Comparison of treatment of hepatic hydrothorax with catheter drainage versus serial thoracentesis

The Global Burden of Pleural Diseases

Pleural diseases include a spectrum of disorders broadly categorized into pneumothorax and pleural effusion. They often cause pain, breathlessness, cough, and reduced quality of life. The global burden of diseases reflects regional differences in conditions and exposures associated with pleural disease, such as smoking, pneumonia, tuberculosis, asbestos, cancer, and organ failure. Disease burden in high-income countries is overrepresented given the availability of data and disease burden in lower-income countries is likely underestimated. In the United States, in 2016, there were 42,215 treat-and-discharge visits to the emergency room for pleural diseases and an additional 361,270 hospitalizations, resulting in a national cost of $10.1 billion.

Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax

Background/Aims: The management of hepatic hydrothorax (HH) remains a challenging clinical scenario with suboptimal options. We investigated the effect and safety of pigtail catheter drainage compared to intermittent thoracentesis. Methods: This multicenter, retrospective study included 164 cirrhotic patients with recurrent pleural effusion from March 2012 to June 2017. Patients with neoplasms, cardiopulmonary disease, and infectious conditions were excluded. We compared the clinical outcomes of pigtail catheter drainage versus thoracentesis for variables including complications related to procedures, overall survival, and re-admission rates. Results: A total of 164 patients were divided into pigtail catheter (n = 115) and thoracentesis (n = 49) groups. During the follow-up period of 6.93 months after discharge, 98 patients died (pigtail; n = 47 vs. thoracentesis; n = 51). The overall survival (p = 0.61) and 30-day mortality (p = 0.77) rates were similar between the pigtail catheter and thoracentesis groups. Only MELD scores were associated with overall survival (adjusted HR, 1.08; p < 0.01) in patients with HH. Spontaneous pleurodesis occurred in 59 patients (51.3%) in the pigtail catheter group. Re-admission rates did not differ between the pigtail catheter and thoracentesis groups (13.2% vs 19.6% p = 0.7). A total of five complications occurred, including four total cases of bleeding (one patient in the pigtail catheter group and three in the thoracentesis group) and one case of empyema in the pigtail catheter group. Conclusions: Pigtail catheter drainage is not inferior to that of intermittent thoracentesis for the management of HH, proving it may be an effective and safe clinical option.

Hepatic hydrothorax in a child and its management

Hepatic hydrothorax is a rare complication of portal hypertension. The optimal treatment for this condition is liver transplantation. Liver transplantation is significantly more manageable in children who weigh more than 8 kg. Here, an implantable pleural access device was used in a 5-month-old infant for painless iterative punctures to relieve respiratory symptoms, while waiting for liver transplantation and the patient's growth. The patient underwent successful transplantation 3 months later with a more optimal weight.

An Unexpected Hepatic Hydrothorax After a Successful Kasai Portoenterostomy: A Case Report

Hepatic hydrothorax (HH) represents a rare complication of portal hypertension among adult cirrhotic patients. Here, we describe a pediatric case of HH, observed in a biliary atresia infant. The child presented with recurrent right-sided pleural effusion, after a successful Kasai portoenterostomy with restoration of bile flow and without overt signs of hepatic failure. Recurrence of HH led the patient to liver transplant despite a low pediatric end-stage liver disease value. Although rare, HH can also occur in children and should be suspected in patients with portal hypertension and respiratory distress. HH may be an indication for liver transplantation.

Efficacy and safety of transjugular intrahepatic portosystemic shunt in difficult-to-manage hydrothorax in cirrhosis

BACKGROUND

Pleural effusions (PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited.

METHODS

Consecutive hospitalized cirrhotics having PE were retrospectively analysed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment (SMT), thoracentesis, catheter drainage and TIPS.

RESULTS

Of 1149 cirrhotics with PE (mean Child-Pugh 10.6 ± 1.8 and MELD 21.2 ± 7.4), 82.6% had hepatic hydrothorax (HH) and 12.3% were suspected tubercular PE (TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P < .01) on follow-up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP [Odd's ratio, OR: 4.5] and catheter drainage [OR: 2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. Fifty-one patients were selected for TIPS [lower mean CTP 9.9 ± 1.6 and MELD score 18.7 ± 5.4]. Despite reduction in pressure gradient from 23.1 ± 3.8 mm Hg to 7.2 ± 2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy (eight patients, six resolved) and ischaemic hepatitis (four patients, two resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD > 25, SBP and septic shock.

CONCLUSION

Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. The role of haemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.

Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

PURPOSE

Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage.

MATERIALS AND METHODS

Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled.

RESULTS

The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index <19 kg/m², refractory hepatic hydrothorax not managed with liver transplantation, Child-Turcotte-Pugh score >10, and history of severe encephalopathy (grade >2) were associated with poor survival.

CONCLUSION

Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Pleural Effusion Outcomes in Intensive Care: Analysis of a Large Clinical Database

BACKGROUND

Pleural effusions are common in critically ill patients. However, the management of pleural fluid on relevant clinical outcomes is poorly studied. We evaluated the impact of pleural effusion in the intensive care unit (ICU).

METHODS

A large observational ICU database Multiparameter Intelligent Monitoring in Intensive Care III was utilized. Analyses used matched patients with the same admission diagnosis, age, gender, and disease severity.

RESULTS

Of 50 765, 3897 (7.7%) of critically ill adult patients had pleural effusions. Compared to patients without effusion, patients with effusion had higher in-hospital (38.7% vs 31.3%, P < .0001), 1-month (43.1% vs 36.1%, P < .0001), 6-month (63.6% vs 55.7%, P < .0001), and 1-year mortality (73.8% vs 66.1%, P < .0001), as well as increased length of hospital stay (17.6 vs 12.7 days, P < .0001), ICU stay (7.3 vs 5.1 days, P < .0001), need for mechanical ventilation (63.1% vs 55.7%, P < .0001), and duration of mechanical ventilation (8.7 vs 6.3 days, P < .0001). A total of 1503 patients (38.6%) underwent pleural fluid drainage. Patients in the drainage group had higher in-hospital (43.9% vs 35.4%, P = .0002), 1-month (47.7% vs 39.7%, P = .0005), 6-month (67.1% vs 61.8%, P = .0161), and 1-year mortality (77.1% vs 72.1%, P = .0147), as well as increased lengths of hospital stay (22.1 vs 16.0 days, P < .0001), ICU stay (9.2d vs 6.4 days, P < .0001), and duration of mechanical ventilation (11.7 vs 7.1 days, P < .0001).

CONCLUSIONS

The presence of a pleural effusion was associated with increased mortality in critically ill patients regardless of disease severity. Drainage of pleural effusion was associated with worse outcomes in a large, heterogeneous cohort of ICU patients.