A case series: Egyptian experience in using chemical pleurodesis as an alternative management in refractory hepatic hydrothorax

Pulmonary complications of portal hypertension: The overlooked decompensation

The systemic nature of cirrhosis and portal hypertension has long been recognized, and the amount of data characterizing the interplay between each system is becoming ever so complex. Lung involvement was among the first described associated entities in cirrhosis, with reports dating back to the late nineteenth century. However, it appears that throughout the years, interest in the pulmonary complications of portal hypertension has generally faded, especially in contrast to other decompensating events, as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers. Despite affecting up to 10%-15% of patients with advanced liver disease and having a proven prognostic impact, hepato-pulmonary syndrome, porto-pulmonary hypertension, and hepatic hydrothorax are frequently misdiagnosed, mistreated, or misinterpreted. This lack of precision might adversely impact patient care, referral to expert centers, and, ultimately, liver disease-related mortality and successful transplantation odds. The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities. The paper focuses on the essential theoretical aspects, addressing the most critical knowledge gaps on the one hand and, on the other hand, critically discussing one key issue for each complication.

Pleural Interventions in the Management of Hepatic Hydrothorax

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.

A study of efficacy and safety of tranexamic acid versus iodopovidone in pleurodesis via pigtail catheter in management of recurrent pleural effusion

Background

Researches to detect the ideal agent for pleurodesis are still continuous; iodopovidone is one of the best agents for pleurodesis that are commonly used. Tranexamic acid is also considered by many authors as a safe, cheap, and effective agent for pleurodesis.

Results

Group I (patients subjected to pleurodesis using tranexamic acid) had a higher complete response with a success rate 88% compared with 76% for group II (patients subjected to pleurodesis using iodopovidone) at the end of the study in 12 weeks. Complications were nearly equal in both groups. Chest pain, hypotension, and fever were the most common reported complications.

Conclusions

Tranexamic acid and iodopovidone were found to be effective alternative agents for pleurodesis with low cost and minimal complications.

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.

Hepatic hydrothorax: An update and review of the literature

This review considers the modern concepts of pathogenesis, diagnostic methods, and treatment principles of hepatic hydrothorax (HH). HH is the excessive (> 500 mL) accumulation of transudate in the pleural cavity in patients with decompensated liver cirrhosis but without cardiopulmonary and pleural diseases. It causes respiratory failure which aggravates the clinical course of liver cirrhosis, and the emergence of spontaneous bacterial pleural empyema may be the cause of death. The information was collected from the PubMed database, the Google Scholar retrieval system, the Cochrane reviews, and the reference lists from relevant publications for 1994-2016 using the keywords: “liver cirrhosis”, “portal hypertension”, “hepatic hydrothorax”, “pathogenesis”, “diagnostics”, and “treatment”. To limit the scope of this review, only articles dealing with uncomplicated hydrothorax in patients with liver cirrhosis were included. The analysis of the data showed that despite the progress of modern hepatology, the presence of HH is associated with poor prognosis and high mortality. Most patients suffering from it are candidates for orthotopic liver transplantation. In routine clinical practice, stratification of the risk for an adverse outcome and the subsequent determination of individual therapeutic strategies may be the keys to the successful management of the patient’s condition. The development of pathogenetic pharmacotherapy and optimization of minimally invasive treatment will improve the quality of life and increase the survival rate among patients with HH.

Clarifying the distinction between case series and cohort studies in systematic reviews of comparative studies: potential impact on body of evidence and workload

Distinguishing cohort studies from case series is difficult.We propose a conceptualization of cohort studies in systematic reviews of comparative studies. The main aim of this conceptualization is to clarify the distinction between cohort studies and case series. We discuss the potential impact of the proposed conceptualization on the body of evidence and workload.All studies with exposure-based sampling gather multiple exposures (with at least two different exposures or levels of exposure) and enable calculation of relative risks that should be considered cohort studies in systematic reviews, including non-randomized studies. The term "enables/can" means that a predefined analytic comparison is not a prerequisite (i.e., the absolute risks per group and/or a risk ratio are provided). Instead, all studies for which sufficient data are available for reanalysis to compare different exposures (e.g., sufficient data in the publication) are classified as cohort studies.There are possibly large numbers of studies without a comparison for the exposure of interest but that do provide the necessary data to calculate effect measures for a comparison. Consequently, more studies could be included in a systematic review. Therefore, on the one hand, the outlined approach can increase the confidence in effect estimates and the strengths of conclusions. On the other hand, the workload would increase (e.g., additional data extraction and risk of bias assessment, as well as reanalyses).

Efficacy of nonsurgical tigecycline pleurodesis for the management of hepatic hydrothorax in patients with liver cirrhosis

Chemical pleurodesis is one of the therapeutic tools to control hepatic hydrothorax. Tetracycline and derivatives have been widely accepted as an effective and safe treatment for the purpose, but availability is the big concern. Tigecycline is an antibiotic derivative of tetracycline, which has demonstrated to be an effective pleurodesing agent in animal models. The aim of the study was to document two successful tigecycline pleurodesis in patients with decompensated liver cirrhosis, who were not candidates for liver transplantation. Both patients were undergoing palliative treatment for cirrhosis and developed massive pleural effusion on the right side. They underwent chemical pleurodesis in the first instance. Diagnostic thoracocentesis was done to rule out differentials and to confirm the clinical suspicion, following which, complete drainage of pleural fluids was achieved. Tigecycline of 3 mg/kg was instilled intrapleurally via the thoracic catheter, as per the protocol. The medical records and images were thoroughly reviewed. There was no recurrence of the effusion for at least 3 months, with no detected complications in the short- or long-term follow-up. In conclusion, pleurodesis with tigecycline seems to be effective and safe for the management of symptomatic hepatic hydrothorax and should therefore be promoted in the setting of liver cirrhosis at least for a short-term relief, especially in patients who do not meet the criteria for liver transplantation.

Management of refractory hepatic hydrothorax

PURPOSE OF REVIEW

Treatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax.

RECENT FINDINGS

Hepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of cases. Primary management options for these patients include serial thoracenteses, transjugular intrahepatic portosystemic shunt (TIPS) placement, and insertion of an indwelling pleural catheter (IPC). Response rate to TIPS, being the first choice whenever possible, is about 80%. IPC is emerging as a feasible alternative in patients who require frequent therapeutic thoracenteses, particularly if TIPS is contraindicated. Pleurodesis is not advocated because of the low likelihood of a pleural symphysis owing to the rapid re-accumulation of pleural fluid. The only cure for hepatic hydrothorax, a defined complication of end-stage liver disease, is liver transplantation.

SUMMARY

No single treatment option for refractory hepatic hydrothorax is ideal. However, in patients with contraindications to or who are awaiting liver transplantation, TIPS seems the most beneficial therapy, whereas IPC promises to be an alternative second-line consideration.

Symptomatic hepatic hydrothorax successfully treated with transjugular intrahepatic portosystemic shunt (TIPS)–role of titration of portosystemic gradient reduction to avoid post‐TIPS encephalopathy

Key Clinical Message

We describe a challenging case of hepatic hydrothorax secondary to nonalcoholic steatohepatitis cirrhosis. Our management involved successfully treating the hydrothorax with a transjugular intrahepatic porto-systemic shunt but having to manage the subsequent complication of hepatic encephalopathy. We conclude with a review of the available literature.

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.