Thoracoamniotic shunting for fetal pleural effusions with hydrops

OBJECTIVE

The purpose of this study was to evaluate perinatal outcome after thoracoamniotic shunting for fetal pleural effusions with hydrops.

STUDY DESIGN

This was a retrospective study.

RESULTS

Shunting was performed immediately after diagnosis and was successful in all 54 of the cases that were attempted. There were 7 pregnancy terminations, 9 in utero deaths, and 38 live births, of which 7 children died in the neonatal period and 31 children survived. Among the liveborn infants, 27 infants were delivered preterm (71%), of whom 7 infants (15%) had preterm premature rupture of membranes and 4 infants (8.5%) had chorioamnionitis. Perinatal death (23/54 infants; 43%) was related to underlying anomalies (7 cases), pulmonary hypoplasia (5 cases), chorioamnionitis (2 cases), or treatment failure for unknown reasons (9 cases). All 31 survivors had chylothorax; for 28 of the survivors, the chylothorax was primary, and for 3 survivors, the chylothorax was the result of right congenital diaphragmatic hernia, pulmonary sequestration, or Noonan syndrome.

CONCLUSION

After the shunting, pleural effusion with hydrops has a 57% survival rate; premature delivery is the leading source of morbidity.

Radionuclide evaluation of pleural-peritoneal shunt before pleurodesis

OBJECTIVES

Talc pleurodesis can be offered to patients with hepatic hydrothorax. The authors wanted to determine their patient's eligibility for talc pleurodesis by excluding a pleural-peritoneal shunt.

MATERIALS AND METHODS

The authors measured the size of the talc particles and matched them with the radionuclide particle size. After injecting radiopharmaceutical into the pleura, the authors imaged the abdomen for possible migration.

RESULTS

In their patient, there was no migration of radionuclide from the thorax into the abdomen.

CONCLUSION

Injecting radionuclide into the thoracic cavity and then imaging for an extended period of time is one way to determine whether the patient has a pleural-peritoneal shunt.

Large diaphragmatic defect as the cause of hydrothorax in a cirrhotic patient: demonstration with peritoneal scintigraphy and magnetic resonance imaging

A 52-year-old man with history of post-hepatitic cirrhosis presented with ascitis and respiratory distress. Chest X-ray on admission showed a large right hydrothorax. Thoracentesis yielded a large volume of a clear transudate fluid. Peritoneal scintigraphy showed rapid migration of radiotracer into the right pleural cavity, confirming the abdominal origin of the pleural fluid and suspecting a large diaphragmatic defect. MR imaging study using ultrafast sequences confirmed the large diaphragmatic defect.

Reduction of Pleural Effusion by OK-432 in a Fetus Complicated with Congenital Hydrothorax

A 29-year-old, primiparous woman was referred to our hospital at 21 weeks of gestation because of right pleural effusion in the fetus shown by routine ultrasonographic examination. Cytology revealed abundant lymphocytes, suggesting chylothorax. We removed the pleural effusion and injected OK-432 into the chest cavity at 24 and 25 weeks of gestation. Pleural effusion declined and an adhesion between the lung surface and the pleural membrane seemed to form. At 33 weeks of gestation, a female infant was born by cesarean section (1,090 g and Apgar score 6/8). Although she demonstrated slight retraction and tachypnea, management could be achieved by administration of oxygen alone without mechanical ventilation. Later, the baby was diagnosed as suffering from the Cornelia de Lange syndrome with characteristic features. OK-432 injections could thus prevent complications of chylothorax and hypoplastic lungs, without injury to either the baby or the mother.

Isotopic exploration of hepatic hydrothorax: ten cases

OBJECTIVE

The aim of this retrospective study was to evaluate the performance of peritoneal scintigraphy for the diagnosis of peritoneopleural communication in patients with cirrhosis and to discuss its role in therapeutic management.

PATIENTS AND METHODS

Ten patients with cirrhosis and pleural effusion were included in this study. Cirrhosis was due to viral hepatitis in eight patients, auto-immune disease in one patient and of unknown origin in one. The pleural effusion was right-sided in nine patients and bilateral in one. 99m-technetium sulfur colloid peritoneal scintigraphy was performed in all patients.

RESULTS

Scintigraphy revealed peritoneopleural communication in nine patients. In four patients, radioactivity appeared in the pleural cavity within a few minutes after injection of the radiotracer. In three of them, a large diaphragmatic defect was demonstrated by ultrasonography, magnetic resonance imaging or thoracoscopy. Complete response to medical treatment was observed in four patients. Scintigraphy revealed rapid radioactivity migration in four patients; diuretic treatment led to resolution of the hydrothorax in one of them. Three patients whose hydrothorax was refractory to medical treatment were treated by pleurodesis with talc. Resolution of the hydrothorax was achieved in one of them.

CONCLUSION

Peritoneal scintigraphy is a simple non-invasive method enabling confirmation of peritoneopleural communication in cirrhotic patients. The importance of the diaphragmatic defect can also be evaluated, providing a significant contribution to therapeutic decision-making.

[Do position control methods for central venous catheters prevent complications? Hydromediastinum caused by an initially correctly placed tri-lumen subclavian catheter by using intra-atrial ECG recording--a case report]

Central venous catheters (CVCs) can be associated with various complications which arise during insertion, with the catheter in situ or upon its removal. Here we report a case of secondary CVC malposition that occurred despite checks of CVC position by different methods. A subclavian triple-lumen catheter was retracted until intra-atrial ECG indicated reversal to a normal P-wave. Blood was successfully aspirated through all three lumens, and the catheter was fixed at 11 centimeters intracorporal length and used intraoperatively. A postoperative chest X-ray demonstrated an intravenous CVC length of only a few centimeters, which was accepted because of the inconspicuous results of previous monitoring. Fifteen hours after CVC insertion, the patient developed a swelling in the subclavian and right neck region, a pronounced hydromediastinum and small bilateral pleural effusions caused by paravenous infusion through the most proximal CVC lumen. After instantaneous removal of the catheter, the patient recovered without further complications. This case demonstrates that even carefully-fixed multi-lumen catheters can partially dislocate due to a patient's movements or changes of position. Therefore, repeated aspiration of blood from the most proximal lumen should be performed to detect secondary CVC malposition. Moreover, repeated chest radiographs are useful in verifying a correct CVC position and detecting late complications. In summary, CVC complications can occur with delay, are potentially life-threatening and may necessitate repeated checks of catheter position. This case report discusses different approaches to detecting malposition and reviews rare CVC complications.

Successful early in utero management of fetal hydrothorax in a twin pregnancy

We present a case of dichorionic diamniotic twin pregnancy in which one of the fetuses was found to have a major pleural effusion at 15 weeks of gestation. A single-needle pleural fluid aspiration was performed at 15 and 16 weeks, but the fluid reaccumulated quickly after each procedure and at 16 weeks, the fetus was found to become progressively hydropic. A shunt was then successfully inserted at 17 weeks, which is the earliest gestation reported so far in the literature for such a procedure to treat isolated hydrothorax. Because we felt that the fetus would be too small for a classical double-pigtail pleuroamniotic shunt, we used a multilength double-pigtail bladder stent (Harrison drain; Cook; Spencer; Indiana; USA) via a 13-gauge echo tip trocar. This shunt could be used for both singleton and twin pregnancies presenting with fetal pleural effusion from as early as 16 to 17 weeks to prevent the development of fetal hydrops and polyhydramnios and subsequent premature delivery. Treatment at this stage of gestation would also minimize the risk of lung hypoplasia, which is the main clinical issue when shunts are inserted after 24 weeks.

Echocardiographic evaluation of fetal hydrothorax: the effusion ratio as a diagnostic tool

OBJECTIVE

Fetal hydrothorax may lead to hydrops and is associated with mortality as high as 50%. The objective of this study was to define the pathophysiology of fetal hydrothorax and its relation to hydrops.

METHODS

Measurements from echocardiograms of 33 fetuses diagnosed with hydrothorax were made, and included diameters of the thorax, heart, inferior vena cava, right ventricle (RV), left ventricle (LV) and aortic and pulmonary valves. Doppler-derived velocities were measured in the aorta and pulmonary artery just above the aortic and pulmonary valves. The ratio of the area of the effusion to the area of the thorax (effusion ratio) was calculated. Variables were converted into Z-scores from regression equations based on normal data. Features of fetuses with and without hydrops were compared.

RESULTS

Higher effusion ratios were noted in hydropic versus non-hydropic fetuses. Compared to a normal population, study subjects had smaller dimensions of LV, RV and aortic and pulmonary valves. They also had higher pulmonary artery peak velocities. The comparison between non-hydropic and hydropic fetuses revealed lower values for LV and pulmonary valve dimensions, and peak aortic velocity in hydropic fetuses. The severity of LV compression correlated significantly with effusion ratio.

CONCLUSION

Fetal hydrothorax is accompanied by compression of the cardiac structures, resulting in altered cardiac hemodynamics. Echocardiographic assessment, including the measurement of effusion ratio, may be a useful tool in guiding fetal therapy.

Successful treatment of primary fetal hydrothorax with a double basket catheter

Fetal pleural effusions can sometimes be detected before birth with ultrasonography. Intervention may be warranted when there is a condition that results in hydroplastic lung and/or fetal hydrops. A 22-week-old fetus with a severe pleural effusion and hydrops was successfully treated by long-term pleural drainage with a double basket catheter from 22 to 39 weeks of gestation.

Systemic amyloidosis involving the diaphragm and acute massive hydrothorax during peritoneal dialysis

Hydrothorax secondary to trans-diaphragmatic fluid leakage through a peritoneo-pleural communication is an occasional, potentially serious complication of peritoneal dialysis. The etiology of this condition is not clear, being thought to be due either to congenital or acquired diaphragmatic fenestrations or acquired scarcity of muscle fibers in the tendinous part of the diaphragm which are compounded by increased intra-abdominal pressure during the dwell period of peritoneal dialysis. We report a 54-year-old woman who developed irreversible acute renal failure from adjuvant chemotherapy for ovarian cancer previously resected surgically. Three days after the onset of continuous ambulatory peritoneal dialysis, she developed acute respiratory distress associated with a massive right hydrothorax secondary to a peritoneo-pleural communication demonstrated by scintigraphy. At autopsy 2 weeks later, systemic amyloidosis was surprisingly found and histologic examination of the right hemidiaphragm showed the presence of amyloid, among sparse muscle fibers. This is the first case report of a distinct pathological process, i.e. amyloidosis, involving the diaphragm associated with a peritoneo-pleural communication causing massive hydrothorax at the onset of peritoneal dialysis.

CSF hydrothorax--VP shunt complication without displacement of a peritoneal catheter

Cerebrospinal fluid hydrothorax is reported as a rare complication of ventriculoperitoneal (VP) shunt. A 16-month-old boy known to have congenital hydrocephalus and a Dandy-Walker cyst presented with serious respiratory distress. Examination revealed right pleural effusion and congested throat. Thoracocentesis with drainage of the pleural cavity for 10 days failed to free the patient from pleural effusion. Following an intraperitoneal injection of Omnipaque a chest X-ray was done, and samples of pleural fluid taken before and after the injection were compared on X-ray, revealing the presence of contrast in the postinjection pleural effusion. Changing the VP shunt for a ventriculo-atrial shunt resulted in immediate (within 1 day) complete disappearance of the pleural effusion and of the patient's chest symptoms. Probable causes of this rare complication are discussed, and attention is drawn to the possibility of its appearance and early recognition. Intraperitoneal injection of contrast material followed by X-ray examination of fluid in the chest is a simple, safe, and reliable method of diagnosis when it is suspected.

[Delayed hydrothorax induced by a pericutaneous central venous catheter; report of a case]

We report herein a case of 53-year-old woman who suffered a hydrothorax induced by a central venous catheter which had been placed to facilitate total parenteral nutrition. The central venous catheter was inserted into the superior vena cava through the right subclavian vein. Chest X-ray film after insertion revealed proper position of the tip. She suddenly developed dyspnea and tachycardia due to right-sided hydrothorax 21 days after the insertion of the catheter. Chest X-ray showed massive pleural effusion in the right thorax, and the catheter tip inadvertently turned upward. The continuous mechanical force of the catheter tip against the SVC wall was considered to be the cause of this life-threatening delayed hydrothorax.

[A "sweet" hydrothorax]

BACKGROUND

Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD).

CASE REPORT

A 68-year-old man on CAPD consulted for rapidly progressive dyspnea. An elevated glucose level in the pleural puncture fluid and Tc-99m peritoneoscitigraphy demonstrated pleuroperitoneal communication via Larrey's cleft led to the diagnosis of "sweet" hydrothorax. Resolution was achieved with pleurocentesis and interruption of CAPD.

DISCUSSION

Although rare, hydrothorax should be retained as a possible diagnosis in patients who develop dyspnea within the first 2 months after institution of CAPD. Chemistry of the pleural fluid and Tc-99m scintigraphy provide the diagnosis. Conservative treatment by pleural puncture or pleurodesis is indicated. In most cases, CAPD can be resumed without recurrence.

Reliability of prenatal sonographic lung biometry in the diagnosis of pulmonary hypoplasia

OBJECTIVE

The purpose of the present study was to assess the value of biometric lung measurements for the diagnosis of severe fetal pulmonary hypoplasia by investigating whether a significant correlation between two-dimensional lung biometry measurements and autopsy findings could be established.

METHODS

This was a prospective study carried out between 1995 and 1997. Nomograms for normal fetuses of the anterior-posterior and transverse inner thoracic diameters, which describe the growth and shape of the lung, were used as a basis for diagnosis of pulmonary hypoplasia in fetuses at high risk of developing the condition (the fetuses had bilateral renal agenesis or multicystic kidneys; chronic PROM <25 gestational weeks or hydrothorax). Pregnancy was terminated by abortion or intrauterine death in 29/43 high-risk fetuses and autopsies were performed. Only the 29 fetuses for which there were autopsy findings were included in the study.

RESULTS

The best plane for diagnosing pulmonary hypoplasia was the four-chamber view. The diagnostic accuracy for this view as expressed by the sensitivity was 57% for the anterior-posterior diameter and 44% for the transverse diameter; as expressed by the specificity it was 42% for the anterior-posterior diameter and 50% for the transverse diameter. The results for the four-chamber view for the various high-risk conditions were as follows: for fetuses with chronic PROM we obtained sensitivities of 75% and 50% (anterior-posterior and transverse dimensions, respectively) and specificities of 80% and 60% (anterior-posterior and transverse dimensions, respectively). The sensitivities of lung biometry in fetuses with hydrothorax were 1% and 80% for the two diameters, but there was a low specificity. In fetuses with bilateral renal agenesis or multicystic kidneys we obtained sensitivities of 36% and 30% (anterior-posterior and transverse dimensions, respectively) and a specificity of 50% (anterior-posterior dimension).

CONCLUSIONS

The present results show that two-dimensional lung biometry is not a suitable method for antenatal detection of pulmonary hypoplasia. However, in individual cases with high risk for pulmonary hypoplasia, lung biometry might prove to be an additional diagnostic parameter.

Successful treatment of primary fetal hydrothorax with hydrops by pleuroamniotic shunt placement

We treated a case of primary fetal hydrothorax with hydrops. A pleuroamniotic shunt catheter inserted at 30 weeks accomplished resolution of hydrops and was maintained until cesarean delivery at 34 weeks with no need for further prenatal intervention. At age 9 months, the infant showed no effusion or pulmonary compromise.

Noncardiac thoracic anomalies

FHT is a rare diagnosis that may be an isolated finding or associated with multiple fetal anomalies, congenital infection or isoimmunization. The natural history of the lesion is variable. The effusion may regress spontaneously; remain stable in size; or progress to involve both sides of the chest and produce fetal hydrops, pulmonary hypoplasia, and fetal or neonatal demise. Hydrops is associated with significant fetal mortality. Antenatal decompression of the hydrothorax with pleuroamniotic shunting or thoracocentesis may result in a significant decrease in perinatal morbidity and mortality. Persistent hydrothorax can usually be treated with noninvasive measures in the newborn period.

A new approach to prenatal treatment of extralobar pulmonary sequestration

Fetal hydrothorax and hydrops is a frequent complication of extralobar pulmonary sequestration which is associated with a high perinatal mortality and severe respiratory insufficiency in the newborn. In a 27-week-old fetus with this condition, injection of 1 ml of pure alcohol and pleuro-amniotic shunting achieved resolution of hydrops. The pregnancy progressed to term and a healthy neonate was delivered who did not require postnatal surgery.

Severe unilateral hydrothorax as the only manifestation of the ovarian hyperstimulation syndrome

BACKGROUND

Unilateral hydrothorax is rarely the sole manifestation of the ovarian hyperstimulation syndrome (OHSS) and is suggestive of the severity of the disease.

CASE

A 35-year-old woman presented with mild dyspnea 2 weeks after ovarian stimulation with hMG and hCG and IVF-ET. Chest X-ray revealed a large pleural effusion on the right side. Three consecutive thoracocenteses were needed to drain a total of 6,800 cm(3) of fluid. Following drainage, the respiratory symptoms disappeared. An uneventful pregnancy is in progress.

CONCLUSIONS

Thoracocentesis is safe and efficient for the treatment of hydrothorax and may be repeated as often as necessary. Clinicians should be aware of the possibility of unilateral hydrothorax as the sole symptom of OHSS.

Successful treatment of hepatic hydrothorax with octreotide

Hepatic hydrothorax is a rare complication of cirrhosis. Controlling ascites formation is the goal of therapy. We report the case of an adult patient presenting with alcoholic cirrhosis who developed first a symptomatic hydrothorax, refractory to diuretics and fluid and sodium restriction, and then an hepatorenal syndrome. Treatment consisted of chest tube insertion and 5 days' intravenous infusion of octreotide. Complete clinical and biological data were reviewed. Octreotide administration resulted in an increased urinary outflow and sodium output, concomitant with improved renal function. The patient has been free of symptoms after discharge from hospital for a follow-up period of 5 months. This observation raises interesting issues regarding the possible utility of splanchnic vasoconstrictors, reducing portal hypertension, in the treatment of refractory hepatic hydrothorax.

[Bilateral hydrothorax with hydromediastinum after accidental catheter dislocation]

We report a complication during the insertion time of a central venous catheter in a patient with intracerebral bleeding. This complication was caused by an inadvertent dislocation of a subclavian catheter. Hydromediastinum and bilateral hydrothorax developed. There was a clear diagnosis followed by removal of the central venous catheter after radiological investigations could explain the cause of the complication and the clinical symptoms. In the course of events mediastinitis was diagnosed. The clinical condition improved under antibiotic therapy. The patient could be transferred to another clinical unit for endovascular treatment of an arterio-venous cerebral malformation.

A successful surgical repair of the hepatic hydrothorax using pneumoperitoneum: report of a case

A successful surgical repair of a right hepatic hydrothorax in the absence of ascites is reported. A technetium-99m scintigram that was injected intraperitoneally provided evidence of a one-way flow of fluid from the peritoneal to pleural cavity. To identify any possible minute defects in the diaphragm, carbon dioxide was insufflated into the peritoneal cavity during the operation. We performed a direct suture of the defect observed on the diaphragm. The pleural effusion subsequently vanished after the operation.

Refractory hepatic hydrothorax treated with transjugular intrahepatic portosystemic shunt

A 66-year-old cirrhotic woman was referred to our hospital for evaluation of refractory pleural effusion and dyspnea. Massive right sided-pleural effusion but no ascites was detected. She had been treated with diuretics and albumin, repeated thoracenteses, and pleural drainage with an intercostal catheter, all of which had failed to relieve her symptoms. The diagnosis of hepatic hydrothorax without ascites was made by injection of technetium-99m-sulfur colloid into the peritoneal cavity. A transjugular intrahepatic portosystemic shunt was placed and successfully reduced the pleural effusion, resulting in complete relief of her symptoms. The patient has been free of symptoms for 18 months after the procedure.

[Hydrothorax caused by intravasal triple-lumen subclavian catheter]

A case in which a patient developed right-sided hydrothorax due to extravasal infusion of total parenteral nutrition (TPN) is reported. The catheter was a triluminal catheter and the tip was shown to be correctly placed in the superior vene cava by x-ray after injection of radio-opaque contrast. The most proximal injection port located 4.5 cm from the tip of the catheter was documented to be sited in the superior mediastinum outside the vena cava. The infusion was given through the proximal port of the catheter. The mechanisms underlying this complication are discussed. The case emphazises the need to control the position of all infusion ports regularly when using central venous catheters with more than one lumen.

Hepatic hydrothorax in the absence of ascites

Pleural effusion due to hepatic cirrhosis and ascites is well known, but hepatic hydrothorax in the absence of ascites is a rare complication. We report a case of liver cirrhosis due to hepatitis C virus with a large and recurring pleural effusion that had an apparent abdominal source in the absence of ascites. We review the characteristics and treatment for hepatic hydrothorax in the absence of ascites.

The use of the diagnostic radionuclide ascites scan to facilitate treatment decisions for hepatic hydrothorax

A 44-year-old man had an intractable right-sided pleural effusion due to cirrhosis, despite the absence of abdominal ascites. Instillation of Tc-99m macroaggregated serum albumin under CT guidance into the peritoneal space demonstrated transdiaphragmatic communication. This finding indicated the necessity for decompressing the portal system to treat the hydrothorax. The diagnostic radionuclide ascites scan may play an important role in the treatment approach to such patients.

The role of midtrimester targeted fetal organ screening combined with the "triple test" and maternal age in the diagnosis of trisomy 21: a retrospective study

OBJECTIVE

Our purpose was to evaluate the role of fetal ultrasonography in prenatal detection of trisomy 21.

STUDY DESIGN

A retrospective study was performed on all cases of trisomy 21 diagnosed prenatally or postnatally between January 1990 and December 1993 in the Jerusalem metropolitan area. Our program of prenatal detection of trisomy 21 is a three-tiered, chronologically progressive screening that includes maternal age, biochemical serum markers, and targeted fetal organ survey. Sixty-seven thousand ninety-two babies were born during the study period; 17,084 maternal biochemistry analyses (triple test) were performed; and 6315 fetuses were karyotyped.

RESULTS

One hundred eight cases of trisomy 21 were diagnosed prenatally and postnatally. The overall rate of detection of trisomy 21 was 92.2% when our recommendations were followed. Among those cases diagnosed prenatally, 66.6% of trisomy 21 cases had been referred for fetal karyotyping because of maternal age > or = 35 years, 18.5% because of abnormal triple test results, and 11.1% because of fetal ultrasonographic findings associated with trisomy 21. Among women < 35 years old, 80% of trisomy 21 cases were detected prenatally. Of these, 50% had been referred for karyotyping because of triple test results and 30% because of abnormal ultrasonographic findings.

CONCLUSION

Midtrimester ultrasonographic targeted fetal organ screening plays a critical role in prenatal diagnosis of trisomy 21 among women under the age of 35 years.

Tension hydrothorax due to ventriculopleural shunting

Tension hydrothorax is rare, with few cases reported in the literature dating back to the late 1960s. We report a case of tension hydrothorax in a patient with a ventriculopleural shunt who improved dramatically after thoracentesis. The discussion includes a brief review of ventriculopleural shunts and pleural physiology.

Peritoneoscintigraphy using Tc-99m MAA for diagnosis of diaphragmatic disruption in a peritoneal dialysis patient

Massive hydrothorax is an infrequent but well-recognized complication of continuous ambulatory peritoneal dialysis (CAPD), and is often regarded as a contraindication to its use. We describe here a patient with massive hydrothorax that appeared during CAPD. Peritoneoscintigraphy was performed to demonstrate the clinical suspicion of a pleuroperitoneal communication and the pleurodesis using tetracycline was commenced and this allowed the successful continuance of CAPD.

Cardiotocographic and Doppler velocimetric patterns, pre- and post-thoracentesis, in a case of fetal hydrothorax

Fetal hydrothorax is associated with elevated perinatal mortality. Management of this condition is controversial given that in utero spontaneous resolution has been described. A case of fetal hydrothorax associated with an extralobar lung sequestration that showed pathologic cardiotocographic patterns and abnormal Doppler velocimetry indices in several fetal vascular beds in reported. All pathologic patterns improved after fetal thoracentesis. It can be concluded that monitoring fetal well-being by means of cardiotocography and Doppler velocimetry may help in timing thoracentesis in cases of fetal hydrothorax.

[Refractory hydrothorax in primary biliary cirrhosis: successful treatment with transjugular intrahepatic portosystemic stent shunt]

HISTORY AND CLINICAL FINDINGS

A 55-year-old woman with known primary biliary cirrhosis (PBC) was hospitalized because of increasing dyspnoea. A year before she had for the first time experienced a right-sided pleural effusion which had to be drained every 4 weeks. Physical examination revealed dullness on percussion and greatly decreased breath sounds on auscultation over the entire right thorax. In addition there were signs of moderate ascites and leg oedema.

INVESTIGATIONS

Chest radiograph showed a homogeneous shadowing of the right thorax without mediastinal shift. Diagnostic thoracocentesis produced a serous effusion, a transudate on chemical analysis, comparable to the composition of the ascitic fluid. Bacteriological and cytological tests on both fluids were unremarkable.

TREATMENT AND COURSE

The right pleural effusion was presumed to be due to a hydrothorax from the ascites caused by portal hypertension associated with the PBC. Despite continuous diuretic treatment and thoracocentesis with albumin substitution every 3 days there was no improvement and implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) was performed. This effectively lowered portal pressure and markedly improved the patient's condition so that further thoracocentesis were no longer necessary. 3 weeks after TIPSS implantation she was discharged in good condition. Radiography 3 weeks later demonstrated continued reduction in the hydrothorax.

CONCLUSION

Hydrothorax is a rare complication of liver cirrhosis. TIPSS implantation can provide lasting resolution and corresponding clinical improvement of a hydrothorax, especially in those conditions which are refractory to diuretic treatment and thoracocentesis.