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Tenderness under sternum: Sternal pain – different causes


Top 7 Causes of Sternum Pain | How to Get Relief

3. Muscle strain

  • Sharp or achy pain in the sternum
  • Worsening pain with movement
  • Muscle spasm
  • Bruising or tenderness of a chest wall muscle

A strained or pulled muscle in the chest wall can cause chest bone pain. This injury is caused by overuse or repetitive movement, an increase in activity level, or a sudden improper movement. Pulled muscles can also happen during an illness that causes coughing or vomiting.

Rest, ice, and over-the-counter pain medications can relieve muscle strain. But in more severe cases, you may need physical therapy or surgery.

4. Heartburn and acid reflux

  • Burning pain in the chest, abdomen, or throat after eating
  • Pain in the sternum
  • Bad breath or bad taste in your mouth

Heartburn is a brief burning pain in your throat, chest, or abdomen that is caused by stomach acid. When it happens frequently, it can be a sign of acid reflux.

Both heartburn and reflux are caused by a problem with the sphincter (ring of muscles) that separates the esophagus from the stomach. When the sphincter doesn’t close tightly or opens too frequently, stomach acid or food can travel out of the stomach back into the esophagus.

Heartburn can also be caused by a hiatal hernia, which happens when part of the stomach slips through a hole in the diaphragm (the muscle that separates the chest from the abdomen).

Certain foods and drinks, including spicy or fatty foods, alcohol, and coffee, can trigger heartburn. Overweight people and pregnant women have a higher risk for reflux.

Your doctor may prescribe changes to your lifestyle and diet, medications, and sometimes surgery.

5. Pleurisy


The lungs and the inside of the chest are covered with a thin protective tissue called the pleura. Pleurisy is inflammation and swelling of this tissue. A viral or bacterial lung infection, autoimmune disease, or other conditions in the lungs or chest can cause pleurisy.

Rest, over-the-counter anti-inflammatory medications (ibuprofen), and sometimes antibiotics can help you get better.

6. Heart attack

  • Pain or pressure under the sternum
  • Pain radiating to the arm or jaw
  • Shortness of breath
  • Nausea
  • Sweating

Some people having a heart attack experience chest pain in or under the sternum. A heart attack is a blockage in an artery of the heart, which prevents blood and oxygen from reaching that area. It is caused by a blood clot that travels from a fatty buildup (plaque), inside the artery.

Heart attack can be life-threatening and requires immediate treatment. When you go to the ER for sternum pain, you’ll likely have tests like an EKG, blood tests, and a chest X-ray.

Treatment should begin as soon as possible after symptoms start, so call 9-1-1, if your pain could be heart related. You may get medications or have a procedure like a heart catheterization with balloon or stent treatments to open up your arteries. Severe cases may need surgery to create a bypass around the blocked artery.

7. Sternum fracture

  • Pain in the sternum
  • Worsening pain when breathing, coughing, or moving
  • Swelling and tenderness of the sternum

Sternum fracture is a break in the sternum bone. This usually only happens in a serious trauma, like a car accident or falls from a high height. Seatbelts save lives in car accidents, but they cross over the sternum, which can fracture it in a high-impact crash.

Because breaking the bone requires such force, doctors will order additional CT scans to check for injuries to the vital organs behind the sternum, including the heart, lungs, and major blood vessels.

Ice, over-the-counter pain medications, and, sometimes, prescription pain medications may relieve your sternum pain. You may need surgery to fix the break or to treat other injuries inside the chest.

A number of the conditions mentioned here (for instance, costochondritis, muscle strain, and pleurisy) are what doctors refer to as a “diagnosis of exclusion.” This means that there’s not one specific test to make the diagnosis and that the symptoms can mimic the symptoms of other serious conditions. Once we rule out anything serious, we treat the non-serious problem that is most likely. —Dr. Jacobsen

Other possible causes

Other conditions that may cause pain near the sternum include:

  • Pneumonia or bronchitis
  • A blood clot in the lung (pulmonary embolism)
  • Anxiety
  • Tumors
  • Patients who have had open heart surgery may have chronic pain in the sternum because doctors have to split this bone in half to perform the procedure.
  • Some people have genetic conditions that cause the sternum to sink into the chest or to jut forward, and this may cause pain.

Costochondritis: Diagnosis and Treatment – American Family Physician

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18. DynaMed. Fibromyalgia. http://www.ebscohost.com/dynamed (subscription required). Accessed April 15, 2009.

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Tietze Syndrome – NORD (National Organization for Rare Disorders)

Tanner J. Chest Wall Pain. In: Oxford Textbook of Musculoskeletal Medicine, 2nd edition. Hutson M, Ward A, editors. 2016 Oxford University Press. Oxford, UK. pp. 319-321.

Imamura M, Imamura ST. Tietze syndrome. In: Essentials of Physical Medicine and Rehabilitation. Musculoskeletal Disorders, Pain, and Rehabilitation, 3rd edition. Frontera WR, Silver JK, Rizzo Jr. TD, editors. 2015 Elsevier Saunders, Philadelphia, PA. pp. 582-587.

Brummett CM, Cohen SP. Managing Pain: Essentials of Diagnosis and Treatment. Oxford University Press. New York, NY; 2013:370-371.


Kaplan T, Gunal N, Gulbahar G, et al. Painful chest wall swellings: Tietze syndrome or chest wall tumor? Thorac Cardiovasc Surg. 2015;[Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/25742551

McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87:177-182. http://www.ncbi.nlm.nih.gov/pubmed/23418761

Gijsbers E, Knaap SFC. Clinical presentation and chiropractic treatment of Tietze syndrome: a 34-year-old female with left-sided chest pain. J Chiropr Med. 2011;10:60-63. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110396/

Brunse MH, Stochkendahl MJ, Vach W, et al. Examination of musculoskeletal chest pain – an inter-observer realiability study. Man Ther. 2010;15:167-172. https://www.ncbi.nlm.nih.gov/pubmed/19962338

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Kamel M, Kotob H. Ultrasonographic assessment of local steroid injection in Tietze’s syndrome. Br J Rheumatol. 1997;36:547-50. http://www.ncbi.nlm.nih.gov/pubmed/9189056

Aching rib cage causes | AXA Health

Ribcage pain – whether on the left or right hand side – can occur for many reasons. Most commonly this will not be due to any serious underlying condition but there are some medical reasons that may need to be ruled out:

What are the possible causes of ribcage pain?

1) Trauma or muscular pain

Trauma – if you have had a traumatic injury to the ribs, or even something such as forceful coughing, you may have caused some bruising, or even broken a rib. If you feel that this may be the cause of your pain the best things you can do are to take painkillers as required and use an ice pack to the affected area to help reduce inflammation. Try to practice ‘deep breathing’ also, as this will make sure that your lungs are fully inflating and reduce the risk of developing a chest infection (NHS, 2021).

Straining of the intercostal muscles – These are the muscles that connect the ribs and expand and contract when we breathe; like any other muscle in the body, these can become inflamed and cause us pain. Pain through a muscular strain will tend to occur when taking deep breaths. The treatment options for this type of strain will be similar to that above for a broken or bruised rib.

2) Cardiac Pain

We may feel pain in our ribcage that could indicate a cardiac concern, such as heart failure. If you were suffering from a condition that was affecting the function of the heart you would most likely be experiencing some additional symptoms (BHF, 2021) including: 

  • Shortness of breath
  • Swelling feet and legs; this swelling can also spread to higher up in the body
  • Feeling unusually tired and week
  • Coughing or wheezing, sometimes bringing up ‘frothy’ or blood-stained mucus
  • Fast heart rate.

If you are experiencing pain along with any of the symptoms noted above it is important to seek and urgent review through your GP to determine the diagnosis.

If you experience chest pain that is severe, that radiates to your arms, back or jaw, or is accompanied by nausea, shortness of breath, sweating, dizziness or feeling extremely unwell then you must seek an emergency review at your local Accident and Emergency department.

3) Costochondritis

This condition refers to the inflammation of the cartilage which joins your rib cage to your breastbone (sternum). This condition does not lead to any long-term complications and will usually improve on its own within a few weeks, however, unfortunately, some people will have relapses (NHS, 2021).

Symptoms of costochondritis include:

  • Pain when deep breathing, coughing or sneezing
  • Pain that worsens when you put pressure on the chest
  • Pain that is worsened when lying down.

The main treatment for costochondritis is pain killing medications such as anti-inflammatories (NHS, 2021). If these do not manage your pain or you condition is not resolving, then your GP may want to look into other alternative treatments.

4) Gall stones

Gallstones are formed when a substance, usually cholesterol, forms into a small stone within the gall bladder. Gallstones will often cause no problems, and you may have no symptoms at all of them, but if one of the stones becomes lodged in a duct inside the gall bladder this this can trigger a pain called biliary colic (NHS, 2021). 

Pain from gallstones is usually felt in the centre of your abdomen, under the ribs or on your right-hand side. Sometimes the pain will be triggered by eating particularly fatty foods, and you won’t notice relief after being sick, having your bowels open or passing wind.

If you develop complications from gall stones, including biliary colic or inflammation of the gallbladder known as cholecystitis you may experience:

  • Jaundice (yellowing of the skin and whites of the eyes)
  • Persistent severe pain
  • Vomiting
  • Fevers.

Gallstones usually only need to be treated if they are causing complications. If you do require treatment then this will usually be surgery to remove the gallbladder using keyhole surgery (NHS, 2021).

5) Diseases of the liver

There are a number of different types of diseases that can affect our livers, including cirrhosis or hepatitis, and most of these will often have no symptoms in the early stages. As the disease progresses you may expect to see some symptoms, including abdominal pain. Some symptoms you might experience include (British Live Trust, 2021):

  • Nausea
  • Jaundice
  • Itching of the skin
  • Dark coloured urine
  • Pale/clay coloured stools
  • Abdominal pain, often on the right side under the ribs
  • Fatigue
  • Weight loss
  • Frequent or easy bruising or bleeding
  • Changes in personality.

If you are experiencing abdominal pain with any of the above symptoms, or you are concerned about your liver, the best thing to do is to get in touch with the GP for a physical review and some blood tests.  Lifestyle choices can have a really big impact on our liver health and liver disease is often preventable.

6) Pancreatitis

Pancreatitis is the inflammation of the pancreas (an organ that plays a vital role in hormone production and digestion) which can be both acute and chronic. Acute pancreatitis can make someone feel extremely unwell and can be very dangerous so needs prompt medical attention (NHS, 2021). 

One of the main causes of pancreatitis can be gallstones or heavy alcohol use but it can also develop due to other causes including injury and infection. 

The main symptom of acute pancreatitis is severe pain that is felt in the upper abdomen, just below the ribs, but you may experience other symptoms along with this pain including (NIDDK, 2021):

  • Fever
  • Nausea or vomiting
  • Fast heartbeat
  • Swollen abdomen
  • Jaundice
  • Diarrhoea.

As above someone with pancreatitis may be extremely unwell, and will often look and feel it as well, so if you believe you may be suffering from this condition it is very important to seek an urgent medical assessment, either through your local Accident and Emergency department or by calling NHS 111.

7) Acid reflux and stomach ulcers

Pain from heartburn and acid reflux can sometimes be felt in the chest area. The pain here is caused by stomach acid travelling up the oesophagus. Along with heartburn, if you are experiencing acid reflux you may also experience:

  • A sour or unpleasant taste in your mouth
  • Bad breath
  • Bloating
  • Nausea
  • A hoarse voice
  • Recurring coughs or hiccups.

Your symptoms will often worsen after eating, and when lying down and bending down, if your pain is due to acid reflux (NHS, 2021).

If you develop an ulcer in the lining of your stomach, then you will likely also experience the symptoms listed above. If you believe you have a stomach ulcer or struggling with acid reflux it is best to seek an assessment with your GP for investigations into this (NHS, 2021). In some cases, a stomach ulcer can perforate, and bleed, if you are experiencing any of the symptoms below then you must seek an urgent medical review:

  • Vomiting blood
  • Sudden intense pain that worsens
  • Passing black or tar like bowel motions.

As you say your pain seems to come on after eating then this may be something your doctor may need to investigate further.

8) Inflammatory bowel disease

Inflammatory bowel disease is the collective name for the diseases that cause inflammation in the digestive tract; the main two forms being ulcerative colitis and Crohns disease (Crohns and colitis UK, 2021). Pain from these conditions will usually be felt lower down in the abdomen, however sometimes we can get referred pain to other areas of the body, including in the ribs. If you are suffering with an inflammatory bowel disease you will likely have other accompanying symptoms including: 

  • Diarrhoea – this can sometimes be mixed with mucus, blood or pus
  • Cramping in the abdomen
  • Fatigue
  • Loss of appetite and unexplained weight loss
  • Anaemia
  • Mouth ulcers
  • Inflammation in other areas of the body (Crohns and colitis UK, 2021).

If you are experiencing any of the symptoms noted above along with the rib pain, then you should speak to your GP to discuss your symptoms.

9) Appendicitis

Appendicitis, is when the small part of the intestine known as the appendix becomes infected and inflamed. This needs examination by a GP or emergency doctor as it may need surgery (NHS, 2021). This pain will usually be felt in the lower right hand side of the abdomen but if you are experiencing worsening pain, especially if accompanied by fever, nausea and loose stools then it is important to seek an assessment to rule this out.

With any of these issues it is important to get a diagnosis and treatment through your GP. If symptoms worsen or you experience any of the following, you should go to the accident and emergency department of your hospital:

  • Pain becomes unbearable
  • Vomiting blood or passing blood when you have your bowels open
  • Black stools
  • Crushing pain in chest
  • Worsening symptoms that you cannot manage at home.

While of course no amount of healthy living can absolutely guarantee good health, the fact that you have such a healthy lifestyle makes a serious cause much less likely.

If you’re otherwise entirely well and have no other symptoms, it would be reasonable for you to try some regular over the counter pain killers to see if they help your symptoms; as long as there’s no medical reason you can’t take them (please note that long term use of some anti-inflammatory medications can cause irritation of the stomach lining). Otherwise, after this length of time, see your GP – they can ask more detailed questions on associated symptoms.

Answered by the Health at Hand team.  

Sources and further reading


BHF, 2021. Heart failure. (Accessed: 25 Feb 2021).

British Liver Trust, 2021. Symptoms of liver disease. (Accessed: 25 Feb 2021).

Crohns and Colitis UK, 2021. About Crohns and colitis. (Accessed: 26 Feb 2021).

NHS, 2021. Acute pancreatitis. (Accessed: 25 Feb 2021)

NHS, 2021. Appendicitis. (Accessed 26 Feb 2021).

NHS, 2021. Bruised or broken ribs. (Accessed: 25 Feb 2021).

NHS, 2021. Costochondritis. (Accessed 25 Feb 2021).

NHS 2021. Gallstones. Symptoms. (Accessed: 25 Feb 2021)

NHS, 2021. Heartburn and acid reflux. (Accessed 25 Feb 2021).

NHS, 2021. Stomach ulcer. (Accessed 25 Feb 2021)

NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases), 2021. Symptoms and causes of pancreatitis. (Accessed 25 Feb 2021).

Esophagitis – UCLA Robert G. Kardashian Center for Esophageal Health

What is esophagitis?

Esophagitis means inflammation of the esophagus, which is the muscular tube that connects the mouth to the stomach and allows the food bolus to pass through. Esophagitis is a macroscopic damage to the lining of the esophagus, manifesting as breaks in the lining or ulcerations.

What causes esophagitis?

Gastroesophageal reflux disease (GERD) is the most common cause of esophagitis. Gastroesophageal reflux is when stomach acid backs up from the stomach into the esophagus. Gastroesophageal reflux is a normal physiologic process and often does not cause symptoms, esophageal injury, or other complications. Gastroesophageal reflux becomes a disease (GERD) when it either causes symptoms or causes macroscopic damage to the esophagus. This macroscopic damage to the lining of the esophagus is called esophagitis.

Other less common causes of esophagitis include infections, certain medications, eosinophilic esophagitis, caustic ingestions, and some autoimmune conditions.

What are the symptoms of esophagitis?

Esophagitis can produce symptoms of chest pain (usually behind the sternum), heartburn, odynophagia (painful swallowing), and/or dysphagia (difficulty swallowing, sensation of food sticking). Rarely, esophagitis can be severe enough to cause bleeding.

How is esophagitis diagnosed?

Esophagitis is best diagnosed with an upper endoscopy. During the upper endoscopy, the esophageal inflammation can be directly visualized and the severity of the esophagitis can be determined. Esophageal biopsies can also be taken to evaluate for certain causes of the esophagitis if needed. Complications of esophagitis, such as bleeding, can also be treated as needed during endoscopy. Sometimes, esophagitis can be diagnosed on a barium swallow, where the esophagus is coated with swallowed barium and X-rays are taken, but this method is less sensitive than an upper endoscopy.

What are the treatment options for esophagitis?

Treatment for esophagitis varies depending on the cause of the esophagitis. For the common cause of reflux esophagitis, lifestyle changes and medical treatment for acid reflux (e.g. proton pump inhibitor) is used to heal the esophagus by decreasing esophageal exposure to injury from stomach acid.

Rheumatoid Arthritis, Chest and Rib Pain: What Is Costochondritis?| EverydayHealth

Costochondritis is caused by inflammation of the cartilage that connects your breastbone, also known as your sternum, to your ribs. The pain associated with this condition can closely mimic a heart attack or other cardiac problems, but research published in the German journal Der Internist suggests that as many as 50 percent of all chest pains are caused by musculoskeletal disorders.

RELATED: What Does Arthritis Pain Feel Like?

Common Causes of Costochondritis

There are rubbery segments of cartilage — called costosternal joints — that attach the ribs to the breastbone, and chest pain can occur when the cartilage in those joints gets inflamed. “Costochondritis is typically a result of some sort of mechanical stress, like you coughed too hard or you reached too far and pulled something,” says Harry L. Gewanter, MD, a pediatric rheumatologist in Richmond, Virginia. For example, chest pain symptoms could occur after you physically strain yourself moving furniture. While these symptoms can be extremely painful, the condition is not life-threatening.

Sharp Pain and Pressure: Costochondritis Symptoms Can Be Scary

The hallmark symptom of costochondritis is pain in the chest wall of varying intensity, and it tends to be described as “sharp,” “aching,” or “pressure-like,” according to research published in the journal American Family Physician. The pain can become even worse with upper body movement or by breathing deeply, since it involves joints that flex when you inhale. Although the second to fifth costochondral joints of the ribs are most frequently affected — and especially ribs three and four — it can impact any of the seven rib junctions. Pain can take place in multiple sites, but it’s most frequently unilateral, which means it takes place on only one side of the body. “It can feel like someone stuck a knife in you, and it can take your breath away,” says Dr. Gewanter.

RELATED: Do Your Chest and Ribs Hurt? The Culprit Could Be Psoriatic Arthritis

Naturally, intense symptoms can be scary, as Kelly O’Neill describes in her blog, Rheumatoid Arthritis Warrior. This is especially the case if you don’t understand the cause or haven’t experienced it before. But there’s a good chance that the cause behind the pain isn’t serious.

Recognizing and Diagnosing Costochondritis

X-rays don’t show soft tissue well and there’s not a blood test for it, so costochondritis is typically diagnosed by a doctor through a physical exam. Older adults experiencing these symptoms may need to get an EKG to rule out the possibility of cardiac problems.

RELATED: Mystery Symptoms That Could Be Rheumatoid Arthritis

According to Costochondritis, StatPearls medical education book published in January 2021, “The most important part of the diagnosis of costochondritis is ensuring other, more deadly causes of chest pain have been ruled out.” These can include acute coronary syndrome, pneumothorax, pneumonia, aortic dissection, pulmonary embolism, or an esophageal perforation.

The Costochondritis–Rheumatoid Arthritis Connection

Costochondritis isn’t directly related to RA, but inflammation from RA can be a reason for damage to the rib cartilage. “Costochondritis also happens in people with rheumatic diseases because their joints aren’t working properly, so they can move the wrong way and tweak their bodies even further,” says Gewanter. “It’s a biomechanical issue, and it can become a house of cards.”

While the chest pain may be related to an inflammatory disease, such as rheumatoid arthritis or ankylosing spondylitis, it can also be partially caused by noninflammatory conditions, such as fibromyalgia.

Costochondritis Is Not the Same as Tietze Syndrome

Costochondritis is often confused with Tietze syndrome, a similar but less common disorder that typically involves swelling of the second or third rib that can last for months. According to the American Family Physican review, Tietze syndrome typically affects people who are younger than 40 and is considered rare, while costochondritis is more common and can affect children, teens, and adults, says Gewanter. In fact, he says, “the rib cages of kids are extra flexible, so that increases the opportunity to irritate the costochondral junctions.” Local swelling is typically present with Tietze’s, while it is not with costochondritis, though the RA advocate O’Neill notes inconspicuous swelling with her costochondritis. “In reality, whatever you want to call it, both conditions are treated in essentially the same way,” says Gewanter. Tietze syndrome can subside without treatment, but over-the-counter pain medication may be used.

How Costochondritis Chest Pain Is Treated

Treatment typically takes the form of oral pain relievers — typically either Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil or Motrin (ibuprofen). Ice or heating pads can help, says Gewanter, as can minimizing activities that provoke your symptoms. Cough suppressants can also help reduce discomfort, and sometimes physical therapy is used to help diminish soreness.

Easing Pain and Other Symptoms of Costochondritis

Some people find relief by splinting the chest using an Ace wrap or something similar to try to minimize chest movement, he says. “But there really is no great way to treat it, outside of time,” says Gewanter.

RELATED: Home Remedies and Alternative Treatments for Rheumatoid Arthritis

There’s also no real way of knowing how long the pain will last, though the American Family Physician report says that it can last from weeks to months, though for some it may last for a year. “Patients with costochondritis should be educated and reassured that this is a benign condition that will eventually resolve itself,” the journal states, sometimes without any treatment at all.

Hodgkin’s lymphoma presenting as lytic sternal swelling


Hodgkin’s lymphoma may involve various organs including lymph nodes, spleen, liver, pleura and bone. Involvement of bone is relatively uncommon and has been reported in about 7% of cases.[1] If present however the commonly involved bones are vertebrate, ribs, pelvis, long bones and sternum. The lesions may be lytic or sclerotic or mixed.[2] The most common subtype of Hodgkin’s involving the bone is nodular sclerosis type.[2] Solitary osseous involvement is rare and concomitant non osseous organ involvement is more common. The 5-year survival of the disease is relatively good and is around 56-89%.[3] We would like to present a case of Hodgkin’s lymphoma affecting multiple organs including sternum. The diagnosis was delayed because of evidence of granulomas and epithelioid cells on cytopathology and the patient was mistreated for tuberculosis.

A 30-year-old female presented with central chest pain since 1 year which was stabbing in nature and since past 6 months it increased with inspiration. Swelling over the sternum appeared 10 months back [- encircled]. She had progressive shortness of breath since 3 months which was accompanied by orthopnea. She also complained of loss of weight and appetite. Previous fine-needle aspiration cytology of the sternal swelling had revealed granulomas and epithelioid cells on the basis of which she had been receiving anti-tubercular treatment (ATT) since past 5 months. She had also received a course of ATT 5 years back for pulmonary tuberculosis. She presented to us with progressive dyspnea despite treatment. Physical examination revealed a sternal swelling and multiple enlarged cervical lymph nodes. Abnormal blood tests included raised total leukocyte counts (24,700/μl, normal range 4000-11000/μl). Chest X ray revealed a left upper lobe heterogeneous lesion with cavitation and bilateral pleural effusion []. Pleural fluid was lymphocytic (cells = 1500/cm3, 96% lymphocytes), exudative with low adenosine deaminase (ADA = 17.9 IU/L), negative for malignant cytopathology and Mycobacterium tuberculosis PCR. Computed tomography of chest [] revealed sternal lytic lesion (encircled) compressing the heart, bilateral pleural effusion and fibrocavitory lesion involving the left upper lobe. CT abdomen revealed hepatosplenomegaly, ascitis and enlarged lymph nodes in pre and para-aortic regions. An excisional cervical lymph node biopsy [ revealed infiltration with variant of Reed Sternberg cells (vertical arrow), eosinophils (horizontal arrow), neutrophils, plasma cells and lymphocytes showing mitosis (encircled). The overall morphology of the lymph node was suggestive of mixed cellularity type of Hodgkin’s lymphoma. Immunohistochemistry revealed staining with CD15 and CD30 suggestive of Hodgkin’s lymphoma. The patient was given Adriamycin, Bleomycin, Vinblastine and Dacarbazine. She however succumbed to the disease after 1 cycle of chemotherapy and died.

(a) Swelling present over the lower part of sternum (encircled) (b) Chest X ray shows left upper lobe fibrocavitatory lesion with left pleural effusion

(a) CT chest shows a sternal lytic lesion compressing over the heart and major vessels (b) Excisional cervical lymph node biopsy shows infiltration with variant of Reed Sternberg cells (vertical arrow), eosinophils (horizontal arrow), neutrophils, plasma cells and lymphocytes showing mitosis (encircled)

Hodgkin’s lymphoma (HL) is a common B-cell-derived lymphoma and may sometimes have unusual presentations. There are five histopathological variants of HL including mixed cellularity, nodular sclerosis, lymphocyte depleted, lymphocyte rich and nodular lymphocyte predominant HL (NLPHL).[4] Granulomas may sometimes be visible in Hodgkin’s lymphoma[5,6] and these patients are often mistreated for tuberculosis or sarcoidosis.[7] Other granulomatous diseases include toxoplasmosis, Kikuchi-Fujimoto’s disease and certain malignancies like malignant lymphomas. Previous cases of granulomatous reaction in Hodgkin’s lymphoma have been reported in lymph nodes,[6] spleen[5] and bone.[2] Strong clinical suspicion and inadequate response to ATT should prompt further histopathological work-up. Our patient also had low ADA in pleural fluid and poor response to ATT, further emphasizing the role of histopathology for diagnosis. The sensitivity and specificity of pleural fluid ADA levels in various studies ranges from 72% to 95% and 81% to 87%, respectively.[8,9] Thus, a low ADA makes a diagnosis of tuberculosis less likely. In such cases demonstration of acid-fast bacilli in the biopsy specimen or histopathology is essential to make a diagnosis. Immunohistochemistry also plays an important role in confirming the diagnosis of HL, as evident in our case. CD30 is positive in almost all cases of HL and CD15 is positive in 80% cases of HL.[10]

Clinically Hodgkin’s lymphoma presents with painless and rubbery lymph nodes. B symptoms which include fever, night sweats and loss of weight (>10% in less than 6 months) are seen in 25% cases. Sometimes HL may present with mediastinal lymphadenopathy with or without superior vena cava obstruction.[11] Pleural effusion is seen 15-45% of cases depending on tumor staging and extra-nodal involvement.[12] Chylothorax[13] has also been reported in the literature. Abdominal involvement includes lymphadenopathy, hepatomegaly, splenomegaly and ascites. Bone marrow involvement is seen in only 5-8% cases.[14] The above patient presented with sternal swelling, cervical lymphadenopathy, pleural effusion, hepatosplenomegaly and ascites. Early osseous involvement is rare and often the bone is involved at a later stage. The sternal swelling with pressure on her heart, probably explains her orthopnea. Moreover, she had B symptoms that included loss of weight, which explains her poor prognosis.

The above case is being presented to highlight few peculiarities. Firstly, though a rare presentation, Hodgkin’s lymphoma may involve the sternum and a differential for HL should always be kept in cases of osseous involvement. Second, epithelioid cells and granulomas may sometimes be visible on pathology in HL. Third, multiple organ involvement, strong clinical suspicion and inadequate response to treatment were indications to an alternate diagnosis. Fourth, further histopathological examinations with immunohistochemistry are useful in such cases.

90,000 sternum handle is … What is sternum handle?

sternum handle
(manubrium sterni, PNA, BNA, JNA) the upper, widest part of the sternum, articulating with the clavicle and the first two pairs of ribs.

Comprehensive Medical Dictionary.

  • arm thalamic
  • rumination


See what a “sternum handle” is in other dictionaries:

  • Sternum handle – (manubrium sterni) Sternum handle (manubrium sterni) Sternum (front view): 1 – jugular notch; 2 – clavicular notch; 3 – sternum handle; 4 – rib cuts; 5 – the body of the sternum; 6 – xiphoid process … … Atlas of human anatomy

  • Handle – (manubrium) anterior sternum (sternum) of mammals.The composition of R. may include a prosternum, that is, the anterior section of the sternum, which is independent in lower mammals and, perhaps, corresponding to the anterior section of the sternum of amphibians … … Brockhaus and I.A. Efron

  • Handle (Manubrium, Multiple Manubria) – 1. Upper sternum (see Sternum). Connects with the clavicle and the first costal cartilage; the second costal cartilage connects to the sternum between its arm and the body, uniting them.2. An arm-like part of the hammer (inner bone … … Medical terms

  • HANDLE – (manubrium, pl. Manubria) 1. Upper sternum (see. Sternum). Connects with the clavicle and the first costal cartilage; the second costal cartilage connects to the sternum between its arm and the body, uniting them. 2. The handle-like part … … Explanatory Dictionary of Medicine

  • Sternum body – (corpus sterni) Sternum body (corpus sterni) Sternum (front view): 1 – jugular notch; 2 – clavicular notch; 3 – sternum handle; 4 – rib cuts; 5 – the body of the sternum; 6 – xiphoid process Thoracic … … Atlas of human anatomy

  • Sternum and ribs – Sternum (Fig.14) is called a long, spongy bone of a flat shape, which closes the chest in front. Three parts are distinguished in the structure of the sternum: the body of the sternum (corpus sterni), the handle of the sternum (manubrium sterni) and the xiphoid process … … Atlas of Human Anatomy

  • Bones of the trunk – … Atlas of human anatomy

  • Sternum – Sternum, sternum, unpaired elongated bone with a slightly convex anterior surface and, accordingly, a concave posterior surface.The sternum occupies a section of the anterior chest wall. It distinguishes between the handle, the body and the xiphoid … … Atlas of human anatomy

  • SKELETON – (from the Greek skeletos dried) of animals is a system of relatively dense formations that make up a more or less durable skeleton of an animal or its parts. On the one hand, skeletal formations protect more delicate tissues and organs … … Great Medical Encyclopedia

  • Xiphoid process – (processus xiphoideus) Xiphoid process (processus xiphoideus) Sternum (front view): 1 – jugular notch; 2 – clavicular notch; 3 – sternum handle; 4 – rib cuts; 5 – the body of the sternum; 6 – xiphoid … … Atlas of human anatomy

90,000 “You have such beautiful breasts, but you cut yourself.”Why, when visiting a sanatorium, it is better to keep quiet about your stigmas – Society – News of St. Petersburg


“This is still so humiliating. “You have cuts on your arm. You must immediately leave the territory of the sanatorium. ” I go in a taxi and just cry, ”Karina Istomina wrote on Twitter on Twitter . Users of social networks were outraged by the situation: the St. Petersburg resort, which promises “a balance of health, youth and beauty,” refused the client in a moment of mental adversity. Those who were not indifferent immediately rushed to pessimize the hotel’s rating on various resources – for “discrimination”.Due to medical confidentiality, the hotel cannot present its own version of events in detail.

Karina Istomina is a frequenter of fashionable parties in secular Moscow, host of the Musical Thursday program on TikTok and co-host of the Girlfriends project on the Tender Editor Youtube channel. She is used to talking openly about her psychological problems. For example, in the final issue of Girlfriends at the end of 2020, she said that “in November every morning I woke up and thought: why am I still alive”. “I don’t know how to control it, it lives its own life and drives you crazy,” the girl admitted.

Photo: screenshot from YouTube Attached to the message is a soothing photo of pine trees against the background of the sky. But just an hour later, she stunned the audience with a story about why walking was canceled.

Photo: screenshot from twitter.com- Some kind of (…) endless punk rock concert. ”

The girl was immediately supported by likes and retweets.

“I had a rest (…) under the distress program. I was sobbed all over, – added Karina. – Moreover, the most annoying thing is that I have a stable condition. There is no selfharma and I am clean. I just wanted to sleep and walk in the woods. And no one asked me about my mental health before arrival ”. A storm broke out in the comments. Everyone was worried about the question: how could an institution making money from those in need of a psychological reboot do this? Karina Istomina explained that the clinic referred to some legal rules, but did not show any documents confirming this.

“I would not have any questions if it was indicated in the price list on the site that if a person has a mental illness, then he cannot go to this sanatorium, but they said that they never had people like me,” the girl wrote (spelling and punctuation of the original retained. – Ed. Note). – They would have asked for a certificate from a psychiatrist in advance and that’s it, I would have brought it, it would have been written there that I was in remission, but I was under supervision all the time.

The telegram channels immediately responded to the situation, telling the story in detail and describing it as a “big scandal.”So it became known that the scene is the First Line Hotel in Zelenogorsk, which positions itself as an “innovative prevent age resort” and a five-star international project. Services include biohacking and age management.

The creator and ideologist of First Line is Maria Grudina, wife of the director and co-owner of the hotel, Yuri Grudin. LLC Life Energy Saint Petersburg – under this name First Line appears in the SPARK system – Yuri Grudin founded about three years ago together with his brother, developer Andrei Grudin.In June 2020, Andrei Grudin was found dead in his office in Moscow. A suicide note was found near the body. This fact, in the context of Karina Istomina’s story, made a stronger impression on social media users than the list of possible contraindications for using the resort’s services published on his website. The thirteenth item (there are 16 of them) is “mental and behavioral disorders in a state of exacerbation or unstable remission, including those that pose a danger to the patient and others.”Those who nevertheless went to the site in search of this list noted that the contraindications are designated as “possible” and not “required”. But in the order of the Ministry of Health No. 1029n “On the approval of lists of medical indications and contraindications for spa treatment,” the same list is designated simply as “medical contraindications.” Without a hint of options.

But not indifferent Internet users began to read the documents, but began to write reviews in search engines about the “First Line” as a place “showing discrimination.”Before Karina Istomina was denied the opportunity to practice Nordic walking, the clinic’s rating on Facebook was 5 points out of 5 possible. In less than a day, it dropped to 4.3 – thanks to several comments from different users about “disrespectful attitude towards guests.”

First Line’s attending physician Natalya Tyuricheva, who conducted the initial reception of Karina Istomina, noted that First Line was forced to refuse the client in accordance with the order of the Ministry of Health.

“I haven’t seen the guest’s Twitter post because of my busy schedule, I don’t have time to browse social networks,” said the doctor. – At the initial appointment, the guest revealed absolute contraindications for undergoing the distress program. But I have no right to comment or supplement in any way the information that Karina Istomina has already reported about herself on social networks, since all this information belongs to the category of medical confidentiality. Any situation that occurs in the clinic is a medical secret.I can only say that when making a decision to refuse service, we are guided not only by the order of the Ministry of Health, but also by considerations of the safety of our guests. ”

The creator and ideologist of First Line, Maria Grudina, in an interview with Fontanka, noted that the resort sometimes has to refuse guests.

“We are very much limited by medical confidentiality when commenting on this situation,” said Maria Grudina. “And we have no right to state in detail the reasons for our decision. Yes, we do distress programs.But we cannot provide services if they carry potential health risks to the guest. We never kicked Karina Istomina out. None of the employees of our clinic could utter the phrase that the guest should leave the territory of the sanatorium because of cuts on his arm, this is simply impossible. Over the years, we have helped thousands of people cope with their psychological problems, but only within the framework of our competencies. There are areas in which we are not competent and are not allowed to work. And that’s why we sometimes have to refuse our guests.Our service director and chief physician explained the reasons for the refusal to Karina, the conversation was conducted in a correct and friendly manner. There are certain indications for undergoing a distress program. But all of them do not go beyond the scope of spa treatment. Such treatment does not occur at the stage of acute physical or mental illness. We are by no means stigmatizing these diseases. And we will be glad to see Karina Istomina as a guest at any other moment, when she will not have the absolute contraindications that were identified this time ”.

Karina Istomina herself, in an interview with Fontanka, noted that she did not want a conflict situation to develop, but immediately after the incident she felt like Dostoevsky’s heroine – “humiliated and insulted”. As it turned out, the girl still managed to practice Scandinavian walking. “I am a psychoactivist (people who raise the issue of stigmatizing people with mental and mental disorders – Ed.) . And I do not hide the fact that I have a chronic disease with which I have been seen by a psychiatrist.But now I am in a stable state of remission, – said Karina. – My distress program consisted only in the fact that I had to walk in the woods and swim in the pool. I checked into “First Line” on the evening of February 8th, I was supposed to leave on February 11th. The next day I got tested, went to the doctor for examination, then left to practice Scandinavian walking. On examination, I took off my T-shirt. The doctor who performed the examination asked if I had a breast made. I say “No”. And she says: “You have such beautiful breasts, but you are cutting yourself.”How should I react to this? And on the evening of February 9, a doctor and an administrator came to me. And they said that I must urgently leave the clinic. I don’t want conflict. I just want the clinic staff to draw conclusions and communicate with guests in a different way. If I had any kind of gastritis, which is also on the list of contraindications, but is not stigmatized, they would talk to me differently. ”

Venera Galeeva, Fontanka.ru

Three centuries of Petersburg cuisine

Stewed duck sweets in berry glaze and black crispy greek

This signature dish was inspired by two recipes from the famous almanac of Ignatius Radetsky “St. Petersburg Cuisine”, published in the middle of the 19th century: “roast of young stuffed turkey” and “chestnut croquettes”.In the process of cooking duck, the chef of the Symposium restaurant Artem Gul uses the technology of stewing over low heat with the addition of spices to give the duck meat a delicate texture and interesting aroma. The black and red currant glaze is prepared on the basis of an authentic chestnut croquettes recipe, and the original buckwheat sprinkle, painted black with cuttlefish ink, enriches the dish with another slightly crispy texture. “Sweets” are served on cold birch coals, accompanied by spectacular “smoke”, turning the acquaintance with the dish into a small gastronomic show.

Jellied pike perch with tiger shrimp and burnt scallop

Chef Artem Gul created his own recipe for jellied pike perch with tiger shrimp and burnt scallop based on the traditional dish “cold veal sternum” from the book of Ignatiy Radetsky. Unlike the classic recipe, the chef uses Ladoga pike perch as the base of the jellied chef. The dish with original geometry is served in the author’s manner in the form of two separate cubes, where inside transparent jelly three layers are effectively laid out: tiger shrimp, burnt scallop and a sprig of young fern.The appetizer is served with green pea cream with wasabi horseradish and a crunch made from homemade grain bread.

Stroganoffs from rapans and oyster mushrooms stewed in brine

An original recipe from the gastronomic almanac of Ignatius Radetzky – “Russian sturgeon with cucumbers” – creatively rethought by the chef of the “Symposium” restaurant. In the author’s recipe Gul Artem, instead of sturgeon, rapanas are used, which are stewed in cucumber brine at a low temperature for more than 4 hours.Then stewed rapanas are mixed with fried oyster mushrooms, which add additional mushroom flavor and aroma to the dish. The special delicacy of the mix of the main ingredients is achieved by the delicate addition of charcoal cream. The dish is decorated with slightly crispy Nizhyn cucumbers, laid out in a circle in the form of a wreath, and served with airy fried potato cream.

90,000 Rehabilitation massage after coronavirus infection COVID-19 (Covid) and pneumonia

COVID-19 has rapidly burst into our lives, changing the usual way.Especially strongly the changes associated with the new insidious disease have affected various areas of medicine. Massage therapy plays a very important role in the recovery process of the body affected by Covid-19. The medical center “Es Class Clinic” provides services for conducting massage courses after the coronavirus infection COVID and pneumonia in Ulyanovsk.

What changes occur in the lungs with COVID-19

By its nature, this disease is one of the types of respiratory viral infections, which can occur with various complications.The most aggressive form is pneumonia. A person infected with the SARS-CoV-2 virus develops inflammatory processes in the respiratory system. Even with an asymptomatic course, a large load falls on the respiratory system and immunity, which cannot but affect negatively the state of health.

If it enters the lungs, the virus can provoke the development of inflammation in a viral or viral-bacterial type. In this case, the main blow is taken by the alveoli – the smallest bubbles that are an important part of the pulmonary system.They are responsible for oxygenating the blood and removing carbon dioxide. The destruction of the alveoli leads to the destabilization of gas exchange processes and leads to the accumulation of inflammatory exudate in the alveoli. As a result, connective fibrous tissue is formed in the affected areas, due to which the vital volume of the lungs is reduced, they cannot fully function, which can lead to disability or death.

Particular attention should be paid to drawing up a well-thought-out rehabilitation plan that allows you to achieve full recovery.Rehabilitation massage after COVID-19 (Covid) and pneumonia is one of the most effective methods of restoring the normal functioning of the respiratory system and other vital organs.

The benefits of massage treatments

Health restoration activities should be started as early as possible – only this will help to achieve the maximum effect. Rehabilitation massage after COVID-19 (Covid) and pneumonia is an integral part of treatment that contributes to:

  • effective resorption of inflammatory foci;
  • stimulation of the process of blood supply and lymph flow;
  • ventilation stabilization;
  • stimulation of sputum separation and excretion;
  • Strengthening muscles, including respiratory.

It is not recommended to resort to massage procedures at the stage of the acute phase! It should also be noted the effectiveness of special breathing exercises, which have a positive effect on the functioning of the nervous system and increase the level of ventilation of the respiratory tract.

Features of massage after coronavirus infection COVID and pneumonia

The main massage technique included in the complex of the session is movements that cause vibration. As a result, blood supply is significantly improved, breathing is stabilized, and the process of sputum discharge is significantly activated.The most affordable and simple option for rehabilitation massage after COVID-19 (Covid) and pneumonia is patting your back with your palms for several minutes.

In more severe cases, the workout begins with the sternum with a gradual transition to the back and neck areas, after which the masseur returns to the chest. This option is aimed at stimulating the outflow of fluid from all parts of the respiratory tract. Warming movements also have a positive effect on the patient’s condition.

Massage after coronavirus infection COVID and pneumonia requires special care and caution from the doctor, since excessive diligence can lead to undesirable results.

The effectiveness of massage in the fight against psychological problems after coronavirus infection COVID and pneumonia

Such a complex disease as COVID is a severe stress not only for the respiratory system, but also for the nervous system. The patient has to endure a lot as a result of intensive care that requires hospitalization.Many patients can develop post-resuscitation syndrome, causing increased anxiety, poor sleep, and other psychosomatic symptoms.

Can massage sessions help in this case? Definitely yes! After all, the calm and confident touch of the hands of a professional massage therapist has a calming and pacifying effect. It is such a massage that we propose to undergo in Ulyanovsk for recovering from COVID coronavirus infection and pneumonia. You can sign up for procedures at the Es Class Clinic medical center on our website or by phone +7 (8422) 50-54-63.


When buying a course of 12 sessions of rehabilitation massage after Covid-19 and pneumonia – 2 additional sessions as a gift.

“Business Petersburg”. Six scenes from the life of meat

The exhibition of Igor Pestov “Tenderness” has opened in the gallery of Marina Gisich.

Shreds of juicy meat stuck in the grinder screw. The two-meter propeller hangs in the darkness, like a cyclopean spacecraft from a fantastic action movie. Marble veins, twisted veins and moonlight of steel are spelled out with glaze. This picture from the life of minced meat is called “Tenderness”.

A huge bull’s head. The skin is flayed. Muscles and folds of fat are written in detail. An eye rolling in horror. Bloody horn.And the cyanotic oval of the seal of the meat-packing plant on the whole bovine cheek. This poignant portrait of a victim of the meat industry is called Innocence. In the theater of the flesh, the intestines shimmer with mother-of-pearl, the baking blood turns purple, lumps of fat and blood vessels tangled in knots fall out of the ripped sternum. Painting is teeming with meat and giblets. What is staging this meat show, these monumental panels? We are guests of honor of the anatomical theater, and now Dr. Tulpa’s successor will kindly introduce us to the secrets of the structure of the body? Or should you see an abstractionist texture in these compositions with skinned carcasses and entrails? Or is the artist painting a soup set especially for us in order to reveal to us the secrets of the world chef’s backstage? We will comprehend the meaning of minced meat before it is stewed in gutted peppers, will we comprehend the meaning of a rabbit before it is baked in sour cream?

Six scenes from the life of meat play out in front of us a spectacle of juicy painting.Moreover, these are not still lifes with food a la Snyders and not homage to the old masters who painted a skinned rabbit, a stingray and a bull’s carcass. These are works in the spirit of pop art. Igor Pestov makes pictures that are not inferior in entertainment to posters, posters and banners. His painting argues with the media industry, for all that, it is not only about the rivalry of the artist’s ancient craft and modern visual technologies. The life of meat is an allegory. All this frozen in galactic gloom assortment of a butcher’s shop, according to the artist’s plan, tells about the war of all against all, the battle of the sexes, eternal sado-maso love-hate and other misfortunes of the human soul.The meat series was conceived by Igor Pestov as an ethical judgment on the crisis of humanistic values, and also as a form of artistic self-purification. These pictures cannot be called appetizing.

Vegetarians, please do not disturb.

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Pericarditis – Cardiology | Hirslanden Switzerland

The bursa (pericardium) is a two-layer shell made of delicate tissue with a thin dividing gap between the two layers.The pericardium bends around the heart from all sides and ensures uninterrupted pumping function of the heart with the direction of blood into the chest cavity. The most common cause of inflammation of this bursa is viral infections. Less commonly, bacterial infections are responsible for inflammation. Along with viral and bacterial infections, also heart attack , immune reactions, metabolic diseases, neoplastic diseases or injuries can lead to inflammation of the heart bag or pericardial effusion .

Cardiac tamponade is a serious complication of pericardial effusion. In this case, the heart, due to the pressure on it of the accumulated fluid in the pericardium, is compressed and pressed. The normal performance of the heart is severely impaired by this contraction and pressure. In this case, it is necessary to act urgently to relieve the heart. As a long-term sequelae pericarditis can lead to scarring of the pericardium. Scars can “lace up” the bursa so tightly that the heart can lose its ability to be sufficiently elastic and stretchable.In this case, they speak of an armored heart (Pericarditis constrictiva – constrictive pericarditis).

Depending on the severity of pericarditis, the picture of complaints can be different – more or less pronounced. Sometimes patients feel only a little overwhelmed and have a slight fever. But also stabbing pains behind the sternum, which intensify with inhalation, may indicate pericarditis. Differentiating pericarditis from other diseases occurring in the chest is often difficult due to nonspecific symptoms.

Pericardial effusion with cardiac tamponade causes shortness of breath with shortness of breath, cyanosis (bluish color of the skin) and palpitations (increased heart rate), and shock may also develop.

Along with an external physical examination, including auscultation of the heart, additional tests are performed to diagnose pericarditis or pericardial effusion. These include ECG , [ echocardiography ], blood tests and, in any case, radiological examinations such as CT or MRI .
Treatment of pericarditis depends on the cause of the bursa inflammation. Inflammation of the bursa of viral etiology is treated with anti-inflammatory and analgesic medications. In the case of bacterial pericarditis, antibiotics are also prescribed. For inflammation of the bursa due to the immune response, cortisone is prescribed.

For pericardial effusion or pericardial tamponade, the fluid should be aspirated as quickly as possible. This is possible with puncture of the pericardial cavity.Surgical treatment options with partial or complete removal of the bursa are used for chronic pericarditis or scarring of the bursa.

90,000 Fibrosis of the heart and liver. Renin-angiotensin-aldosterone system and fibrosis


Drapkina Oksana Mikhailovna , Executive Director of Internet Sessions, Secretary of the Interdepartmental Council for Therapy of the Russian Academy of Medical Sciences:

– I will give the next lecture.It will be called “Fibrosis of the heart and liver: what is in common.”

Dear colleagues, the topic of fibrosis, in my opinion, is very relevant. It gives us the opportunity, if possible, to make our tissues (connective, parenchymal, muscle cells, any other tissue) live longer. Fibrosis is the natural aging of the body. Fibrosis of any organ (I want to emphasize again), any cell (it can be an endothelial cell, a cell of a vessel, liver). The mechanisms of development of fibrosis are very similar.

Today I will try to start our educational course, which we hope to make continuous. Not only cardiologists will be involved in this problem. Hepatologists will definitely be involved in it. In particular, Professor Pavlov, who works in our clinic. He is very seriously concerned with the problem of the liver. Pulmonologists and so on.

My task today is to tell about the possible parallels between the formation of fibrosis of the heart and liver. Are there such parallels or are these fictitious attempts to link together different processes.

I would like to pay attention to the role of the renin-angiotensin-aldosterone system in the pathogenesis of fibrosis formation. We have already seen this ubiquitous angiotensin-2, which interacts with type 1 angiotensin receptors. He will examine all the adverse effects (in particular, by affecting insulin resistance, increases the pressure of an obese hypertensive).

Now let’s look at it from a slightly different angle. From the standpoint of the development of fibrosis.

What is it. Definition.Fibrosis is a thickening of connective tissue with scarring. We are very familiar with areas of fibrosis after, for example, myocardial infarction.

These cicatricial changes can be in various organs. They occur, as a rule, at the site of chronic inflammation: atrophy or dystrophy.

Molecular definition can be given. We can say that fibrosis is an excessive accumulation in tissues of fibroblasts and extracellular matrix proteins, including collagen.

Today, within 20 minutes, we have to trace the fate of collagen, which is the main structural unit of tissue fibrosis.

The history of the study of the issue dates back to 1872, when William Gull and Henry Sutton describe arteriocapillary fibrosis that develops in kidney disease.

In the 1930s, the Nobel laureates have already worked. They worked to uncover the structure of collagen. She was revealed.


In the 1960s, John Ross and Eugene Brownwald begin to study the effects of angiotensin on heart function.Then the first works on the relationship between diabetes mellitus and myocardial fibrosis appeared. Or hypertrophied left ventricle due to arterial hypertension, myocardial fibrosis.

Earlier Georgy Fedorovich Lang , the indisputable authority of the Russian medical school, already found “gentle fibrosis” (as he said) in the hearts of patients suffering from arterial hypertension.

More recently, quantitative and qualitative assessment of fibrosis has become possible. Of course, we strive in our diagnostic capabilities to develop more and more methods that will be non-invasive.Of course, liver biopsy and myocardial biopsy are not always available.

Liver biopsy is available – myocardial biopsy is difficult to perform. Now they are fighting over which of the methods will be comparable in sensitivity and specificity to the morphological one.

The main characters – whom we should know by sight, talking about fibrosis. These are fibroblasts, collagen. And here we are interested in collagen of the first and third types. These are components of the extracellular matrix. Basically, here we will focus on proteoglycans.

By themselves, matrix metalloproteinases and their inhibitors (that is, the ratio of matrix metalloproteinases, which are responsible for the degradation of collagen, and inhibitors of matrix metalloproteinases) will be those targets that can be acted upon by various therapeutic agents in order to either increase collagen synthesis or have a greater effect to its degradation.

Profibrotic markers. The most famous are, of course, TGF beta (growth marker).


What is collagen.Collagen is a triple helix. This triple helix of collagen is one third of all proteins in the human body. It is formed by protein chains. When these triple helices of collagen, which are stretched out by protein chains, converge, stitch together, then rod-shaped collagen molecules are formed. They form very strong, non-extensible collagen fibrils. Their strength is comparable to that of steel.

You understand how difficult it is, for example, to reverse fibrosis. In my opinion, it is better to do everything possible to prevent fibrosis from forming.

How collagen synthesis occurs. Collagen synthesis is a process that requires cellular and extracellular synthesis. The collagen precursor is synthesized on the ribosomes, on the surface of the endoplasmic riticulum. It’s called preprocollagen. Then there is a post-tranquilization modification in the Golgi complex. Some signal peptides are cleaved.

Procollagen appears, which still carries a long propeptide at one end. This is followed by hydroxylation and glycosylation.Oxidation of cystoine residues leads to the formation of intermolecular disulfide bonds.

The very last stage is condensation with the formation of intra- and intermolecular bonds. When all these stages are passed, we get collagen.

(Slide Show).

A slice of the left ventricular myocardium of any patient. It is important that the connective tissue framework of the myocardium consists of three main components: epimysia, endomysia, perimysia. Endomysias surround a large muscle fiber.These are dense bundles of collagen that make up the connective tissue layer that surrounds the entire myocardium. Epimysia are part of the epicardium and endocardium.

Endomysias are collagen fibers that surround each muscle fiber to form a mesh sheath. Capillaries are also located around these muscle fibers. This is also very important. Interpersonal relationship between muscle fiber and capillary.


Endomysia and epimysia connect perimysia.The role of perimisia is extremely important in relaxation processes. Perimisia are rather thick bundles. They thicken, shorten during systole and lengthen, practically turning into a solid tape during diastole. How elastic the perimisium will be, so will our heart be elastic.

Thus, in the process of myocardial fibrosis, which we will talk more about today, these three bundles are of great importance. Epimysias, endomisias, perimysias.

(Slide Show).

Ultrastructural level. On the left is an electron micrograph of a fragment of the left atrium. We see how collagen fibers are located between the fibroblast and the capillary. Most likely, here we are talking about endomysia.

Shown beside how the cardiomyocyte is separated from the capillary by a thin plate of fibroblast growth. If the fibroblast is activated (we will recall a little later what agents it can be activated by), this will lead to the fact that the process of the fibroblast will gradually be replaced by connective tissue.

Let’s make the complex simple. Let’s ask ourselves: what is the process of collagen formation? Or what is fibrosis. Fibrosis is the predominance of collagen synthesis over its breakdown.

Collagen synthesis and conversion requires lysyl oxidase activity. Then metalloproteinase comes into play. Metalloproteinase inhibitors will reduce the action of the latter metalloproteinases. Collagen degradation occurs.

What we see (fibroblast) should not be confused. It must be understood that this is not just the predominance of collagen synthesis over its breakdown.This is also the process of collagen structuring. Only structured collagen plays a role in the development of fibrosis, and not just collagen bundles that will be scattered throughout the myocardium.


We are well aware of the different types of fibrosis, which indicate which pathway: the pathway of apoptosis or necrosis, the tissue will go. Normal tissue consists of cardiomyocytes that connect end to end.

If myocardial infarction suddenly occurs and reparative fibrosis is formed at the site of the scar, then normal cells begin to alternate with cells – areas of connective tissue.Such reparative fibrosis occurs at the site of degenerative changes. Here arthrophy and tissue dystrophy underlies this type of fibrosis.

Reactive fibrosis is what we see more often. These are all hypertensive patients (many, in any case) with a long history of arterial hypertension (AH), with poorly treated AH. Reactive fibrosis. This is where the extracellular matrix increases. Collagen bundles become thicker.

Vladimir Leonidovich spoke today about arrhythmias.It is my deep conviction that, apparently, fibrosis processes are to blame for arrhythmias (especially in supraventricular arrhythmias). In particular, it may be in the atria.

We will have 20 minutes of discussion. I think that everyone will be able to speak about this.

In many experimental studies, it has been proven that fibrosis can serve as the basis for the development of tachyarrhythmias. The most arrhythmogenic zone is the zone of the mouth of the pulmonary veins. They try to limit this zone during minor surgical interventions for rhythm disturbances.

(Slide Show).

In tachyarrhythmias, the sections take on the following shape. White are areas of fibrosis. The more fibrosis, the more preparedness of such an atrium will be for such arrhythmias.


We see disorganized bundles of myocardial sleeves here. They very densely envelop the mouth of the pulmonary veins. Accordingly, there are even works that suggest that the manifestations of fibrosis and its prevalence and localization may have a prognostic value for the choice of tactics for managing a patient with arrhythmia.

What affects fibrosis. What is beneficial for us, on the contrary, is to stimulate in order to prevent the development of fibrosis. We are interested in stimulants and inhibitors of fibrogenesis.

Angiotensin-2 belongs to the stimulants of fibrogenesis. There are intimate connections between angiotensin-2 and TGF beta. These connections are not fully disclosed. Today we will try to talk about them again.

Other growth factors. The second character we know very well is aldosterone. The more angiotensin-2 and aldosterone in the plasma or tissue system of our patient, the greater his ability to have fibrosis of the heart and (as I will show later) the liver.

Endothelin, catecholamines, adhesion molecules, galectin-3. Much work is now underway on the role and specificity of galectin-3, which increases during fibrosis. On the other hand, an increase in the synthesis of nitric oxide, an increase and activity of natriuretic peptides, bradykinin, prostaglandins leads to the fact that fibrosis in such patients (if the activity of these agents is high) will occur to a lesser extent.

Hormones well known to us (growth hormone, thyroxin, angiotensin-2 and aldosterone).If we compare their influence on several stages in the development of fibrosis (on collagen synthesis, on collagen degradation and collagen accumulation), note that growth hormones and thyroxine affect collagen synthesis and degradation. In these practically equally directed processes, conditions are not created for the accumulation of collagen and the accumulation of connective tissue.

On the contrary, the influence of angiotensin-2 and aldosterone predominates on collagen synthesis. Angiotensin also reduces collagen degradation, which has a very pronounced effect on collagen accumulation.Aldosterone mainly acts on collagen synthesis without affecting collagen degradation. Accordingly, accumulation also occurs, but to a much lesser extent.


(Slide Show).

A well-known diagram was published in 2008. Cardiomyocytes and fibroblasts. The muscle fiber contains cardiomyocytes and fibroblasts. Cardiomyocytes are shown in pink. Fibroblasts are depicted as ugly shapes in blue with a nucleus.

In response to mechanical stretching (for example, an increase in pressure in the left ventricle due to the fact that the systemic arterial pressure (BP) rises or for some other reason), the pressure inside the ventricle rises.According to the pressure gradient, there will be an increase in the system, for example, the left atrium. This results in mechanical stretching, which stimulates TGF beta activity.

At the same time, angiotensin-2, influencing the same mechanisms and the mechanisms that occur in fibroblasts, also activate the activity of TGF beta. All this leads to the fact that the organization of collagen and other extracellular matrix proteins increases and fibrosis occurs.

What can act on fibrosis.Something that can block the renin-angiotensin-aldosterone system. There have been many isromental models that have shown that angiotensin-converting enzyme inhibitors lead to significant reductions in fibrosis.

Today I will focus more on “Lisinopril”, since I also brought liver fibrosis into this fibrosis.

If we talk about liver fibrosis, the mechanism was similar. Again, we see in the arena TGF beta, which will be activated by angiotensin-2.You have the right to ask me: where will angiotensin-2 in the liver come from? The liver tissue (like any tissue) is supplied with blood vessels. There are many vessels. It is from the processes of vascular changes that the processes of fibrogenesis in the liver begin to occur. I will show this a little later.

There are certain parallels in the development of fibrosis of the liver and heart. These parallels lie in the same clinical predictors of the development of fibrosis and cirrhosis of the liver and cirrhosis and fibrosis of the heart.

First, it’s age. Secondly, it is an increased body mass index.Thirdly, these are comarbid conditions such as, for example, insulin resistance and diabetes mellitus. Today we also talked about how angiotensin-2 affects insulin resistance. This is a change in the level of transaminases and an increase in the level of triglycerides.


In the heart, reactive fibrosis is observed in hypertension and abdominal obesity. Epicardial fat, which is visceral fat and a springboard for adipokine secretion and faster myocardial fibrosis, which is also initially associated with impaired diastole.This means that with fibroblast formation, which increases in such patients.

Thus, we can say with a certain degree of certainty that epicardial fat is a new marker of cardiovascular disease (CVD). It correlates with both visceral fat and subclinical atherosclerosis, with the outcome of acute coronary syndrome (ACS) and, finally, with the diagnosis of metabolic syndrome.

A few more words about liver and heart fibrosis. Commonality of pathophysiology.We must focus on a very interesting agent, galectin-3. Now there are many studies that show that galectin-3 is increased in liver fibrosis.

Personal attention is paid to oral caspase inhibitor and apoptosis inhibitor. These studies are still ongoing.

I promised to prove that the liver and blood vessels are not mutually exclusive things. The liver is permeated with blood vessels. It is with the calillarization of the sinusoid that the processes of fibrous formation begin. If normally the basement membrane is a membrane with pronounced Disse spaces (that is, fenestrations are detected between the sinusoids), then with mechanical damage the sinusoids lose fenestrations.The exchange with the capillary, with the blood flow changes. This is how fibrosis is formed.

Otherwise, ACE inhibitors have something to work with in the liver of such a patient.

The last component is vascular fibrosis. Vascular fibrosis is a process that is required in an elderly person. It increases with age. This is the main reason for the increase and stiffness in hypertension. You can draw a logical connection that a stable increase in blood pressure leads to the activation of fibroblasts, to a decrease in the activity of metalloproteinases.


The only thing that is not clear is what initiates the process of fibrosis.Perhaps the role of immune cells or immune cells that infiltrate the vascular wall plays this unpleasant role.

Perivascular fibrosis associated with diabetes mellitus. There are a lot of such patients.

Dear colleagues, remember your yesterday’s working day, today’s working day. You will probably remember diabetic patients who come with chest pain. On coronary angiography, they have clear coronary arteries. What is the matter here.

The fact is that this anginal status may be the result of extravasal compression of the coronary arteries, because glucose promotes the formation of collagen crosslinks.In patients with diabetes mellitus, perivascular fibrosis is very pronounced.

The effects of blockers inhibiting the renin-angiotensin-aldosterone system are pathogenetically substantiated for the prevention of fibrosis, both in the heart and in the liver. They act on TGF beta, the activity of some metalloproteinases. For example, type I metalloproteinases.

All this confirms the term: what is good for the heart is good for the liver. There is no longer any doubt about this. I will dwell on this briefly.

Non-alcoholic fatty liver disease. It would seem that it is a completely safe, harmless state. But not so harmless. These patients have the potential to die from CVD many times more often than without such suffering.

Increased risk of carotid atherosclerosis. The kinetics of the thrombus changes. Non-alcoholic fatty liver disease is a predictor of CVD, regardless of other risk factors. The ways of applying and correcting this seemingly harmless condition are changing.

If we are talking about fibrosis, then ACE inhibitors, statins, blockers of renin-angiotensin receptors must be used in such a patient.


What to choose. What to appoint obese hypertensive from the position that there is fibrosis in the heart and in the liver. Probably, drugs that do not require additional metabolization in the liver, which circulate in the plasma link of the renin-angiotensin-aldosterone system, come to the fore here.

From this point of view, Lisinopril has proved to be very good. We use the drug “Diroton” in our practice. When you ask doctors if there is an original drug “Lisinopril”, they all answer that it is “Diroton”.He has proven himself so well. Its metabolic neutrality and lack of transformation in the liver are captivating.

Very often, a patient with fibrosis (this is a high-risk patient) needs combination therapy. We’ve talked a lot today about this combination (extremely interesting, metabolically neutral). Calcium antagonists and what blocks the renin-angiotensin-aldosterone system.

There is a combination “Equator”, which consists of “Lisinopril” and beloved by all “Amlodipine” (“Amlodipine”), which we also use in patients.

In this regard, I would like to recall and refer to the results of the research that we conducted earlier. We tried to see what Lisinopril would do in a patient with concomitant liver disease.

We took patients with hypertension (mild and moderate). There were 25 patients. We looked after them for 12 weeks. The dose of “Lisinopril” was titrated from 5 mg to 20 mg per day. It turned out that during a routine examination …

There were 4 visits, at each visit the patient’s clinical status was examined in detail: electrocardiogram, echocardiogram, dose titration and blood pressure monitoring were performed.The patients were assigned in this way. These were mainly patients with moderate hypertension. The experience was not very great. The seniority prevailed from one to five years.

According to concomitant liver disease, the patients were distributed as follows: mainly patients who had alcoholic liver damage were included. At the third visit, a significant decrease in blood pressure was already noted against the background of “Lisinopril”. All this was accompanied by a decrease in the level of transaminases, glutamine transpeptidase and alkaline phosphatase.

All patients showed excellent tolerance. One patient ended up taking Lisinopril in this study due to a headache.


So what can we say about liver and heart fibrosis. First, this problem is urgent. Second, these two processes in two completely different organs (vessels must be added here) have a lot of similar indicators. This makes it possible and necessary to use drugs that have proven themselves well in terms of effects on the cardiovascular system and on the liver.