Hepatic hydrothorax: pathophysiology, diagnosis, and management

Hepatic hydrothorax occurs in approximately 5 to 12% of patients with cirrhosis and portal hypertension. Various therapeutic modalities ranging from dietary and pharmacologic interventions to surgical approaches are available for the management of this condition. Treatment must be individualized based on the patient's response to conservative management as well as the severity of the underlying liver disease. Hepatic hydrothorax may be complicated by spontaneous bacterial empyema, which portends a poor prognosis with a mortality rate of up to 20%. All patients with hepatic hydrothorax should be evaluated for possible liver transplantation.

Management options for hydrothorax complicating peritoneal dialysis

Hydrothorax as a result of pleuroperitoneal communication occurs in approximately 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication), possibly coupled with reduction of intra-abdominal pressure. This review corroborated the findings from 10 major population-based case series in which 60 of the 104 cases (58%) were able to resume long-term peritoneal dialysis (PD). Temporary interruption of PD alone was successful in half of them. As compared to this conservative approach, as well as chemical pleurodesis via intercostal chest drain, video-assisted thoracoscopic intervention (including direct pleurodesis and diaphragmatic repair) has shown a promising role. Efficacy of thoracoscopic treatment has been confirmed by several case series from various centers and the demonstration of a success rate in excess of 90%. With accumulating experience using the thoracoscopic technique, it remains to be seen whether this mode of treatment will obviate the traditional closed pleurodesis.

Hepatic hydrothorax

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.

Management of massive and persistent ascites and/or hydrothorax after liver transplantation

PURPOSE

To describe the results of the treatment of eight liver transplantation (LT) patients subsequently developing large volumes of long-lasting ascites.

PATIENTS AND METHODS

Between August 1996 and February 2003, 405 LTs were performed in 375 patients, eight (1.97%) of whom (six men and two women of mean age of 55.4 +/- 5.2 years) subsequently developed massive (> 500 mL/d) and persistent ascites and/or hydrothorax. All patients were HCV positive. The mean age of the liver donors was 66.8 +/- 21.9 years. All LTs were performed by replacement of the recipient retrohepatic vena cava.

RESULTS

The eight patients displayed sinusoidal portal hypertension related to biopsy-proven recurrence of HCV infection. Mean wedged hepatic venous pressure was 14.9 +/- 5.1 mm Hg and mean portal vein/right atrial pressure gradient (PAPG) was 17.3 +/- 4.8 mm Hg. In two patients, the ascites appeared the day after LT; in the remaining six, ascites and/or hydrothorax appeared after 342.3 +/- 167.7 days. Seven patients with a mean PAPG of 18.4 +/- 3.9 mm Hg and a mean plasma/ascites albumin concentration gradient of 2.8 +/- 0.3 g/L were treated by means of a trans-jugular intrahepatic portosystemic shunt TIPS, and one (with a PAPG of 9 mm Hg and a plasma/ascites albumin concentration gradient of 1.38 g/L) by means of spleen arterial embolisation. After a mean follow-up of 558 +/- 147.2 days, the ascites and/or hydrothorax have resolved in five patients (62.5%), one (12.5%) has stable ascites not requiring paracentesis, and two (25%) have died of multiorgan failure.

CONCLUSIONS

These data suggest the efficacy of the aggressive treatment of massive and persistent ascites and/or hydrothorax.

Transjugular intrahepatic portosystemic shunt: current status

The transjugular intrahepatic portosystemic shunt (TIPS) was developed in the 1980s for treatment of complications of portal hypertension. Once it was shown that the shunt could be placed with relative ease, TIPS was rapidly applied to the treatment of many of the complications of portal hypertension. These complications include actively bleeding gastroesophageal varices, prevention of rebleeding from varices, control of refractory cirrhotic ascites and hepatic hydrothorax, and treatment of hepatorenal failure and hepatopulmonary syndrome. TIPS has also been used as therapy for Budd-Chiari syndrome and veno-occlusive disease. Despite these broad applications, TIPS has been compared with other forms of therapy in only 2 situations: prevention of rebleeding from varices and control of refractory cirrhotic ascites. In the trials, TIPS was shown to provide better control of these 2 complications of portal hypertension than standard forms of therapy. However, there was no improvement in survival and the incidence of encephalopathy was greater for patients receiving a TIPS. Thus, the use of TIPS for the control of ascites and prevention of rebleeding from varices should be limited to a select group of patients. There have been no controlled trials for the other indications listed. Despite the apparent efficacy of TIPS in many of these situations, its use should be limited to salvage therapy pending the publication of controlled trials showing it is a better treatment than other forms of therapy.

Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis

BACKGROUND

Acute, massive, unilateral hydrothorax is an uncommon but well-recognized complication of peritoneal dialysis. Its clinical course and treatment outcome after a recently advocated technique of video-assisted thoracoscopic (VATS) talc pleurodesis remains unclear.

METHODS AND RESULTS

Between July 1998 and March 2002, among 475 CAPD patients in two regional hospitals in Hong Kong, nine patients (three men, six women, mean age 53+/-12 years) developed acute hydrothorax due to pleuroperitoneal communication (R=8, L=1) within 5.8+/-4.2 months (median, 5.2 m; range, 2 days to 11.6 months) of commencing peritoneal dialysis. Analysis of simultaneously obtained peritoneal and pleural fluid in all subjects only showed concordance in protein content (consistently<4 g/l), while fluid glucose and lactate dehydrogenase levels were not comparable. The methylene blue test was negative (n=4). Radionuclide scan (n=6) and contrast CT peritoneography (CTP, n=3) detected pleuroperitoneal communication in half and one-third of the patients, respectively. All patients underwent pleurodesis achieved by talc insufflation into the pleural cavity under VATS guidance. All patients were successfully returned to peritoneal dialysis. After a mean follow-up of 18.8+/-12.5 months, hydrothorax recurred in one patient (at 7 months after pleurodesis), who was successfully treated by repeating the procedure.

CONCLUSIONS

Hydrothorax complicating CAPD is more commonly right-sided, and tends to occur within the first year of starting peritoneal dialysis. Isotope scan and CTP are insensitive in diagnosing pleuroperitoneal communication. A low pleural fluid protein content is the most consistent biochemical finding. VATS talc pleurodesis is a safe and reliable treatment of choice that allows sustained continuation of CAPD with low recurrence rate.

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.

[A case of refractory hepatic hydrothorax that was not treated by transjugular intrahepatic portosystemic shunt]

Refractory hepatic hydrothorax has been treated by conservative methods: salt and water restriction, diuretics, thoracentesis, thoracostomy, and pleurodesis. The results, however, havebeen disappointing. Recently, TIPS has emerged as a new method for refractory hepatic hydrothorax, but it may lead to fatal complications. We report a case of refractory hepatic hydrothorax that was not treated by TIPS despite of successful control of ascitest.

Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis

BACKGROUND

Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis.

METHODS

Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery.

RESULTS

One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84).

CONCLUSIONS

With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.

[Pseudo-hydrothorax in peripheral venous catheterization in an extremely premature neonate--case report]

The authors describe very rare complication (pseudopleural effusion) after peripheral venous cannulation (Introcan-W 24G3/4 through v. axilaris) in extremely premature newborn with birth weight 600 grams, which lead to worsening of patient's respiratory insufficiency. Ultrasonographic examination confirmed extrapleural process without necessity of surgical intervention. Cannula extraction and infusion interruption were followed by spontaneous regression of the complication, thereafter artificial ventilation was discontinued and baby was discharged.

Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax

PURPOSE

To evaluate safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for hepatic hydrothorax (HHyd).

MATERIALS AND METHODS

Twenty-one patients underwent TIPS creation for HHyd. A prospective TIPS database and medical records were reviewed. Clinical and radiographic outcomes were recorded as complete (symptom/effusion resolution), partial (improved symptoms/effusion), or none. Data patterns were examined with chi(2) tests and Kaplan-Meier analysis.

RESULTS

Patients included 12 women and nine men, with a mean age of 56 years, all with Child class B (n = 7) or C (n = 14) disease. The technical success rate was 100%. Mean follow-up was 223 days. Twenty-nine percent (six of 21) died within 30 days of TIPS creation, 10% (two of 21) underwent transplantation within 30 days, and 62% (13 of 21) survived beyond 30 days. Data were incomplete in two patients. Clinical response was classified as complete in 63% (12 of 19), partial in 11% (two of 19), and none in 26% (five of 19). Radiographic response was classified as complete in 30% (six of 20), partial in 50% (10 of 20), and none in 20% (four of 20). Nonresponders had multisystem organ failure, and all but one died within 30 days. However, of the 13 patients surviving longer than 30 days, 10 (77%) had a complete clinical response.

CONCLUSION

TIPS is a relatively safe and effective method of controlling HHyd. The majority of patients experienced improvement or resolution of clinical symptoms with a variable reduction in the quantity of pleural fluid. There was a tendency among nonresponders to die within 30 days.

Ex utero intrapartum treatment (EXIT) of severe fetal hydrothorax

Ex utero intrapartum treatment (EXIT) of a fetus with severe bilateral hydrothorax is described. EXIT allows therapeutic interventions on the neonate while maintaining fetoplacental circulation. Thus it may be useful for fetuses presenting with severe pleural effusion towards the end of gestation and in whom in utero drainage is technically not possible or available and drainage post partum would result in profound and prolonged hypoxia until sufficient drainage of pleural fluid allowed lung expansion.

Supracostal approach in percutaneous nephrolithotomy: experience with 102 cases

PURPOSE

To assess retrospectively the safety and efficacy of the supracostal approach in percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

Among 862 patients who underwent PCNL between April 1986 and December 1999, supracostal puncture was performed in 102. Their stones were either solitary (66.5%), multiple (15.7%), or staghorn (19.6%). Upper ureteral calculi were the commonest indication (32.4%). The interspace between the 11th and 12th ribs was used in all cases. After tract dilatation with telescopic metal dilators, pneumatic or ultrasound lithotripsy was used for fragmentation.

RESULTS

Complete clearance was achieved in 79.5%. Ten patients (9.8%) had pleural violation in the form of hydrothorax, pneumothorax, or hydropneumothorax. All of these patients were managed successfully by intercostal chest tube drainage.

CONCLUSION

Supracostal puncture in a safe and effective approach with acceptable morbidity in selected cases of staghorn, upper ureteral, and upper caliceal calculi.

Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide

Hepatic hydrothorax is a dreaded complication in patients with liver cirrhosis. Placement of chest tubes can alleviate respiratory distress, but patients often succumb due to excessive fluid and protein loss via the open drain. Our case illustrates that high-dose octreotide can strongly reduce hepatic hydrothorax drainage volume. This allows removal of the chest tube, which would otherwise not have been possible.

Hepatic hydrothorax: a retrospective case study

PURPOSE

To present the pathophysiology, differential diagnoses, assessment techniques, and treatment options for hepatic hydrothorax.

DATA SOURCES

A case study is presented with supporting material from current medical literature.

CONCLUSIONS

Hepatic hydrothorax is a pleural effusion caused by the flow of ascitic fluid into the pleural space through an actual defect in the diaphragm. Successful outcomes depend on early detection and timely referral of often-subtle lung involvement.

IMPLICATIONS FOR PRACTICE

Although incidence is reported to be as high as 12% in cirrhotic patients, standard medical references attach little importance to pulmonary risks in this population. Hepatic hydrothorax should always be considered in the cirrhotic patient with a pleural effusion.

Chemical pleurodesis for hepatic hydrothorax

BACKGROUND

Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed.

OBJECTIVE

This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment.

METHODS

Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis.

RESULTS

These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure.

CONCLUSION

This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.

[TIPS - Transjugular intrahepatic portosystemic shunt. A review]

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.

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.

Resolution of refractory hepatic hydrothorax after chemical pleurodesis with minocycline

Management of refractory hepatic hydrothorax is a challenge to physicians in clinical practice. We reported two patients with hepatic hydrothorax, non-alcoholic cirrhosis and rapidly recurring pleural effusion. They failed to improve with diuretics and repeated thoracentesis. Refractory hepatic hydrothorax was successfully treated by minocycline-induced pleural symphysis. After pleurodesis, ventilatory function returned to normal in both patients. No recurrence of pleural effusion was noted. We suggest that minocycline pleurodesis is an alternative treatment for refractory hepatic hydrothorax because it is simple, safe and effective.