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Bommena S, Fallon MB. Pulmonary Complications of Portal Hypertension. Clin Liver Dis 2024; 28:467-482. [PMID: 38945638 DOI: 10.1016/j.cld.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.
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Affiliation(s)
- Shoma Bommena
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, AZ, USA
| | - Michael B Fallon
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, 475 North 5th Street, Phoenix, AZ 85004, USA.
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2
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Alshabani K, Rivera E, Paton A, Lara JC, Fernandez-Bussy S, Majid A. Pleural Port-A-Cath for Symptomatic Refractory Hepatic Hydrothorax in Nontransplant Liver Patients. Ann Am Thorac Soc 2024; 21:823-826. [PMID: 38691004 DOI: 10.1513/annalsats.202306-580cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 12/08/2023] [Indexed: 05/03/2024] Open
Affiliation(s)
- Khaled Alshabani
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Estefania Rivera
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Alichia Paton
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Juan Camilo Lara
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | | | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
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Garin D, Voirol U, Vaucher J, Grandmaison G. Left hepatic hydrothorax without ascites. BMJ Case Rep 2024; 17:e258427. [PMID: 38199650 PMCID: PMC10806850 DOI: 10.1136/bcr-2023-258427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Hepatic hydrothorax (HH) is a complication in patients with cirrhosis and portal hypertension. It predominantly presents in the right pleural cavity and usually associates with ascites. Few cases of HH occurring without detectable ascites have been reported. This case report comprehensively presents a case of a refractory left unilateral HH without ascites. The patient benefited from palliative care and the HH was managed using a semipermanent indwelling pleural catheter until she died 3 months after diagnosis.
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Affiliation(s)
- Dorian Garin
- Division of Internal Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Ulysse Voirol
- Division of Internal Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
| | - Julien Vaucher
- Division of Internal Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
- Division of Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Gaël Grandmaison
- Division of Internal Medicine, University and Hospital of Fribourg, Fribourg, Switzerland
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4
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Porcel JM. Expert Review on Contemporary Management of Common Benign Pleural Effusions. Semin Respir Crit Care Med 2023. [PMID: 37263288 DOI: 10.1055/s-0043-1769096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Heart failure (HF) and cirrhosis are frequently associated with pleural effusions (PEs). Despite their apparently benign nature, both HF-related effusions and hepatic hydrothorax (HH) have poor prognosis because they represent an advanced stage of the disease. Optimization of medical therapy in these two entities involve not only the use of diuretics, but also other pharmacological therapies. For instance, all HF patients with reduced or mildly reduced left ventricular ejection fraction can benefit from angiotensin receptor-neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. Conversely, it is better for HH patients to avoid nonselective beta blockers. Refractory cardiac- and cirrhosis-related PEs are commonly managed by iterative therapeutic thoracentesis. When repeated aspirations are needed, thereby diminishing quality of life, the insertion of an indwelling pleural catheter (IPC) may be warranted. However, in selected HH patients who are diuretic-resistant or diuretic-intractable, placement of transjugular intrahepatic portosystemic shunts should be considered as a bridge to liver transplantation, whereas in transplant candidates the role of IPC is debatable. Another benign condition, pleural tuberculosis (TB) is a serious health problem in developing countries. Diagnostic certainty is still a concern due to the paucibacillary nature of the infection, although the use of more sensitive nucleic acid amplification tests is becoming more widespread. Its treatment is the same as that of pulmonary TB, but the potential drug interactions between antiretroviral and anti-TB drugs in HIV-coinfected patients as well as the current recommended guidelines for the different types of anti-TB drugs resistance should be followed.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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Sidhu C, Davies HE, Muruganandan S, Lui MMS, Lau EPM, Lee YCG. Indwelling Pleural Catheter: Management of Complications. Semin Respir Crit Care Med 2023. [PMID: 37257836 DOI: 10.1055/s-0043-1769093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.
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Affiliation(s)
- Calvin Sidhu
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Health, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Macy M S Lui
- Division of Respiratory Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
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Wang S, Zhang R, Wan C, Qin J, Hu X, Shen Y, Chen L, Wen F. Incidence of complications from indwelling pleural catheter for pleural effusion: A meta-analysis. Clin Transl Sci 2022; 16:104-117. [PMID: 36253892 PMCID: PMC9841307 DOI: 10.1111/cts.13430] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/15/2022] [Accepted: 09/19/2022] [Indexed: 02/06/2023] Open
Abstract
Indwelling pleural catheter (IPC) is widely used in patients with pleural effusion (PE). This meta-analysis aimed to comprehensively summarize the clinical complication from IPC. We searched four large electronic databases (PubMed, EMBASE, MEDLINE, and Cochrane Library) for potentially relevant studies and assessed the included studies' quality using the methodological index for nonrandomized studies' criteria. Extracted data were used to pool rates, and to conduct subgroup and meta-regression analyses. Forty-one studies involving a cumulative 4983 patients with 5650 IPCs were included in this meta-analysis. The overall incidence of IPC complications was 20.3% (95% confidence interval [CI]: 15.0-26.3). The top four complications were: overall infection incidence 5.7% (95% CI: 0.7-2.4); overall catheter abnormality incidence 4.4% (95% CI: 2.8-6.3); pain incidence 1.2% (95% CI: 0.4-2.4); and overall loculation incidence 0.9% (95% CI: 0.1-2.1). Subgroup and meta-regression analyses for overall complications and infections by country, PE site, and PE type demonstrated these factors did not contribute significantly to heterogeneity. Further subgroup analyses for infection of benign PE showed that the overall infection incidence (12.6% [95% CI: 8.1-17.8] vs 0.7% [95% CI: 0.0-4.5]) and empyema incidence (9.1% [95% CI: 5.3-13.8] vs 0.0% [95% CI: 0.0-2.3]) of patients with liver-related PE were significantly higher than that of patients with heart-related PE. Our meta-analysis showed reliable pooled incidences of IPC-related complications, with infection being the most common. These results serve to remind clinicians about the incidence of IPC-related complications and emphasize the importance of taking corresponding preventive and therapeutic steps.
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Affiliation(s)
- Shuyan Wang
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Rui Zhang
- Department of Medical InformaticsWest China Hospital, Sichuan UniversityChengduChina
| | - Chun Wan
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Jiangyue Qin
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Xueru Hu
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Yongchun Shen
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Lei Chen
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
| | - Fuqiang Wen
- Department of Respiratory and Critical Care MedicineDivision of Pulmonary Diseases, State Key Laboratory of Biotherapy of ChinaWest China Hospital of Sichuan UniversityChengduChina
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Reiche W, Deliwala S, Chandan S, Mohan BP, Dhindsa B, Ramai D, Perisetti A, Rangray R, Mukherjee S. Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis. World J Hepatol 2022; 14:1258-1268. [PMID: 35978675 PMCID: PMC9258251 DOI: 10.4254/wjh.v14.i6.1258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/06/2022] [Accepted: 05/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting.
AIM To explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE.
METHODS Major databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I2 and classic fail-safe to determine bias.
RESULTS Eight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I2 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I2 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I2 82.5).
CONCLUSION SBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.
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Affiliation(s)
- William Reiche
- Department of Internal Medicine, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Smit Deliwala
- Department of Internal Medicine, Michigan State University at Hurley Medical Center, Flint, MI 48503, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Babu P Mohan
- Department of Gastroenterology, University of Utah, Salt Lake City, UT 84132, United States
| | - Banreet Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah, Salt Lake City, UT 84132, United States
| | - Abhilash Perisetti
- Division of Gastroenterology, Parkview Health, Fort Wayne, IN 46845, United States
| | - Rajani Rangray
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68124, United States
| | - Sandeep Mukherjee
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68124, United States
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