of transparent liquid (pericardiac liquid). Distinctions of a form I. at persons of a different floor are clearly not expressed. The individual distinctions connected with situation and a shape of heart and a shape of a thorax are most considerable. At people with a wide and short thorax, a high level of standing of a diaphragm and cross position of heart of P. has an appearance of a low cone with the wide basis. At persons with a narrow and long thorax, more low level of standing of a diaphragm and vertical position of heart of P. often has a forla of the long, extended cone with the narrow basis. The sizes P. at adults of an oboy yole fluctuate in considerable limits: length of 11,5 — 16,7 cm, the greatest width of the basis is 8,1 — 14,3 cm and the perednezadny size 6 — 10 cm. P.'s thickness reaches 1 mm. At P. children differs in bigger transparency, elasticity and expansibility. At adult P. a little rastyazhy, is strong and can sustain pressure to 2 atm.

Fig. 2. A type of a pericardium in front (lungs are taken away, the mediastinal pleura is removed): 1 — the left general carotid artery, 2 — the left subclavial artery, 3 — an aortic arch, 4 — the left vagus nerve, 5 — front aortal torsion of a pericardium, 6 — the left lung, 7 — the forefront of a pericardium, 8 — a diaphragm, 9 — torsion of a pericardium on an upper vena cava, 10 — an upper vena cava, 11 — the right vagus nerve, 12 — a brachiocephalic trunk.
Fig. 3. Options of an arrangement of the line of transition of a pericardium to an epicardium (the pericardium is removed on a transitional fold): and, 6 — an anterior aspect: 1 — an aortic arch, 2 — a transitional fold of a pericardium on the ascending aorta and a pulmonary trunk, 3 — the left pulmonary artery, 4 — the pericardium covering a pulmonary trunk, 5 — the left pulmonary veins, 6 — a transitional fold of a pericardium on pulmonary veins, 7 — the pericardium covering the ascending part of an aorta, 8 — a transitional fold of a pericardium on an upper vena cava, 9 — an upper vena cava, 10 — an arterial sheaf; in — the back view: 1 — the pericardium covering a back surface of an aortic arch (pozadiaortalny torsion), 2 — an upper vena cava, 3 — the pericardium covering an upper vena cava, 4 — the right pulmonary artery, 5 — an upper right pulmonary vein, 6 — a transitional fold of a pericardium between pulmonary veins (side torsion of pulmonary veins), 7 — the lower right pulmonary vein, 8 — a transitional fold of a pericardium on the lower vena cava, 9 — the lower vena cava, 10 — the left pulmonary veins, 11 — a transitional fold of a pericardium on the left auricle (a slanting bosom of a pericardium), 12 — a transitional fold of a pericardium between the left pulmonary artery and veins (torsion of the left upper pulmonary vein), 13 — the left pulmonary artery, 14 — an arterial sheaf.

In P. allocate four parts: lobby (pars ant.); lower, or phrenic (pars inf., s. diaphragmaticae back, or mediastinal (pars post., s. medi-astinalis), and side, or pleural (partes lat., s. pleurales). P.'s surface, directly adjacent to a front chest wall, is designated as a grudino-costal part (pars sternocostalis). The forefront of P. begins from its transitional fold on the ascending aorta and a pulmonary trunk and stretches to a diaphragm. It has the form of a convex kpereda of the triangular plate turned by top up (fig. 2). This part P. is fixed to a chest wall by means of top and bottom grudinoperikardialny sheaves. The sizes of the forefront of P. happen from 7,5 to 13,9 cm (more often than 10 — 12 cm) in the frontal plane and from 6 to 10 cm (7 — 8 cm are more often) in sagittal. Surface of the bottom smooth. Side parts P. at different people are various in a form and the sizes that depends on the provision of pleural leaves. Behind they proceed in a back wall of P., in front — in a lobby, from below — in lower. The tail of P. differs in bigger complexity of an anatomic structure. Adults have its height of 5 — 8,6 cm, width at the level of upper pulmonary veins of 1,5 — 4,7 cm, at the level of the lower pulmonary veins of 2,6 — 4,8 cm. The tail is fixed by trakheoperikardialny and vertebral and pericardiac sheaves. Above upon transition of a parietal plate of a serous pericardium to a visceral plate, or an epicardium, P. forms the transitional folds which are located in the basis of heart, hl. obr. on large vessels (fig. 3).

In P. there is a number of the isolated cavities called by bosoms (sine). The anteroinferior bosom is between grudinoreberny and lower (phrenic) part P. It passes dugoobrazno in the frontal plane and has the form of a trench. Depth it can reach several centimeters. In this bosom at perikardita, haemo - and hydropericarditis skapli-vatsya liquid. The cross bosom lies at the top of the tail of P. and is in front limited to the serous P. surrounding the ascending aorta and a pulmonary trunk, behind — right and left auricles, cordial ears and an upper vena cava, from above — the right pulmonary artery, from below — a left ventricle and auricles. Length of a cross bosom adult 5,1 — 9,8 cm, diameter of the right entrance have 5 — 5,6 cm, a diametrlevy entrance of 3 — 3,9 cm. The cross bosom reports the tail of P. from a lobby. Having entered fingers into a cross bosom, it is possible to capture an aorta and a pulmonary trunk. The slanting bosom is located in the bottom of the tail of P. between lower hollow and pulmonary veins. In front it is limited to a back surface of the left auricle, behind — a back wall of P. Vysot of a slanting bosom at adult 6 — 8 cm, width is 1,9 — 7,5 cm, volume is 15 — 35 ml.

In various departments of a transitional fold between an epicardium and P. there is a number of bukhtoobrazny slit-like deepenings — P.'s (fig. 3) torsions.

Blood supply

P.'s Arteries come from branches of an internal chest artery and chest aorta. The quantity of sources of blood supply can reach 7. These are perikardodiafragmalny, mediastinal, bronchial, esophageal, intercostal arteries and arteries of a thymus.

In the field of transitional folds of P. vascular balls contain, to-rye participate in products of pericardiac liquid.

Veins P. carry out outflow of blood from intramural venous networks P. They are located near arterial networks and connected with venous networks of an epicardium. Outflow of blood comes from intramural veins on perikardodiafragmalny veins and veins of a thymus (in system of an upper vena cava), on bronchial, esophageal, mediastinal, intercostal and upper phrenic veins (in system of an unpaired and semi-unpaired vein).

A lymph drainage

Absorbent vessels in P. develop of three networks limf, the capillaries and vessels which are located in different layers. In a surface collagenic and elastic layer of P. there is initial, or capillary, limf, a network from which form taking away limf, the vessels of the first order forming larger limf, networks in a deep collagenic and elastic layer. Outflow of a lymph from these main limf, networks is made on taking away limf, to the vessels of the second order passing in periblasts of P. and forming in it the third network large limf, vessels. From the last network the vessels of the third order bringing a lymph to regional limf form already limf. nodes.

Innervation The item is carried out by nerves from vegetative textures of a mediastinum. Also intercostal nerves participate in an innervation also left returnable. In P.'s wall different interoretseptor are found.

The histology

Fibrous P. contains a large amount of the collagenic and elastic fibers creating several groups of bunches of a certain direction. One of these groups begins at the level of the left cordial ear and passes further fanlikely down and to the right, covering the forefront of P. in the field of the left and right ventricles. The second group is located also in the forefront and goes from the area P. corresponding to an arterial cone, down almost parallel bunches. The same fibrous bunches in the tail of P. go from the lower vena cava up from right to left. Besides, tsirkulyarno the located fibrous bunches lie around vessels of the basis of heart. Fibrous and serous P., being a whole, form 6 layers (from within a knaruzha): mesothelium, basal membrane, surface layer of collagenic fibers, surface collagenic and elastic layer, layer of elastic fibers and deep layer of thick collagenic and elastic fibers.

According to D. A. Zhdanov, through all layers of P. as well as an epicardium, there pass the «nasasyvayushchy hatches» connected with limf, vessels and taking part together with venous and limf, educations in absorption of liquid from a pericardiac cavity.

Pathology

P.'s Defeats accompany many diseases at which in patol, process serous covers (are involved see. Polyserositis ), heart (see. Myocardial infarction , Pancarditis ) or other bodies of a thorax contacting with P. Naiboley often are observed infectious and allergic perikardita, especially tubercular and rheumatic nature, to-rye are shown a wedge, options dry (fibrinous) and exudative (serous, serous and purulent, purulent, etc.) a pericardis with corresponding simntomatiky (see. Pericardis ).

At the diseases which are followed by the general disturbances of blood circulation, hypostases, a hemorrhagic syndrome and also at some tumors in P.'s cavity fluid accumulation of a noninflammatory origin is possible — hydrocardia (see), hemopericardium (see), and in the rare occurences and a chilopericardium — accumulation of chyle liquid at emergence of a fistula between P.'s cavity and chest limf, a channel.

Very seldom gas or air gets into a pericardiac cavity and develops pneumopericardium (see). Traumatic injury of a thorax to development of pheumothorax (a rupture of a cavity, the rupture of a gullet or stomach reporting them with P.'s cavity or direct wound of P.) happens its reason. Presence of gases quite often is explained by ichorization of exudate. When P.'s leaves are penetrated by vials of gas, speak about a pneumatosis of the Item.

At an anthracosis (see. Pneumoconiosis ) the lymphogenous anthracosis of P. is sometimes observed, at Krom on P. find black spots or network of punctulate inclusions of coal.

Except some forms of a pericardis actually P. belong the defects of its development (revealed at men three times more often than at women), and also injuries, tumors, parasitic invasions

of P. Defekt of a pericardium — the most rare defect of its development described for the first time by Columbus (M. by R. Columbus) in 1559 to pathology. Allocate three types of defect: total absence of P., formation of the general plevroperikardialny cover for heart and the left lung and partial defect (different size) between P. and the left pleural cavity. P.'s defects are quite often combined with other malformations and arise most often as a result of maldevelopment of kyuvyerovy channels owing to which gradual movement there is separation of pleural cavities from a cavity of the Item.

At uncomplicated defect of P. symptoms can be absent, but hernias with strangulation of heart and possible death are in some cases described. At strangulation of heart surgical treatment is necessary.

Diverticulums and cysts of a pericardium can be as inborn (a consequence of a malformation of P.), and acquired. They are found most often at the age of 20 — 40 years.

Many researchers identify inborn diverticulums and coelomic cysts of P. (pericardiac hernias). Defect of formation of pericardiac and plevroperikardialny tselom is the cornerstone of their education: lack of merge of one of primary lacunas with others in the place of formation of a pericardiac tselom. Macroscopically they predstavlyt themselves protrusion of a knaruzha of a parietal layer of P. of a sacculate or bukhtoobrazny form with thin walls, lobular is more rare. The cavity of protrusion is reported with a cavity P. (diverticulum) or is separated from it (cyst). The cavity of a cyst contains insignificant quantity (in rare instances to 2 l and more) colorless or light yellow liquid, sometimes with impurity of blood. Microscopically the wall of a cyst is formed by fibrous connecting fabric with infiltrates of lymphoid and monocytic cells and covered by the mesothelium sometimes forming papillary growths.

The acquired P.'s cysts arise after hematomas, at band regeneration of tumors of P., and also at a parasitic invasion (echinococcus).

The acquired P.'s diverticulums are usually connected with the organization of fibrinous exudate at P.'s inflammation or upon transition to P. of an inflammation from a pleura — so-called inflammatory diverticulums. The last can disappear at elimination of inflammatory process and a rassasyvaniya of exudate. At cicatricial processes in a front mediastinum the parietal layer of P. can be involved in a hem, be delayed and form a traction diverticulum of the Item. If at the same time in P.'s cavity a large amount of liquid collects, then protrusion of a parietal layer pulses synchronously with cordial reductions — a so-called pressure diverticulum. Pressure diverticulums can not have any communication with traction, then they are located in a lower part of P. also are sent to the right side that gave the grounds to A. I. Abrikosov to explain their education with P.'s weakness in this place.

In 1/3 cases diverticulums and P.'s cysts have neither subjective, nor objective no wedge, manifestations. When there are complaints, they are not specific (uncertain feelings and pains in heart, an asthma, fatigue).

At the cysts and diverticulums of the big size squeezing coronary (coronal, T.) vessels, auricles, bronchial tubes, a gullet, are possible such a wedge, manifestations as stenocardia (see), ciliary arrhythmia (see), pneumorrhagia (see), signs of bronchial obstruction, dysphagy (see). If these educations are located in the right cardiophrenic corner, patients quite often complain of pains in right hypochondrium and an anticardium, irradiating in the right shoulder. Klien, a picture is more accurately expressed at diverticulums which filling by pericardiac liquid changes at a postural change of a body that causes irritation of interoretseptor.

The diagnosis of cysts and P.'s diverticulums is based on a multiprojective rentgenol, a research; it is possible to establish connection of the revealed education with P. sometimes only during surgery.

Treatment at expressed a wedge, symptomatology consists in excision of a diverticulum. At diverticulums of an inflammatory origin therapy of a basic disease is carried out.

Wounds of a pericardium are usually combined with wounds of heart, more often getting. As the complication is possible development cardiac tamponades (see). In days of the Great Patriotic War the postwound hemopericardium more than in half of cases was complicated by purulent pericardis (see). Development of chronic cardial compression after an injury of the Item is described.

Foreign bodys get into P.'s cavity through a wall of a gullet (a needle, a stone); they or are in it freely, or are encapsulated. In response to implementation of foreign bodys the inflammation which regarding cases is coming to an end with an obliteration of a cavity of the Item develops in P.

Diagnosis of traumatic damages and foreign bodys of G1. is based on comprehensive examination of the patient. At the same time radiological and electrocardiographic researches have the leading value. For diagnosis of a hemopericardium carry out a puncture of the Item.

Treatment is defined by the volume and the nature of an injury; if necessary make surgical removal of foreign bodys. Carry out therapy of a secondary pericardis depending on its communication with the infectious beginning, from character and the speed of increase of exudate in a pericardiac cavity (see. Pericardis ).

Dystrophies of a pericardium arise as a result of the general disturbances of exchange (fatty, proteinaceous, pigmental, salt). At obesity of high degree in an epicardium the layer of a fatty tissue up to 0,5 — 1,5 cm thick, especially in the field of a right ventricle is formed, sometimes fatty segments in the form of clusters hang down in a cavity of the Item.

Sliming of G1 fabric. it is observed at senile age and at a sharp cachexia; it develops in the epicardial fat gaining gelatinous character. The atrophy of fat and serous treatment of connecting fabric (a serous atrophy of fatty tissue) is the cornerstone of it.

Disturbances of a salt metabolism lead to diffusion or focal calcification of P. most often connected with hron, its inflammation, however cases of primary calcification of P. of not clear etiology are described. Adjournment of urate salts is found sometimes at gout.

Hemorrhages in P. differ at a number of diseases. Hemorrhages in an epicardium dot or in the form of spots of irregular shape are observed at asphyxia, hemorrhages in a parietal layer — at hemorrhagic diathesis of any etiology, sepsis, leukoses, at poisoning with phosphorus, carbon monoxide, lighting gas, a lewisite, alcohol. They are located in fibrous fabric and do not take a mesothelium. In the outcome of hemorrhages in P., and sometimes and in the outcome of perikardit can develop hemosiderosis (see) the Item.

Parasitic defeats of a pericardium make 0,9 — 1,75% of all cases of diseases of P., cause them an echinococcus (see. Echinococcosis ), a cysticercus (see. Cysticercosis ), a trichinella (see. Trichinosis ).

Parasitic cysts are originally localized, as a rule, in a myocardium, but in process of growth can reach a visceral layer of serous P. which under the influence of

a constant compression is exposed to an atrophy. Occasionally parasitic cysts are formed between leaves of the Item. At a rupture of bubbles in P.'s cavity there are free-floating affiliated bubbles and a scolex. Sometimes in pericardiac liquid find a cysticercus or a trichina. After death of parasites of a cyst obyzvestvlyatsya. Separate cases are described histoplasmosis (see) with sharp calcification of P. caused by presence of parasites.

Parasitic defeats of P. it is long proceed asymptomatically. Large or multiple cysts can cause a circulatory unefficiency (short wind, hypostases, cyanosis). The break of a big cyst in a pericardiac cavity conducts to a cardiac tamponade. Detection of dome-shaped protrusions of contours of heart allows to assume presence of a parasite in P. at rentgenol. a research, and also pain in heart and signs of a circulatory unefficiency in combination with manifestations of allergization of an organism (an eosinophilia of blood, a polyarthralgia, pleurisy). Treatment of hl. obr. surgical (removal of a cyst), however it is possible not always (at multiple cysts with primary localization in a myocardium operation is often impracticable).

Tumors of a pericardium divide on primary and secondary. Primary tumors both high-quality, and malignant are observed seldom. From benign tumors of P. are described fibroma (see. Fibroma, fibromatosis ), a leiomyofibroma (see. Leiomyoma ), fibrolipoma, lipoma (see), hemangioma (see) and lymphangioma (see), a dermoid cyst (see. Dermoid ), teratoma (see), neurofibroma (see). They have more or less correct round form and overhang on a leg in P.'s cavity, weight them sometimes reaches 500 g

Krom of true tumors of P., the so-called pseudoneoplasms presented by the organized trombotichesky masses or fibrinous exudate (a so-called edematous fibrous polyp) meet. They can reach the size of large apple.

Small fibromas and lipomas are extremely seldom distinguished is intravital (radiological). Large benign tumors of P. are characterized by the symptomatology connected with a prelum of the respiratory tracts passing in a mediastinum, a gullet (disturbance of swallowing), nervous trunks and bronchial tubes (cough, short wind). At a compression of cameras of heart (most often auricles) and large veins venous stagnation in the respective pools or a generalized circulatory unefficiency develops. The prelum of an aorta is shown by the systolic noise heard over the narrowed site. Degree of a compression of an aorta is usually small, and disturbances of arterial perfusion are observed seldom. Fast-growing angiomas and teratomas can lead to fatal bleedings, be complicated by a hemorrhagic pericardis, malignizirovatsya.

The issue of expediency of surgical removal of benign tumors of P. is resolved depending on expressiveness by a wedge, symptoms. Rapid growth of a tumor is the unconditional indication to surgical treatment. *

Malignant tumors of P. meet a little more often. From primary tumors of P. sarcomas are observed (round and veretenoobraznokletochny), angiosarcomas (see), mesotheliomas (see) in all gistol, options. Davis (M. of J. Davies, 1975) considers that all types of sarcomas of P. have a mesothelial origin and shall be regarded as mesotheliomas. Tumors happen in the form of a limited polypostural outgrowth to hemorrhagic exudate in P.'s cavity or in the form of diffusion tumoral infiltration of walls to an obliteration of a cavity («cancer glaze heart»). If the tumor emits slime, P.'s cavity is filled with heavy, viscous colourless body. Microscopically mesotheliomas happen three types: purely fibrous, purely epithelial (or ferruterous with high content of acid mucopolysaccharides) and mixed (epitelialnofibrozny). Metastatic tumors meet more often primary, find them in 5% of the dead of a breast cancer, bronchial tubes, lymphosarcomas, melanomas. They usually are complicated by a «inexhaustible» hemorrhagic pericardis.

Wedge, symptomatology is defined by features of growth and innidiation of tumors. More often metastasises are noted in a mediastinum, a pleura, lungs. Along with the signs of a prelum which are found and at benign tumors, the symptoms connected with the infiltriruyushchy growth of a tumor in a myocardium (pains in heart, infarktopodobny changes of an ECG) or other bodies and fabrics, adjacent to P., are observed. «Glaze» cancer of P. can be shown by symptoms of «armored heart» (see. Pericardis ).

Treatment surgical; if it is impossible, carry out radiation therapy (see) which in some cases stops progressing of tumoral process for months and even for years. See also Mediastinum, tumors .

Diagnosis of diseases

For diagnosis of pathology of P. conduct all-clinical examination of the patient with use as the main, and additional methods. From the last the greatest value for recognition of diseases of P. has rentgenol, a research.

The main methods of inspection of the patient give the greatest information at diagnosis of a dry pericardis (the anamnesis, the analysis of complaints to stethalgias, listening of a friction murmur of P.) and for detection of an exudate in a pericardiac cavity (change topics of an apical beat and expansion of limits of relative and absolute percussion dullness of heart) at an exudative pericardis, gidro-and a hemopericardium.

The significant role at diagnosis of perikardit is played by Electrophysiologic methods of a research, first of all electrocardiography (see), revealing changes of a final part of a ventricular complex, characteristic of a dry and vypotny pericardis (see. Pericardis ). Fonokardiografiya (see) allows to find «pericardium tone», pathognomonic for chronic cardial compression. Echocardiography (see) promotes detection of the minimum quantities of an exudate in a pericardiac cavity. For definition of character of an exudate and the nature of a disease carry out a lab. researches (biochemical, immunological, cytologic) the liquid extracted from a pericardiac cavity by a puncture of the Item.

Radiodiagnosis of diseases of a pericardium is based on identification of signs of change of P. or adjacent bodies. P.'s changes are demonstrated by roughness and an illegibility of contours of a cordial shadow, a thickening and strengthening of a shadow of P., existence in it of limy inclusions, deformation of cordial arches, signs of an exudate in a pericardiac cavity and change of character of teeth on rentgeno-and elektrorentgenokimo-grams. Changes of the bodies, next to P., are expressed in their shift, deformation at the expense of their pushing off, change of the sizes of a cordial shadow, restriction of shift it at a postural change of the body investigated and at breath. The final conclusion about P.'s condition requires artificial contrasting of his cavity (see. Pneumopericardium ).

Radiodiagnosis of diseases of P. is often complicated because of the masking symptoms of the basic or associated disease.

Differential diagnosis is carried out with the heart diseases which are followed by dilatation of cavities (rheumatic defects, myocardites), and also with some diseases of a pleura and lungs, the additional shadows which radiological are shown in heart. Rentgenol, a research in the conditions of an artificial tsnevmoperikard with a double contrast study allows to make the final diagnosis.

Fig. 4. A straight line(s) and side roentgenograms of a thorax of the patient with a coelomic cyst of a pericardium: in the right cardio-phrenic corner a round shadow of a cyst, closely adjacent to a cordial shadow.

The coelomic cyst and P.'s diverticulum are usually found accidentally at rentgenol, a research. The cyst is almost always located in nizhnepravy department of a front mediastinum (fig. 4, and, b), more rare at the left, in a cardiophrenic corner. Exclusively seldom other localization of a cyst meets. A form of a cyst usually round, seldom polygonal (after the postponed inflammatory process or in the presence of a multichamber cyst), changing at change of position of a body, breath and functional trials. It close or closely prilezhit to heart and is frequent to a diaphragm; its shadow is homogeneous, on intensity is equal shadows of heart, outside contours accurate. Constancy rentgenol, pictures is characteristic at dynamic observation for many years. The pulsation of a cyst has transfer character.

The differential diagnosis of a cyst of P. is carried out with aortic aneurysm (see) and aneurism of heart (see), echinococcus, tumor, hernia and relaxation diaphragms (see), bronchogenic, dermoid or accessory stomach, neurinoma (see).

P.'s calcification, a cut is observed at an adhesive pericarditis and less often at parasitic diseases radiological comes to light in the form of the characteristic shadows merging in separate strips and even the ring-shaped shadow surrounding heart. Usually calcifications are localized in the field of a coronal furrow and a right ventricle, can extend to the right auricle, exclusively seldom find them in a projection of a left ventricle and never meet on a top. The best projection for their identification is left perednekosy. Tomography (see) allows to define more precisely character, localization and extent of calcifications of the Item.



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B. M. Astapov (rents.), A. M. Vikhert (stalemate. An.), E. E. Gogin (pathology), S. S. Mikhaylov (An., gist., embr.).

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