Isotopic exploration of hepatic hydrothorax: ten cases

International survey among hepatologists and pulmonologists on the hepatic hydrothorax: plea for recommendations

BACKGROUND

The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax.

METHODS

Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management.

RESULTS

Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001).

CONCLUSIONS

The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.

Hepatic Hydrothorax

Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.

Effectiveness and Safety of Pleurodesis for Hepatic Hydrothorax: A Systematic Review and Meta-Analysis

BACKGROUND

Hepatic hydrothorax (HH) is a serious complication of end-stage liver diseases, which is associated with poor survival. There is no consensus regarding the treatment of HH.

AIM

To evaluate the effectiveness and safety of pleurodesis for HH in a systematic review with meta-analysis.

METHODS

All relevant papers were searched on the EMBASE and PubMed databases. As for the data from the eligible case reports, the continuous data were expressed as the median (range) and the categorical data were expressed as the frequency (percentage). As for the data from the eligible case series, the rates of complete response and complications were pooled. The proportions with 95 % confidence intervals (CIs) were calculated by using random-effect model.

RESULTS

Twenty case reports including 26 patients and 13 case series including 180 patients were eligible. As for the case reports, the median age was 55 years (range 7-78) and 15 patients were male. The prevalence of ascites was 76 % (19/25). Seventeen (65.38 %) patients responded favorably to pleurodesis. As for the case series, the mean age was 51.5-63.0 years and 83 patients were male. The pooled prevalence of ascites was 90 % (95 % CI 81-97 %) in 7 studies including 71 patients. The complete response rate after pleurodesis was reported in all studies, and the pooled rate was 72 % (95 % CI 65-79 %). Complications related to pleurodesis were reported in 6 studies including 63 patients, and the pooled rate was 82 % (95 % CI 66-94 %).

CONCLUSION

Pleurodesis may be a promising treatment for HH, but carries a high rate of complications.

Induced negative pressure proposed as a new method for diagnosing hepatic hydrothorax involving minor leaks

Key Clinical Message

Hepatic hydrothorax is known as pleural effusion of hepatic origin, and is difficult to diagnose. We herein report the novel strategy combining radioisotope scintigraphy with chest drainage to definitively diagnose hepatic hydrothorax of an 85-year-old patient which would have been missed with conventional diagnostic methods.

Hepatic hydrothorax

Hepatic hydrothorax (HH) is an uncommon complication in patients with end-stage liver disease. Only 5% to 10% of patients with end-stage liver disease develop HH, which may result in dyspnea, hypoxia, and infection, and portends a poor prognosis. The most likely explanation for development is passage of fluid from the peritoneal space to the pleural space due to small diaphragmatic defects. Initial management consists of diuretics with dietary sodium restriction and thoracentesis, and a transjugular intrahepatic portosystemic shunt may ultimately be required. Afflicted patients can develop morbid and fatal complications, pose management dilemmas, and should warrant evaluation for liver transplantation.

Evidence-based review of the management of hepatic hydrothorax

Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.

Diagnosis of hepatic hydrothorax using contrast-enhanced ultrasonography with intraperitoneal injection of Sonazoid

BACKGROUND AND AIM

We investigated the utility and safety of contrast-enhanced ultrasonography using Sonazoid in the diagnosis of hepatic hydrothorax.

METHODS

The study consisted of seven liver cirrhosis patients with hydrothorax and hydroperitoneum. After obtaining informed consent, Sonazoid was injected intraperitoneally, and enhancement in the peritoneal and pleural cavities was observed.

RESULTS

In all patients, the peritoneal cavity was quickly enhanced after the Sonazoid injection. The pleural cavity was enhanced in five of the seven patients, and these five patients were diagnosed with hepatic hydrothorax. Two patients without enhancement of the pleural cavity were diagnosed with inflammatory hydrothorax.

CONCLUSIONS

This is the first report to confirm transdiaphragmatic movement of ascitic fluid into the pleural cavity using contrast-enhanced ultrasonography with Sonazoid. This method can safely detect ascitic flow in real time, and is thus very useful for the diagnosis of hepatic hydrothorax.

Role of the peritoneopleural pressure gradient in the genesis of hepatic hydrothorax. An isotopic study

SUMMARY

Hepatic hydrothorax is defined as the development of significant pleural effusion in a patient with cirrhosis without primary pulmonary or cardiac disease. This complication is seen in 4-10% of patients with cirrhosis. The pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm. We report two patients with posthepatitis cirrhosis presenting with a significant pleural effusion. The peritoneopleural communication was demonstrated by peritoneal scintigraphy. The role of the peritoneopleural pressure gradient is discussed.

The Undiagnosed Pleural Effusion

The most common causes for undiagnosed transudative effusions are congestive heart failure and hepatic hydrothorax. Pleural fluid N terminal pro-brain natriuretic peptide levels higher than 1500 pg/mL are virtually diagnostic of congestive heart failure. The most common causes for undiagnosed exudative pleural effusions are malignancy, pulmonary embolism, and tuberculosis. Clinical characteristics of patients with a malignant pleural effusion are symptoms for more than 1 month, absence of fever, blood-tinged pleural fluid, and CT findings suggestive of malignancy. Thoracoscopy is useful to establish the diagnosis of malignancy and tuberculosis.