Treatment of refractory, nonmalignant hydrothorax with a pleurovenous shunt

We present a case of long-term successful application of pleurovenous shunting for the management of pleural effusion. Intractable symptomatic hydrothorax developed as a result of transdiaphragmatic migration of hepatic ascites. After failure of traditional treatment by mechanical pleurodesis, a pleurovenous shunt was inserted. After 1 year of follow-up, the effusion is well controlled, and the shunt remains patent.

Cerebrospinal fluid hydrothorax caused by transdiaphragmatic migration of a ventriculoperitoneal catheter through the foramen of Bochdalek

Cerebrospinal fluid hydrothorax is a very rare complication following ventriculoperitoneal shunting. The authors report a case of a 3-year-old girl who developed cerebrospinal fluid hydrothorax (caused by migration of the intra-abdominal catheter through the right vertebrocostal trigone of Bochdalek, the one most unlikely to be congenitally patent) and respiratory distress. The patient was successfully treated with thoracocentesis and shunt revision.

[Unexpected hydrothorax occurring after a long gynecological laparoscopic surgery--a case report]

We experienced a case of the hydrothorax occurring after a long gynecologic laparoscopical surgery. The patient was a 36-year-old woman, weighing 51 kg and 151 cm in height. She had received a gynecological laparoscopy with no complication 5 years before. She showed no abnormalities in the preoperative examinations. The operative course was uneventful. Upon completion of the surgery, we examined the chest X-ray, and found the hydrothorax in the right thoracic cavity. A 16 gauge Angiocath was inserted into the 4th intercostal space, and found 770 ml of fluid containing saline solution, which had been used for irrigating around the uterus. We presumed the saline, which was withdrawn from the right thoratic space, had originated from vertebrocostal trigone in the diaphragm. Because blood gas data were improving, the tracheal tube was extubated. We emphasise that the routine chest X-ray examination is necessary after pneumoperitoneum of long duration.

Outcome of non-immune hydrops fetalis and a fetus with hydrothorax and/or ascites: with some trials of intrauterine treatment

The subject of this study was 38 cases of non-immune hydrops fetalis and 11 cases of fetal hydrothorax and/ or ascites (FH/A), a syndrome characterized by the accumulation of pleural effusion and/or ascitic fluid, without generalized skin edema, due to various etiologies, admitted to the obstetrics ward of Hokkaido University Hospital during the period between 1987 and 1994. Fetal treatment consisted of (1) intravascular transfusion or intra-abdominal transfusion for anemia, (2) frequent centesis or shunt insertion for pleural effusion and ascites, (3) reduction of cystic hygroma by puncturing and OK432 injection, and (4) intravascular or maternal injection with an anti-arrhythmic drugs to treat tachycardia. The outcome of NIHF and FH/A was assessed to be able to make a prognosis in NIHF and to compare the efficacy of fetal therapy in cases with (15 cases: 9 NIHF, 6 FH/A) and without (34 cases: 29 NIHF, 5 HF/A) intrauterine treatment. The average survival rates were 23.1% in NIHF and 54.5% in FH/A. None of fetuses with a chromosomal abnormality or cystic hygroma survived. The average GW at the time of detection of NIHF by ultrasonography was week 24.9 +/- 1.1 (mean +/- S.E., n = 38). The average GW at the time of detection of FH/A by ultrasonography was week 26.6 +/- 1.8 (n = 11). NIHF was detected significantly earlier in the IUFD and early neonatal death group (GW 22.4 +/- 1.4) than in the survivor group (GW 27.6 +/- 1.2) (p < 0.05). FH/A was also detected earlier in the IUFD/early neonatal death group than in the survivor group (GW 21.8 +/- 2.4 vs. 31.1 +/- 1.1, n = 11, p < 0.05). The survival rate in the intrauterine treatment group was higher than in the nontreatment group (treatment group: 10/15; non-treatment group: 5/34, p < 0.001). After the trial of intrauterine treatment in the 15 cases mentioned above, some efficacy was observed in 7 cases (reduction of cysts, effusion or edema, disappearance of arrhythmia).

A unilateral hydrothorax as the only manifestation of ovarian hyperstimulation syndrome: a case report

OBJECTIVE

To describe a rare case of unilateral hydrothorax occurrence after ovarian stimulation for IVF.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 39-year-old female suffering from primary infertility due to a severe male factor.

INTERVENTION(S)

Thoracocentesis with IV albumin administration for correction of a concomitant hypoalbuminemia.

MAIN OUTCOME MEASURE(S)

Laboratory values of hematologic measures and electrolytes, screening of the thoracic fluid aspirated for viral and bacterial infections, resolution of pleural effusion after the second thoracocentesis as determined by chest roentgenogram.

RESULT(S)

Treatment of this manifestation of the ovarian hyperstimulation syndrome (OHSS) by thoracocentesis with albumin perfusion.

CONCLUSION(S)

This report describes a very rare case of thoracic complication after ovarian stimulation. It demonstrates that pleural effusion may be the only manifestation of the OHSS and implies a careful management of patients with pulmonary complaints after treatment with exogenous gonadotropins.

Late development of hydrothorax induced by a central venous catheter: report of a case

We report herein the case of a 47-year-old woman who suffered a hydrothorax induced by a central venous catheter (CVC) which had been placed to facilitate total parenteral nutrition following a left sleeve pneumonectomy for lung cancer. The CVC was inserted into the superior vena cava (SVC) through the left subclavian vein after the operation; however, the tip inadvertently turned upward and came in contact with the lateral wall of the SVC. The patient suddenly developed dyspnea due to a right-sided hydrothorax 47 days after the insertion of the catheter. Indocyamine green administered through the catheter was thereafter found in the pleural fluid. The continuous mechanical force of the catheter tip against the SVC wall was thus considered to be the cause of this life-threatening delayed hydrothorax.

Peritoneopleural communication associated with cirrhotic ascites: scintigraphic demonstration

Demonstration of peritoneopleural communication in patients with cirrhotic ascites has an important impact on treatment planning. We studied 12 such patients and found presence of peritoneopleural communication in five. Two had bilateral, one right-side and two left-side, pleural effusion. Pleural fluid protein content was less than 2 g/dL in all patients.

Hepatic hydrothorax. Diagnosis and management

Twelve cases of right hepatic hydrothorax are reported. Tc-99m SC that was injected intraperitoneally and intrapleurally provided evidence of a one-way flow of fluid from the peritoneal to the pleural cavity. Eight patients, whose hydrothorax was refractory to sodium restriction, diuretics and repeated thoracenteses, were treated by endopleural tetracycline instillation. The pathogenetic role of the diaphragmatic defect and the diagnostic usefulness of radionuclide imaging are stressed.

Postnatal resolution of non-chylous primary fetal hydrothorax

We describe two cases of non-chylous primary fetal hydrothorax not associated with hydrops or associated malformations. Repeated ultrasonographic examinations, to detect development of hydrops or progression of intrapleural effusion, were used to evaluate the need for intrauterine thoracocentesis and to decide the optimal time for delivery. Both infants did well after postnatal evacuation of the intrapleural fluid. Pre- and postnatal investigation to find the pathophysiological mechanism leading to hydrothorax were negative. We conclude, in agreement with previous work, that primary fetal hydrothorax is generally associated with a favourable outcome.

[Ascites, hydrothorax and ovarian tumor: Meigs' syndrome in a patient with small ovaries and increased CA 125 level]

In a 51-year-old woman with bilateral Brenner tumours of the ovaries and with intermittent hydrothorax and ascites, Meigs' syndrome was diagnosed. The serum CA 125 level was 620 U/ml (normal: 5-35). Bilateral ovariectomy, hysterectomy and omentectomy were carried out. The ovaries were not enlarged. Postoperatively, the pleural effusion and ascites resolved and the CA 125 level decreased to 8.4 U/ml. The pathogenesis of hydrothorax probably involves passage through the diaphragm, and the CA 125 may be produced by the peritoneal lining or by the Brenner tumours.

[Acute respiratory failure as the 1st symptom of migration of a central venous catheter into the mediastinum]

Reports a case with late development of hydromediastinum and right-side hydrothorax as a result of migration of the central venous catheter into the mediastinum. Acute respiratory insufficiency was the first symptom of this complication.

Intrauterine diagnosis of hydrothorax in a fetus who had a combination chylothorax and pulmonary sequestration after delivery

Congenital hydrothorax was diagnosed prenatally by transabdominal ultrasonography. Five fetal thoracentesis procedures were performed and biochemical analyses of the fluids were done. After delivery a combination chylothorax and extralobar pulmonary sequestration was demonstrated in the infant. We believe this to be the first case report of this combination investigated prenatally. We suggest that investigators perform biochemical analyses on fetal pleural fluid removed in cases with a single diagnosis. Perhaps by comparing those data with the data reported here, a biochemical marker can be identified that will be useful in distinguishing these two conditions in utero.

Resolution of unilateral fetal hydrothorax with associated non-immune hydrops after intrauterine thoracentesis

Congenital hydrothorax has been successfully managed in utero by two different treatment modalities: thoracentesis and pleuroamniotic shunting. Unfortunately, there is a paucity of data as to which method is better for the management of this problem. This case report supports the use of thoracentesis as the initial procedure for primary fetal hydrothorax. We report a pregnancy complicated by primary fetal hydrothorax with non-immune hydrops that completely resolved after two thoracenteses in the early third trimester. Complete resolution was maintained throughout pregnancy without the need for further antenatal or neonatal intervention, i.e. further thoracentesis, pleuroamniotic shunt placement, intubation, or chest and/or abdominal tube placement. The child was delivered at 42 weeks and is doing well without problems at 1 year of age. We believe that intrauterine thoracentesis should be the initial procedure of choice for the treatment of primary fetal hydrothorax with mediastinal shift, and pleuroamniotic shunting should be reserved for cases that require repetitive thoracenteses.

Pulmonary complications of umbilical venous catheters

Umbilical venous catheters that are pushed in too far will usually cross the atrial septum and may dislodge in a pulmonary vein. The authors report eight neonates with radiographic documentation of this catheter malposition together with either a localized pulmonary opacification or an autopsy report of a pulmonary hemorrhage or infarction corresponding to the catheter position. The lung injury ranged from a transient edema to hemorrhagic pulmonary infarction and hydrothorax. In two cases autopsy demonstrated localized infarction without previous radiographic signs of catheter-related injury.

Feto-amniotic shunting--report of the experience of four European centres

Few reports concerning intrauterine shunting are available. We investigated the impact of this method. In order to evaluate intrauterine shunting and the complication rate for different indications, we sent a questionnaire to all German-speaking level 3 centres. In four level 3 centres, 52 intrauterine catheters were inserted in 34 fetuses. The indications were uni- or bilateral hydrothorax in nine cases, cystic adenomatoid malformation of the lung in four cases, infravesical stenosis in 13 cases, and fetal ascites in eight cases. In three cases (6 per cent), difficulties occurred when the drain was inserted. In 15 cases (29 per cent), the function of the drain was reduced by dislocation or occlusion. The mortality rate caused by shunting was as high as eight per cent (four cases). The application of an intrauterine shunt currently represents a rarely performed ultrasound-guided therapeutic intervention in the fetus. In all cases, the indication for shunting is to avoid compression of normal tissue by cystic structures. A high complication rate restricts the application of drainage to selected cases.

Successful treatment of primary fetal hydrothorax by long-time drainage from week 23. Case report and review of the literature

We report on a case of unilateral primary fetal hydrothorax leading to nonimmunological fetal hydrops (NIHF). The NIHF was treated successfully by inserting two consecutive intrauterine catheters at 23 weeks gestation. The first catheter was dislocated through the uterine wall to the maternal peritoneal cavity. At 36 weeks gestation, the mother had a spontaneous onset of labor after premature rupture of membranes and a normal vaginal delivery of a healthy infant with good perinatal outcome. Shunting of PFHT has rarely been described up to now. This case report supports observations of previous authors that early shunting of pleural effusions may prevent progression of NIHF as well as postnatal pulmonary hypoplasia. Unexpected perinatal complications of fetus, mother or both should not be neglected.

Massive hydrothorax complicating peritoneal dialysis. Isotopic investigation (peritoneopleural scintigraphy)

Massive hydrothorax occurring during continuous ambulatory peritoneal dialysis is a rare complication that may appear at any time during the course of the treatment. Most of the time, it is right-sided and is more frequent in female patients. A case is presented that was investigated by peritoneopleural scintigraphy. A rapid accumulation of the radiopharmaceutical over the right hemithorax was observed. To explain that finding, a macroscopic diaphragmatic defect was suspected. Different therapeutic approaches are presented.

Non-immune hydrops fetalis and bilateral pulmonary hypoplasia in a newborn infant with extralobar pulmonary sequestration

Extralobar pulmonary sequestration was found in a newborn premature infant that presented with non-immune hydrops fetalis, massive bilateral hydrothorax and polyhydramnios in utero. The baby died of severe respiratory insufficiency 15 h after birth. Postmortem examination revealed distended lymphatic vessels in the sequestered lung tissue probably due to impeded lymph drainage. We suggest that not extralobar pulmonary sequestration itself but a subsequent massive unilateral hydrothorax due to severe obstruction of lymph drainage was the cause of the non-immune hydrops fetalis, pulmonary hypoplasia and polyhydramnios. If these symptoms are diagnosed before delivery, a search for extralobar pulmonary sequestration is indicated.

Vascular erosion by central venous catheters. Clinical features and outcome

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.

Right-sided hydrothorax and central venous catheters in extremely low birthweight infants

Central venous catheters (CVCs) have become more common in the care of very low birthweight newborns. Nutrition is enhanced, fluid delivery is more secure, and stress from the intervention of starting new IVs is reduced. Complications of these devices include infection, thrombus or embolus, damage to vessels and organs, and extravascular collections of fluid. Pleural fluid collections can occur due to superior vena caval obstruction with obstruction of lymphatic drainage, and erosion or perforation of the catheter through the vein into the pleural space. Three infants weighing less than 1000 gm had CVCs placed in an antecubital vein. Severe respiratory compromise developed in 1 at 5, 1 at 6, and 1 at 40 hours after line placement, and chest radiograph suggested fluid in the right pleural space. Milky fluid was found in two cases in which the infants received lipid emulsion and parenteral nutrition fluid (PNF). Bright yellow fluid, resembling PNF, was found in the third, not receiving lipids. None of the patients was enterally fed. The tips of the CVCs were adjusted to a more peripheral location and there was no recurrence of pleural fluid, nor were signs of superior vena cava syndrome seen. Etiologies for the unilateral hydrothorax include vein perforation and erosion, but another cause is discussed. A right pleural fluid collection in a patient with a CVC tip in the right subclavian vein is a serious problem, which may be solved with repositioning of the CVC instead of removal.

[Mediastinal cystic lymphangioma as a cause of hydrops fetalis]

This report is upon a case with fetal hydrops on the base of a paracardiac cystic lymphangioma in the mediastinum. The newborn which had hypoplastic lungs and multiple pneumatothoraces died because of a pulmonary insufficiency. An overview is given about the most common causes of the nonimmune fetal hydrops, and the pathomechanisms are discussed.

Transient severe unilateral and subsequent bilateral primary fetal hydrothorax with spontaneous resolution at 34 weeks' gestation associated with normal neonatal outcome

Unilateral primary fetal hydrothorax with spontaneous resolution is a rare occurrence. We present a case in which severe unilateral primary fetal hydrothorax was visualized at 28 weeks' gestation. Two weeks later bilateral primary fetal hydrothorax was documented. Ultrasonographic follow-up demonstrated further dynamic changes in the fetal condition, with an isolated unilateral hydrothorax 1 week later and subsequent complete resolution at 34 weeks' gestation. Delivery resulted in a normal neonate with no signs of pulmonary hypoplasia.

[Percutaneous CT-guided catheter drainage of intrathoracic fluid accumulations]

To verify the value of percutaneous CT-guided drainage of thoracic fluid collections we studied the outcome in 39 patients retrospectively. 24 (61.5%) of the fluid collections were located in the pleural space, 10 (25.6%) in the lungs and 5 (12.8%) in the mediastinum. 11 CT-guided drainages after a previous attempt were necessary in 9 patients, because of recurrent (n = 6) or residual (n = 5) fluid collections. 70% of the drainage procedures were done using Seldinger's, 30% using trocar technique, mainly with 8.3-12 F catheters. The mean duration of drainage was 10.7 days. In 28 patients (71.8%) the percutaneous CT-guided drainage was curative. In 9 cases (23.1%) the patient's course was stabilised and surgery could be applied electively. 2 patients (5.1%) died because of their underlying end-stage malignancy. None of the drainage procedures changed the patient's course to the worse. There was only 1 pneumothorax with no need of any treatment; no other complication occurred. Our results suggest that percutaneous CT-guided drainage of thoracic fluid collections is a safe and straightforward alternative to surgical treatment.

Life-threatening fluid extravasation of central venous catheters

The majority of life-threatening injuries secondary to the placement of central venous catheters, such as bleeding and pneumothorax, occur at the time of initial insertion. When a catheter extravasates in the neck, edema of the neck wall or chest is usually seen, and the pump indicates occlusion. We present four cases in which an uneventful, successful placement of four central lines (three superior vena cava, one inferior vena cava) were followed at greater than 48 hours by either hydrothorax or hydroperitoneum, which resulted in either cardiorespiratory collapse or intraabdominal sepsis. In reviewing these cases, all showed both a change in catheter location on a subsequent x-ray and poor or no blood return on aspiration; paradoxically, the infusion pump in each case did not sense a catheter malposition or occlusion. We conclude that, although the success of central line placement may be documented on insertion, a continual reappraisal of both the function and location of the line is necessary.

[Hepatic hydrothorax without ascites]

A case of hepatic hydrothorax without clinical ascites is reported. The diagnosis was confirmed by intraperitoneal injection of 99mTc-tin colloid: scintigraphic images taken between 5 min and 18 h p.i. demonstrated a one-way transdiaphragmatic flow into the pleural cavity. The therapy consisted of diuretic treatment, pleural drainage and chemical pleurodesis, and resulted in prompt clinical improvement.

[Isotopic method in the demonstration of diaphragmatic defects in a case of pleural effusion associated with cirrhosis: apropos of a case]

A 62-year-old woman presented with massive right-sided hydrothorax associated with cirrhosis of the liver. Chest scintigraphy after intraperitoneal injection of labelled tracer showed movement of the tracer from the peritoneal to the pleural cavity. Medical therapy and thoracocentesis were successful in this case.

Ventriculoperitoneal shunt failure resulting from complications of the thoracic segment of the shunt catheter. Case report

A case of intrathoracic ventriculoperitoneal (V-P) catheter placement and migration resulting in hydrothorax is presented to direct attention to complications involving the thoracic segment of V-P shunt tubing. Inadequate catheter length and upper and lower thoracic segment disconnections are also discussed in addition to the role of radiography, nuclear medicine, and computed tomography (CT) in their evaluation. The lateral thoracic roentgenogram is useful in screening post shunt patients to exclude catheter deviation. Sonography over the extrathoracic tube course offers a rapid check for adjacent fluid collections as the tubing is frequently palpable and easily located by the anterioposterior roentgenogram.

Tension hydrothorax and shock in a patient with a malignant pleural effusion

A patient presented to the emergency department with a malignant pleural effusion associated with shortness of breath, and radiographic evidence of mediastinal shift and hypotension. Tube thoracostomy yielded serosanguinous pleural fluid under pressure and after 1 liter of fluid was drained, the patient's hemodynamic status stabilized. The entity of tension hydrothorax is rare but may be life threatening. The treatment should consist of prompt drainage and efforts to prevent recurrence. As physicians become more adept at prolonging the lives of patients with cancer, tension hydrothorax may become more common.

Hepatic hydrothorax: report of two cases

This paper describes two patients with liver cirrhosis presenting with right sided hydrothorax. The diagnosis of hepatic hydrothorax was confirmed by a radionuclide study using an intraperitoneal injection of radioactive 99mTc-tin-colloid, demonstrating the one-way transdiaphragmatic flow of fluid from the peritoneal to pleural cavities. Pleural taps, salt restriction and diuretics resulted in volume depletion and impaired renal function in the first patient. Medical therapy and a single thoracocentesis were successful in the other patient.

Antenatal diagnosis and treatment of fetal bronchopulmonary sequestration

Bronchopulmonary sequestration with associated nonimmune hydrops has been previously reported with generally poor prognosis for the neonate. We report a case of bronchopulmonary sequestration and associated pleural effusion successfully managed with a transthoracic catheter placement. The embryology and clinical pathophysiology of bronchopulmonary sequestration are discussed.

Tension hydropneumothorax as delayed presentation of traumatic rupture of the diaphragm

Diaphragmatic rupture due to blunt trauma is well recognised though uncommon. Most cases are diagnosed at the time of injury, but a proportion remain undiagnosed, only to present some months or even years later. This "delayed" group can present in a number of ways, including chronic abdominal and chest problems or an acute crisis. Herniation of abdominal viscera is the most common sequel, with strangulation and gangrene as the most serious complication. This paper reports a case of delayed presentation of diaphragmatic rupture and herniation presenting as tension hydropneumothorax due to small bowel perforation. A short discussion addresses the problems in diagnosis of this condition. We believe this to be the first reported case of perforated small bowel leading to tension hydropneumothorax.

[Bilateral hydrothorax with hydromediastinum after cannulation of the left internal jugular vein]

A rare case of combined bilateral hydrothorax and hydromediastinum was encountered during Total Parenteral Nutrition (TPN) via incannulation of the left internal jugular vein in a patient with advanced cancer of the portio. The possible anatomical and technical causes of this very serious complication were investigated in order to assess the importance of specific manual technique and to supply appropriate instrumental back-up that could prevent the recurrence of this sometimes fatal complication of TPN.

Three cases of acute massive hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD)

Acute hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD). We experienced three such cases among patients who started CAPD in our institute between April 1984 and April 1989. One was resolved with pleurodesis using autologous blood. The other two patients were switched to hemodialysis permanently because pleurodesis with autologous blood, tetracycline or OK432 failed. Acute hydrothorax is one important possible complication in CAPD.

External accumulation of radionuclide in hepatic hydrothorax

Hepatic hydrothorax is a complication in approximately 5% of patients with cirrhosis. Ascites is almost always present and helps to suggest the correct diagnosis. However, when ascites is absent, radionuclide imaging has proven to be helpful in establishing that the pleural effusion originated from ascitic fluid. When pleural fluid is rapidly removed, such as by thoracostomy tube drainage, the radioisotope may accumulate outside the thorax and produce a negative scan of the chest. When the radionuclide scan is nondiagnostic and the pleural space is being rapidly drained, the pleural fluid collecting system should always be imaged before rejecting a diagnosis of hepatic hydrothorax.

Tension hydrothorax from intrapleural migration of a ventriculoperitoneal shunt

A male newborn underwent a myelomeningocele repair, with subsequent placement of a ventriculoperitoneal shunt for treatment of hydrocephalus. Five days after shunt surgery, the infant acutely developed a deeply sunken fontanel, pallor, tachypnea, bradycardia, and irritability. Chest radiographs revealed intrathoracic migration of the distal shunt tubing and a tension hydrothorax. Treatment consisted of tube thoracostomy and temporary externalization of the distal shunt tubing. The patient fully recovered. The acute onset of shock in association with a sunken fontanel in a neonate with a shunt should raise the suspicion of tension hydrothorax. For critically ill infants immediate needle aspiration or thoracostomy is suggested. In less severely ill children, exposure of the shunt tubing in the neck and withdrawal of the pleural effusion by the distal shunt tubing may be performed as an emergency measure. The early recognition and urgent management of this problem are emphasized.

Significance of a curled central venous catheter tip

A malpositioned central venous catheter can cause constant excessive pressure on one particular area of a central vein, thus leading to perforation and hydrothorax. The following is a case report of an iatrogenic hydrothorax caused by a malpositioned central venous catheter. The subtle sign of malposition is a slightly curled catheter tip.

Demonstration of hydrothorax by intraperitoneal injection of technetium-99m MAA in the evaluation of peritoneovenous shunt patency

A case of hydrothorax in a patient with recurrent ascites following Le Veen peritoneovenous shunt placement is presented. Patency of the Le Veen shunt was studied by the intraperitoneal injection of Tc-99m MAA with subsequent activity seen in the right hemithorax only. A standard perfusion lung scan showed only the left lung to be perfused. Thus, the right hemithorax activity seen could not be due to shunt patency, but represented direct communication between the labeled ascitic fluid and the right hydrothorax seen on chest x-ray.

Hydrothorax, ascites, and right diaphragmatic hernia

Hydrothorax and/or ascites may be the most striking finding in children with right diaphragmatic hernia. The clinical, radiographic, and pathologic findings of five children with right diaphragmatic defects through which the liver had herniated are described. Three presented with a right hydrothorax, one with a right hydrothorax and ascites, and another with ascites. All four children with large right hydrothoraxes were found to have an incarcerated peritoneal sac filled with fluid in the right side of the chest at surgery or autopsy. Lymphatic congestion and obstruction was the probable cause for the fluid collection, which tended to enlarge with time. This condition may be life threatening, and two of the four patients died soon after birth because of hypoplasia of the lungs. Fetal ultrasonography in both had disclosed right intrathoracic cystic masses, and in one, intrauterine aspiration to decompress the lungs had been attempted. The other two patients are alive and well following surgical repair at 1 week and 7 months of age. Ascites was present in two patients and was believed to be due to hepatic venous obstruction, a mechanism similar to that responsible for the Budd-Chiari syndrome.

Scintigraphic demonstration of a diaphragmatic defect as the cause of massive hydrothorax in cirrhosis

A 64-year-old man presented with a massive right-sided hydrothorax associated with cirrhosis of the liver. There was no clinical evidence of ascites nor other underlying disease. The usual complementary tests failed to demonstrate any causative abnormality. Chest and abdominal scintigraphy after intraperitoneal injection of 99mTc-human serum albumin disclosed early filling of the pleural space by the radiopharmaceutical and suggested a diaphragmatic defect as the cause for this rare association.