A fascinating presentation of hepatic hydrothorax

We report this case of a 43-year-old woman with hepatitis-C cirrhosis who presented with a large right sided pleural effusion complicated by hypoxic respiratory failure and altered mentation necessitating dependence on mechanical ventilation. The pleural effusion spontaneously resolved upon initiation of mechanical positive pressure ventilation and recurred almost immediately after weaning the patient off the ventilator. The pre-ventilation, ventilation and post-ventilation chest X-ray films in chronological order present a striking visual demonstration of fluid dynamics and pathophysiology of hepatic hydrothorax, thereby obviating the need for a dedicated diagnostic test. We also report this case to highlight the treatment strategies for this often intractable complication.     

Management of ascites and hepatic hydrothorax

The natural course of patients with cirrhosis is frequently complicated by the accumulation of fluid in the peritoneal or pleural cavities and interstitial tissue. Functional renal abnormalities that occur as a consequence of decreased effective arterial blood volume are responsible for fluid accumulation in the form of ascites and hepatic hydrothorax. Ascites is the most common complication of cirrhosis and poses an increased risk for infections, renal failure and mortality. Patients have a poor prognosis and it is estimated that nearly half will die in approximately 2 years without liver transplantation. Hepatic hydrothorax is defined as a pleural effusion greater than 500 mL (mostly right-sided) in patients with cirrhosis without cardiopulmonary disease; the estimated prevalence is approximately 5-10%. Liver transplantation is the most definitive cure for both conditions in those patients that are suitable candidates. However, the mainstay of therapy for minimizing fluid accumulation in both conditions includes sodium restriction and administration of diuretics. This article reviews the most current concepts of pathogenesis, clinical findings, diagnosis, and treatment of these complications of cirrhosis.     

Chemical pleurodesis for hepatic hydrothorax.

BACKGROUND: Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed. OBJECTIVE: This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment. METHODS: Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis. RESULTS: These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure. CONCLUSION: This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.     

肝硬化腹水和肝性胸水的治疗

腹水和肝性胸水是肝硬化失代偿期的并发症,其产生主要是由于门脉压升高、激活交感神经系统、肾素-血管紧张素-醛固酮系统、血浆胶体渗透压降低等因素有关,肝性胸水还有膈肌破裂形成裂孔等有关。治疗上多采用利尿剂、排放腹腔积液、输注白蛋白、腹水浓缩静脉回输、外科手术,甚至肝移植等综合治疗措施。     

Case report: hepatic hydrothorax without ascites

Pleural effusion due to hepatic cirrhosis and ascites is well known. We describe three patients with right-sided hepatic hydrothorax in the absence of ascites. The formation of pleural fluid in these patients is probably a result of fluid movement from peritoneal to pleural space across diaphragmatic defects before ascites can form. The differential diagnosis of a right-sided transudative pleural effusion in a patient with chronic liver disease with or without ascites includes congestive left ventricular failure and nephrotic syndrome. These diseases are usually ruled out with standard clinical tests. Patients with hepatic hydrothorax should be treated with fluid restriction and diuretics. Patients with severe symptoms due to refractory hepatic hydrothorax might benefit from pleural sclerosis and surgical closure of diaphragmatic defects.     

Successful treatment of hepatic hydrothorax with octreotide

Hepatic hydrothorax is a rare complication of cirrhosis. Controlling ascites formation is the goal of therapy. We report the case of an adult patient presenting with alcoholic cirrhosis who developed first a symptomatic hydrothorax, refractory to diuretics and fluid and sodium restriction, and then an hepatorenal syndrome. Treatment consisted of chest tube insertion and 5 days' intravenous infusion of octreotide. Complete clinical and biological data were reviewed. Octreotide administration resulted in an increased urinary outflow and sodium output, concomitant with improved renal function. The patient has been free of symptoms after discharge from hospital for a follow-up period of 5 months. This observation raises interesting issues regarding the possible utility of splanchnic vasoconstrictors, reducing portal hypertension, in the treatment of refractory hepatic hydrothorax.     

Ultrasound documentation of diaphragmatic rent in hepatic hydrothorax

Two patients with alcoholic cirrhosis of the liver with ascites were evaluated for the pathogenesis of right sided massive pleural effusion. The clinical course of events suggested a large communication between the peritoneal space and right pleural cavity. Real time ultrasonography revealed evidence of a tear in the right hemidiaphragm. The role of ultrasound in the documentation of cause of hydrothorax in chronic liver disease is highlighted.     

Isotopic exploration of hepatic hydrothorax: ten cases

OBJECTIVE: The aim of this retrospective study was to evaluate the performance of peritoneal scintigraphy for the diagnosis of peritoneopleural communication in patients with cirrhosis and to discuss its role in therapeutic management. PATIENTS AND METHODS: Ten patients with cirrhosis and pleural effusion were included in this study. Cirrhosis was due to viral hepatitis in eight patients, auto-immune disease in one patient and of unknown origin in one. The pleural effusion was right-sided in nine patients and bilateral in one. 99m-technetium sulfur colloid peritoneal scintigraphy was performed in all patients. RESULTS: Scintigraphy revealed peritoneopleural communication in nine patients. In four patients, radioactivity appeared in the pleural cavity within a few minutes after injection of the radiotracer. In three of them, a large diaphragmatic defect was demonstrated by ultrasonography, magnetic resonance imaging or thoracoscopy. Complete response to medical treatment was observed in four patients. Scintigraphy revealed rapid radioactivity migration in four patients; diuretic treatment led to resolution of the hydrothorax in one of them. Three patients whose hydrothorax was refractory to medical treatment were treated by pleurodesis with talc. Resolution of the hydrothorax was achieved in one of them. CONCLUSION: Peritoneal scintigraphy is a simple non-invasive method enabling confirmation of peritoneopleural communication in cirrhotic patients. The importance of the diaphragmatic defect can also be evaluated, providing a significant contribution to therapeutic decision-making.     

Radioisotope scintigraphy in the diagnosis of hepatic hydrothorax

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.     

Refractory hepatic hydrothorax: successful treatment with octreotide.

We report the case of a patient that developed hepatic hydrothorax as the first complication of liver cirrhosis. Due to the lack of response to diuretics, pleurodesis and TIPS, treatment with octreotide was started with resolution of hydrothorax. To the best of our knowledge, this is the third reported case of refractory hepatic hydrothorax with complete and sustained response to octreotide.     

肝性胸水的诊治进展

肝性胸水(hepatic hydrothorax)是肝硬化失代偿期出现的胸腔积液,并排除心肺疾病引起的胸水,发病率为5%～10%~([1]).肝性胸水一般同时存在大量腹水,少量腹水或无腹水的患者亦可发生,是肝硬化相对少见的并发症,但具有潜在危险性.由于多数患者伴有严重的肝功能障碍及代谢紊乱,使治疗较为棘手,常因呼吸功能衰竭或严重缺氧而加重肝功能衰竭导致死亡.     

Refractory hepatic hydrothorax treated with transjugular intrahepatic portosystemic shunt

A 66-year-old cirrhotic woman was referred to our hospital for evaluation of refractory pleural effusion and dyspnea. Massive right sided-pleural effusion but no ascites was detected. She had been treated with diuretics and albumin, repeated thoracenteses, and pleural drainage with an intercostal catheter, all of which had failed to relieve her symptoms. The diagnosis of hepatic hydrothorax without ascites was made by injection of technetium-99m-sulfur colloid into the peritoneal cavity. A transjugular intrahepatic portosystemic shunt was placed and successfully reduced the pleural effusion, resulting in complete relief of her symptoms. The patient has been free of symptoms for 18 months after the procedure. (Received Jan. 19, 1998; accepted June 24, 1998)     

Outcomes of patients with chest tube insertion for hepatic hydrothorax

Purpose  

Case reports and small case series have reported a high rate of complications associated with chest tube placement for hepatic hydrothorax. We describe the in-hospital and 3-month outcomes of patients who have had this procedure.