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Abstract
Patients with advanced chronic liver diseases, particularly with decompensated liver cirrhosis, can develop specific pulmonary complications independently of any pre-existing lung disease. Especially when dyspnea occurs in combination with liver cirrhosis, patients should be evaluated for hepato-pulmonary syndrome (HPS), porto-pulmonary hypertension (PPHT), hepatic hydrothorax and spontaneous bacterial empyema, which represent the clinically most relevant pulmonary complications of liver cirrhosis. Importantly, the pathophysiology, clinical features, diagnosis and the corresponding therapeutic options differ between these entities, highlighting the role of specific diagnostics in patients with liver cirrhosis who present with dyspnea. Liver transplantation may offer a curative therapy, including selected cases of HPS and PPHT. In this review article, we summarize the pathogenesis, clinical features, diagnostic algorithms and treatment options of the 4 specific pulmonary complications in patients with liver cirrhosis.
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Abstract
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.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
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Abstract
Various clinical trials have been published on the optimal clinical management of patients with pleural exudates, particularly those caused by malignant tumors, while little information is available on the diagnosis and treatment of pleural transudates. The etiology of pleural transudates is wide and heterogeneous, and they can be caused by rare diseases, sometimes constituting a diagnostic challenge. Analysis of the pleural fluid can be a useful procedure for establishing diagnosis. Treatment should target not only the underlying disease, but also management of the pleural effusion itself. In cases refractory to medical treatment, invasive procedures will be necessary, for example therapeutic thoracentesis, pleurodesis with talc, or insertion of an indwelling pleural catheter. Little evidence is currently available and no firm recommendations have been made to establish when to perform an invasive procedure, or to determine the safest, most efficient approach in each case. This article aims to describe the spectrum of diseases that cause pleural transudate, to review the diagnostic contribution of pleural fluid analysis, and to highlight the lack of evidence on the efficacy of invasive procedures in the management and control of pleural effusion in these patients.
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Mohamed A, Atef M, Alsebaey A, Musa Elhabshy M, Salama M. Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax. Arab J Gastroenterol 2017; 18:104-107. [PMID: 28579346 DOI: 10.1016/j.ajg.2017.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 10/23/2016] [Accepted: 05/14/2017] [Indexed: 02/08/2023]
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Mohamed A, Atef M, Alsebaey A, Musa Elhabshy M, Salama M. Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax. Arab J Gastroenterol 2017. [DOI: https:/doi.org/10.1016/j.ajg.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Mohamed A, Atef M, Alsebaey A, Musa Elhabshy M, Salama M. Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax. Arab J Gastroenterol 2017. [DOI: https://doi.org/10.1016/j.ajg.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Shimbo A, Matsuda S, Tejima K, Yamahira K, Naka K, Arai M, Fujita S. Induced negative pressure proposed as a new method for diagnosing hepatic hydrothorax involving minor leaks. Clin Case Rep 2014; 2:296-302. [PMID: 25548633 PMCID: PMC4270713 DOI: 10.1002/ccr3.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Asami Shimbo
- Department of General Medicine, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Satoshi Matsuda
- Department of Respiratory Disease, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Kazuaki Tejima
- Department of Gastroenterology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Koh Yamahira
- Department of Radiology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Kenichi Naka
- Department of Radiology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Masahiro Arai
- Department of Gastroenterology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Shuhei Fujita
- Department of General Medicine, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
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E. Mansour A, El-Rahman AA, Besheer T. Prevalence and risk factors for spontaneous bacterial pleuritis in cirrhotic patients with hydrothorax. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013. [DOI: 10.1016/j.ejcdt.2013.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Sahn SA, Huggins JT, San Jose E, Alvarez-Dobano JM, Valdes L. The Art of Pleural Fluid Analysis. ACTA ACUST UNITED AC 2013. [DOI: 10.1097/cpm.0b013e318285ba37] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Spontaneous bacterial empyema (SBEM) is defined as spontaneous infection of a preexisting hepatic hydrothorax. SBEM is diagnosed after exclusion of pneumonia, and, in patients with liver cirrhosis, it is still associated with significant morbidity and mortality. To date, studies focusing on SBEM are rare. This review will highlight the recent data focusing on the clinical characteristics, bacteriology, management, and outcome predictors of cirrhotic patients with SBEM. RECENT FINDINGS The Enterobacteriaceae (Escherichia coli and Klebsiella pneumoniae) are the major causative pathogens isolated from SBEM patients. Therefore, the cornerstone of therapy is antibiotic therapy with immediate empirical use of third-generation cephalosporins as first-line treatment. Chest-tube placement is not necessary. Regression analysis identified three independent factors related to poor outcome: high score of the model for end-stage liver disease-sodium (MELD-Na), initial ICU admission, and initial antibiotic treatment failure. High MELD-Na score may be a useful predictor of SBEM mortality in cirrhotic patients. SUMMARY Although SBEM is a rare complication of cirrhosis, the high mortality rate should increase physicians' index of suspicion in cirrhotic patients with hydrothorax and prompt immediate diagnostic thoracentesis. The MELD-Na score rather than Child-Pugh score may be a strong predictor of in-hospital mortality of SBEM patients.
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Gurung P, Goldblatt M, Huggins JT, Doelken P, Nietert PJ, Sahn SA. Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest 2011; 140:448-453. [PMID: 21273292 DOI: 10.1378/chest.10-2134] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are limited published data defining complete pleural fluid analysis, echocardiographic characteristics, or the presence or absence of ascites on sonographic or CT imaging in patients with hepatic hydrothorax. METHODS We reviewed pleural fluid analysis and radiographic, sonographic, and echocardiographic findings in 41 consecutive patients with hepatic hydrothorax referred to the Pleural Procedure Service for thoracentesis. RESULTS Ascites was detected on sonographic or CT imaging in 38 of 39 patients (97%). Diastolic dysfunction was found in 11 of 21 patients (52%). Contrast echocardiography with agitated saline demonstrated an intrapulmonary shunt in 18 of 23 cases (78%). Solitary hepatic hydrothorax had a median pleural fluid pH of 7.49 (fifth to 95th percentile, 7.40-7.57), total protein level of 1.5 g/dL (0.58-2.34), and lactate dehydrogenase (LDH) level of 65 IU/L (36-138). The median pleural fluid/serum protein ratio and pleural LDH/upper limit of normal serum LDH ratio were 0.25 (0.10-0.43) and 0.27 (0.14-0.57), respectively. The median absolute neutrophil count (ANC) was 26 cells/μL (1-230). Only a single patient had a protein discordant exudate despite 83% of patients receiving diuretics. When comparing solitary hepatic hydrothorax and spontaneous bacterial pleuritis, there was no statistically significant difference among pleural fluid total protein (P = .99), LDH (P = .33), and serum albumin (P = .47). ANC was higher in patients with spontaneous bacterial pleuritis (P < .0001). CONCLUSIONS Hepatic hydrothorax virtually always presents with ascites that is detectable on sonographic or CT imaging. The development of an "exudate" from diuretic therapy is a rare phenomenon in hepatic hydrothorax. In contrast, diastolic dysfunction and intrapulmonary shunting are common in patients with hepatic hydrothorax. There was no statistically significant change in pleural fluid parameters with spontaneous bacterial pleuritis, except an increased ANC.
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Affiliation(s)
- Puncho Gurung
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC.
| | - Mark Goldblatt
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - John T Huggins
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - Peter Doelken
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | - Paul J Nietert
- Division of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC
| | - Steven A Sahn
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
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Tamano M, Hashimoto T, Kojima K, Maeda C, Hiraishi H. Diagnosis of hepatic hydrothorax using contrast-enhanced ultrasonography with intraperitoneal injection of Sonazoid. J Gastroenterol Hepatol 2010; 25:383-6. [PMID: 19817961 DOI: 10.1111/j.1440-1746.2009.06002.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Masaya Tamano
- Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan.
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The impact of preoperative hepatic hydrothorax on the outcome of adult liver transplantation. Eur J Gastroenterol Hepatol 2010; 22:207-12. [PMID: 19779352 DOI: 10.1097/meg.0b013e3283311140] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic hydrothorax is an uncommon, but severe complication of cirrhosis. Orthotopic liver transplantation (OLT) is the best option in case of end-stage liver disease. The impact of hepatic hydrothorax on pre-transplant and post-transplant courses has not been clearly investigated. PATIENTS AND METHODS Eleven patients (group 1) with hepatic hydrothorax and end-stage liver disease out of 346 consecutive patients who underwent OLT between January 2002 and December 2006 were studied. First, pretransplant and posttransplant symptoms and management of hepatic hydrothorax were compared in this group. Second, postoperative complications and survival were compared with two control groups of 11 patients, matched for age, sex, year of transplant, and severity of cirrhosis. Group 2 included patients with tense ascites, but no hepatic hydrothorax. Group 3 included patients without ascites. RESULTS In group 1, 73% of patients needed thoracentesis in the pre-transplant course (55% more than once) and none of the patients needed thoracenthesis in the post-transplant course. Comparing the postoperative period between the three groups, no significant differences in the duration of mechanical ventilation, intensive care unit stay, and in-hospital stay were observed. There were no significant differences in terms of incidence of sepsis and early postoperative death. One-year survival was also similar. CONCLUSION Liver transplantation is a good definitive therapeutic option for cirrhotic patients with hepatic hydrothorax and end-stage liver disease. The need of thoracentesis decreases in the posttransplant course, and the presence of preoperative hepatic hydrothorax did not have a significant negative influence on postoperative outcome.
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Left-sided hepatic hydrothorax diagnosed by contrast-enhanced ultrasonography with intraperitoneal injection of Levovist. J Med Ultrason (2001) 2008; 35:129-32. [DOI: 10.1007/s10396-008-0175-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 02/04/2008] [Indexed: 10/21/2022]
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Huang PM, Han YY, Kuo SW, Lee YC. Color Doppler ultrasonography in detecting transdiaphragmatic flow of hepatic hydrothorax: correlation with thoracoscopic findings. J Thorac Cardiovasc Surg 2008; 138:1251-2. [PMID: 19660259 DOI: 10.1016/j.jtcvs.2008.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 04/16/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Pei-Ming Huang
- Department of Traumatology and Surgery, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7 Chung-Shan S. Road, Taipei, Taiwan
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Roussos A, Philippou N, Mantzaris GJ, Gourgouliannis KI. Hepatic hydrothorax: pathophysiology diagnosis and management. J Gastroenterol Hepatol 2007; 22:1388-93. [PMID: 17645471 DOI: 10.1111/j.1440-1746.2007.05069.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatic hydrothorax is defined as a significant pleural effusion (usually greater than 500 ml) in a cirrhotic patient, without an underlying pulmonary or cardiac disease. The diagnosis of hepatic hydrothorax should be suspected in a patient with established cirrhosis and portal hypertension, presenting with a unilateral pleural effusion, most commonly right-sided. In the vast majority of cases, patients with hepatic hydrothorax have end-stage liver disease. Therefore, they should be considered potential candidates for orthotopic liver transplantation. Until the performance of transplantation, other therapeutic modalities should be applied in order to relieve symptoms and prevent pulmonary complications.
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Abstract
This review will discuss the use of transjugular intrahepatic portosystemic stent-shunt in a number of relatively uncommon clinical situations. In particular, we will focus our paper on the use of transjugular intrahepatic portosystemic stent-shunt for hepatic hydrothorax, hepatopulmonary syndrome, veno-occlusive disease, portal hypertensive gastropathy and gastric antral vascular ectasia, before surgery and after liver transplantation.
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Affiliation(s)
- George Therapondos
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada.
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Smithson-Amat A, Perelló-Carbonell R, Miret-Mas C, Rodríguez-Flores E, Bastida-Vila MT, Nolla-Salas M. [Spontaneous bacterial empyema due to Campylobacter jejuni]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:509. [PMID: 16185586 DOI: 10.1157/13079003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Hepatic hydrothorax is defined as the accumulation of significant pleural effusion in a cirrhotic patient without primary pulmonary or cardiac disease. Hydrothorax is uncommon occurring in up to 4-6% of all patients with cirrhosis and up to 10% in patients with decompensated cirrhosis. Although ascites is usually present, hydrothorax can occur in the absence of ascites. Patients with hepatic hydrothorax usually have advanced liver disease with portal hypertension and most of them will require liver transplantation. Over the last few years, new insights into the pathogenesis of this entity have lead to improved treatment modalities such as portosystemic shunts (TIPS) and video-assisted thoracoscopy for closure of diaphragmatic defects. These modalities may be of help as a bridge to transplantation. The aim of this review is to describe recent developments in the pathogenesis, diagnosis and treatment of hepatic hydrothorax.
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Affiliation(s)
- Chamutal Gur
- Liver Unit, Division of Medicine, Hadassah University Hospital, Jerusalem, Israel
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Cadranel JF, Jouannaud V, Duron JJ. Prise en charge d’un hydrothorax hépatique. Rev Mal Respir 2004; 21:621-36. [PMID: 15292860 DOI: 10.1016/s0761-8425(04)71372-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- J-F Cadranel
- Unité d'Hépatologie, Service d'Hépato-Gastroentérologie et de Diabétologie, Centre Hospitalier Laennec, BP 72, 60109 Creil
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Affiliation(s)
- Yann Consigny
- Service d'Hépatologie, Hôpital Beaujon, 100, boulevard du Général Leclerc, 92110 Clichy Cedex
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Cadranel JF, Jouannaud V, Duron JJ. Prise en charge d’un hydrothorax hépatique. ACTA ACUST UNITED AC 2004; 28 Spec No 2:B287-300. [PMID: 15150525 DOI: 10.1016/s0399-8320(04)95268-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jean-François Cadranel
- Unité d'Hépatologie, Service d'Hépato-Gastroentérologie et de Diabétologie, Centre Hospitalier Laennec, BP 72, 60109 Creil Cedex
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Abstract
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.
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Affiliation(s)
- Nelson Garcia
- Division of Gastroenterology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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26
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Abstract
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.
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Affiliation(s)
- Gary T Kinasewitz
- Department of Medicine, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Abstract
BACKGROUND Pleural effusion (PE) is a rare complication of advanced liver cirrhosis, which may lead to an operation when uncontrolled. The purpose of this study was to evaluate the modality of the occurrence of pleural effusion and to describe its surgical management. METHODS We studied 21 patients who were referred to the department of thoracic surgery because of massive and recurrent PE caused by liver cirrhosis. The PE was a transudate in 16 patients and an exudate in 5. Talc pleurodesis was attempted in all patients. The patients were divided into two groups. Video assisted thoracoscopy was performed in 13 patients in whom the clinical condition permitted general anesthesia; the pleural cavity was entirely explored before pleurodesis (group 1). Chest tube drainage alone was performed in 8 patients who were unable to undergo general anesthesia; talc pleurodesis was performed through the chest tube in these patients (group 2). RESULTS In group 1 the PE was right-sided in 8 patients, left-sided in 3, and bilateral in 2. Diaphragmatic defects were observed in 2 patients, and a fluid leak oozing from the diaphragm was observed in 1 patient. Ten patients were considered cured and were without recurrence. Two patients underwent late recurrence before dying from their liver cirrhosis. Only 1 patient had an early recurrence that was cured by complementary talc slurry. In group 2 all patients presented with a right PE; of these, 3 patients died from septic shock caused by pleural infection. Three patients underwent early recurrence but were cured after repeat talc slurry. One patient had a midterm recurrence. One patient had an early recurrence treated by intrahepatic porto-systemic shunt with partial improvement. CONCLUSIONS Passage of ascites through diaphragmatic defects appears to be the main cause of PE complicating cirrhosis. Patients may benefit from talc pleurodesis. Video assisted thoracoscopy pleurodesis is the technique of choice with consistent results. Repeated talc injection through the drain may prove useful for patients in poor clinical status.
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Affiliation(s)
- Jalal Assouad
- Department of Thoracic Surgery, Georges Pompidou European Hospital, Paris, France
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Xiol X, Castellote J, Cortes-Beut R, Delgado M, Guardiola J, Sesé E. Usefulness and complications of thoracentesis in cirrhotic patients. Am J Med 2001; 111:67-9. [PMID: 11448663 DOI: 10.1016/s0002-9343(01)00744-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- X Xiol
- Servicio Aparato Digestivo, Hospital de Bellvitge "Princeps d'Espanya", L'Hospitalet de Llobregat, Barcelona, Spain
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Jones EG. Hepatic hydrothorax: a retrospective case study. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2001; 13:209-14. [PMID: 11930471 DOI: 10.1111/j.1745-7599.2001.tb00022.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- E G Jones
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
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Bhattacharya A, Mittal BR, Biswas T, Dhiman RK, Singh B, Jindal SK, Chawla Y. Radioisotope scintigraphy in the diagnosis of hepatic hydrothorax. J Gastroenterol Hepatol 2001; 16:317-21. [PMID: 11339424 DOI: 10.1046/j.1440-1746.2001.02441.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pleural effusion in cirrhotic patients (hepatic hydrothorax) may result from migration of ascitic fluid across defects in the diaphragm. Biochemical analysis of ascitic and pleural fluid provides only indirect information about the nature and origin of the effusion. The present study was performed in order to demonstrate the presence/absence of peritoneo-pleural communication by radioisotope imaging. METHODS Ten patients with cirrhotic ascites and pleural effusion were studied with 99mTc sulfur colloid scintigraphy to look for movement of the radiotracer from the peritoneal to the pleural cavity. Serum-ascitic albumin gradient (SAAG) and serum-pleural fluid albumin gradient (SPAG) values were determined in eight patients to examine the nature of the ascitic and pleural fluids. RESULTS Transdiaphragmatic movement of ascitic fluid into the pleural space was demonstrated (generally within 2 h of intraperitoneal injection of the radiotracer) in eight of 10 patients; six on the right side, one on the left and one bilaterally. Two patients in whom pleural fluid was transudative on SPAG values were negative for peritoneo-pleural communications. CONCLUSIONS Radionuclide scintigraphy is a simple, safe and relatively non-invasive method to confirm passage of ascitic fluid across the diaphragm.
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Affiliation(s)
- A Bhattacharya
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Abstract
Hepatic hydrothorax is defined as a pleural effusion in a patient with cirrhosis of the liver and no cardiopulmonary disease. The estimated prevalence of this often debilitating complication in patients with liver cirrhosis is 4% to 10%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. As a result patients are at increased risk of respiratory infection. Initial management consists of sodium restriction, diuretics, and thoracentesis. A transjugular intrahepatic portosystemic shunt may be required. Because most patients with hepatic hydrothorax have end-stage liver disease, a liver transplant should be considered if these options fail.
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Affiliation(s)
- K N Lazaridis
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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