Endoscopies and pleural effusion

PIG Meeting: 24th June 2021

72yo male for gastroscopy and colonoscopy due to upper GIH and obstructive colonic symptoms

Background:

  • Presumed sarcoidosis (hasn’t attended F/U) with mediastinal adenopathy
  • ? metastatic lung malignancy. Previous effusion (? parapneumonic) drainage showed no malignant cells. Effusion now recurred. Nodules in lungs stable on repeat CT.
  • Severe cardiac disease
    • TTE 2021 (in context of admission for anaemia) Severely dilated left ventricle with severe RWMAs. EF 26%. Moderately dilated right ventricle with moderate systolic dysfunction. Moderate AS and AR. Mild to moderate MR. Moderately dilated atria. 
    • IHD – AMI ’09, PCI
  • PHTN – mod/severe at rest. 
  • TIA 2018
  • CKD
  • Ex-smoker

Issues:

  • SOBOE
    • Recent exercise tolerance reduction. Gentle incline, 100m, multiple breaks for SOB.
    • Orthopnoea.
    • ? malignancy
    • ? cardiac component to dyspnoea
  • Patient psychosocial issues
    • Difficult historian
    • DNA for multiple appointments and investigations previously
    • Patient declined face-to-face review in clinic
    • Surgical team unaware of multiple other complex issues

Discussion

  • Fit for endoscopies?
    • Greater issue is the benefit from these procedures. Diagnostic rather than therapeutic.
    • Surgical team has highlighted that if metastatic lung disease present, endoscopies may not need to occur
  • Optimisable?
    • Difficult to know from history alone.
    • Requires face to face review

Plan:

  • Admit for TTE (as unable to secure timely booking pre-admission)
  • Respiratory team will review while inpatient
  • Pending these reviews and pleural fluid drainage, endoscopies may proceed
  • Requires inpatient admission for bowel prep regardless due to multiple severe comorbidities