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1
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Bucurica S, Parolă I, Vasile AG, Maniu I, Mititelu MR. The Impact of Hepatic Hydrothorax on the Outcome of Liver Cirrhosis: A Comparative Study. J Clin Med 2025; 14:212. [PMID: 39797295 PMCID: PMC11720851 DOI: 10.3390/jcm14010212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Revised: 12/14/2024] [Accepted: 12/31/2024] [Indexed: 01/13/2025] Open
Abstract
Introduction: Hepatic hydrothorax (HH) is a severe cirrhosis complication requiring early diagnosis and appropriate management. This study aimed to assess the impact of HH on the disease severity and mortality of cirrhotic patients and compare their clinical and biological profiles with those of patients without HH. Materials and Methods: This retrospective study involved 155 patients diagnosed with cirrhosis, of whom 31 had HH. The diagnosis of HH was based on imaging techniques such as X-ray, ultrasound, and thoracic CT scans. The severity of cirrhosis was evaluated using the Child-Pugh, MELD, MELD-Na, and MELD 3.0 scoring systems. Results: Of the included patients, 83.87% (n = 26) were men, with a 20% incidence of HH. The main etiology was chronic alcohol use. The pleural fluid localization revealed similar numbers of patients with bilateral and right pleural distribution. Patients with HH were predominantly classified in Child-Pugh-Turcotte class C. The MELD, MELD-Na, and MELD 3.0 scores had higher median values in the group of patients with hepatic hydrothorax. Still, death occurred at lower MELD scores when compared with cirrhotic patients without HH (MELD score > 22.5 for patients with HH vs. MELD > 32.5 for patients without HH). (The cirrhotic patients with HH presented lower serum albumin, cholesterol, and triglyceride levels and higher bilirubin, INR, and creatinine values. The mortality rate was higher in the group with HH-58,06% versus 20.97% in the control group (cirrhotics without HH). Conclusions: Hepatic hydrothorax is a serious complication of cirrhosis that requires early recognition and proper management, supported by using biomarkers and scoring systems.
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Affiliation(s)
- Sandica Bucurica
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania;
- Department of Gastroenterology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Ioana Parolă
- Department of Gastroenterology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
| | - Alexandru Gavril Vasile
- Department of Gastroenterology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania;
| | - Ionela Maniu
- Department of Mathematics and Informatics, Faculty of Sciences, Lucian Blaga University Sibiu, 550012 Sibiu, Romania
- Research Team, Pediatric Clinical Hospital Sibiu, 550166 Sibiu, Romania
| | - Mihaela-Raluca Mititelu
- Department of Nuclear Medicine, University of Medicine and Pharmacy Carol Davila Bucharest Romania, 020021 Bucharest, Romania;
- Department of Nuclear Medicine, University Emergency Central Military Hospital, 010825 Bucharest, Romania
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2
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Sundaralingam A, Grabczak EM, Burra P, Costa MI, George V, Harriss E, Jankowska EA, Janssen JP, Karpathiou G, Laursen CB, Maceviciute K, Maskell N, Mei F, Nagavci B, Panou V, Pinelli V, Porcel JM, Ricciardi S, Shojaee S, Welch H, Zanetto A, Udayaraj UP, Cardillo G, Rahman NM. ERS statement on benign pleural effusions in adults. Eur Respir J 2024; 64:2302307. [PMID: 39060018 DOI: 10.1183/13993003.02307-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 06/10/2024] [Indexed: 07/28/2024]
Abstract
The incidence of non-malignant pleural effusions far outweighs that of malignant pleural effusions and is estimated to be at least 3-fold higher. These so-called benign effusions do not follow a "benign course" in many cases, with mortality rates matching and sometimes exceeding those of malignant pleural effusions. In addition to the impact on patients, healthcare systems are also significantly affected, with recent US epidemiological data demonstrating that 75% of resource allocation for pleural effusion management is spent on non-malignant pleural effusions (excluding empyema). Despite this significant burden of disease, and by existing at the junction of multiple medical specialties, reflecting a heterogenous constellation of medical conditions, non-malignant pleural effusions are rarely the focus of research or the subject of management guidelines. With this European Respiratory Society Task Force, we assembled a multispecialty collaborative across 11 countries and three continents to provide a statement based on systematic searches of the medical literature to highlight evidence in the management of the following clinical areas: a diagnostic approach to transudative effusions, heart failure, hepatic hydrothorax, end-stage renal failure, benign asbestos-related pleural effusion, post-surgical effusion and nonspecific pleuritis.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Respiratory Trials Unit, Churchill Hospital, Headington, UK
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Elzbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - M Inês Costa
- Pulmonology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
- Hunter Medical Research Institute, Newcastle, Australia
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Ewa A Jankowska
- Division of Translational Cardiology and Clinical Registries, Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Julius P Janssen
- Dept of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Georgia Karpathiou
- Pathology Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Federico Mei
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Marche, Italy
- Respiratory Disease Unit, University Hospital, Ancona, Italy
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Vasiliki Panou
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Respiratory Diseases, Aalborg University Hospital, Aalborg, Denmark
| | | | - José M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Sara Ricciardi
- Division of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Samira Shojaee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hugh Welch
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology, and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Udaya Prabhakar Udayaraj
- Oxford Kidney Unit, Churchill Hospital, Oxford, UK
- Nuffield Department of Medicine, Henry Wellcome Building for Molecular Physiology, University of Oxford, Oxford, UK
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
- Unicamillus, International University of Health Sciences, Rome, Italy
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Churchill Hospital, Headington, UK
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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3
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Rijal Y, Banjade P, Oli S, Boethel C, Sharma M. Elusive Unilateral Pleural Effusion: Keys to Clinching the Diagnosis. Cureus 2024; 16:e69517. [PMID: 39416574 PMCID: PMC11481422 DOI: 10.7759/cureus.69517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2024] [Indexed: 10/19/2024] Open
Abstract
Unilateral pleural effusions may sometimes be difficult to diagnose. The cause may vary widely, including congestive heart failure, chronic liver and kidney disease, various drugs, and underlying undiagnosed disorders of the lung and pleura. With advancements in chest imaging, new biomarkers, and less invasive methods for obtaining tissue samples, it may be possible to identify the cause of the unilateral pleural effusions whose etiology is unclear. Even reviewing patient history, re-examining pleural fluid, classifying effusions based on Light's criteria, and ruling out pseudoexudates can help understand the cause. We aim to discuss a case of unilateral pleural effusion and, on its backdrop, discuss an approach to elusive unilateral pleural effusion.
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Affiliation(s)
- Yasoda Rijal
- Internal Medicine, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | | | - Seema Oli
- Internal Medicine, University of Pittsburgh Medical Center (UPMC), Harrisburg, USA
| | - Carl Boethel
- Pulmonology and Critical Care, Baylor Scott and White Medical Center, Temple, USA
| | - Munish Sharma
- Pulmonology and Critical Care, Baylor Scott and White Medical Center, Temple, USA
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4
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Trivedi D, Li K, Ahmed S, Fenton F, Shahzad S. Recurrent Left-Sided Hepatic Hydrothorax Leading to Liver-Mediated Dyspnea. Cureus 2024; 16:e63180. [PMID: 39070328 PMCID: PMC11273332 DOI: 10.7759/cureus.63180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/30/2024] Open
Abstract
Cirrhosis is a common liver condition caused by several etiologies including alcohol use disorder, infectious hepatitis, and metabolic dysfunction associated with liver disease. Although common symptomatic complications of cirrhosis include malaise, gastrointestinal bleeding, and abdominal distension, shortness of breath is a less common phenomenon that may occur. Hepatic hydrothorax (HH) is an uncommon cause of shortness of breath that is believed to be caused by the accumulation of ascitic fluid in the pleural space. While most cases of HH occur with ascites and the right side, we hereby present a case of a 70-year-old female with left-sided HH without ascites.
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Affiliation(s)
- Dhaval Trivedi
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Kin Li
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Sana Ahmed
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Franklyn Fenton
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Saleem Shahzad
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
- Pulmonary and Critical Care Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
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5
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Tiwari N, Shlomovitz E, Capel J, Wong F. Innovative Management of a Difficult Case of Hepatic Hydrothorax. ACG Case Rep J 2024; 11:e01372. [PMID: 38854808 PMCID: PMC11161277 DOI: 10.14309/crj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/22/2024] [Indexed: 06/11/2024] Open
Abstract
Hepatic hydrothorax affects 5%-15% of decompensated cirrhosis patients, with up to 26% being refractory to standard treatments. For those ineligible for transjugular intrahepatic systemic shunts or liver transplants, alternatives to repeated thoracentesis are limited but can include the insertion of an indwelling pleural catheter. We present the first case of the use of an automatic low-flow ascites pump (alfapump) to manage nonmalignant pleural effusion in an elderly patient with cirrhosis.
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Affiliation(s)
- Neha Tiwari
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Eran Shlomovitz
- Joint Medical Imaging Department, Toronto General Hospital, University of Toronto, Toronto, Canada
| | | | - Florence Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Toronto General Hospital, University of Toronto, Toronto, Canada
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6
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Vidyani A, Sibarani CI, Widodo B, Purbayu H, Thamrin H, Miftahussurur M, Setiawan PB, Sugihartono T, Kholili U, Maimunah U. Diagnosis and Management of Hepatic Hydrothorax. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:45-53. [PMID: 38389460 DOI: 10.4166/kjg.2023.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 02/24/2024]
Abstract
Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).
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Affiliation(s)
- Amie Vidyani
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Citra Indriani Sibarani
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Budi Widodo
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Herry Purbayu
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Husin Thamrin
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Muhammad Miftahussurur
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
- Helicobacter pylori and Mycrobiota Study Group, Institute Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Poernomo Boedi Setiawan
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Titong Sugihartono
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Ulfa Kholili
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
| | - Ummi Maimunah
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga - Dr.Soetomo Teaching Hospital, Surabaya, Indonesia
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7
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Osman KT, Naritsin A, Amuchi B, Qamar AA. Liver transplantation for refractory hepatic hydrothorax is associated with a greater survival benefit compared to other complications of cirrhosis. Liver Transpl 2024; 30:142-150. [PMID: 37450656 DOI: 10.1097/lvt.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
Hepatic hydrothorax (HH) is a significant complication of cirrhosis associated with increased mortality. Liver transplantation (LT) remains the best treatment modality. We aim to assess predictors of mortality and the survival benefit of LT in patients with HH. A prospectively maintained cohort of adult patients with cirrhosis, being evaluated for LT at our institution, was retrospectively reviewed from 2015 to 2020. The primary outcome was death or LT. Cox proportional hazard regression identified associations between covariates and death. We calculated the years saved due to LT by comparing patients who were on the waiting list with patients who received an LT. This was done by calculating the area under the Kaplan-Meier curve. Censoring occurred at the time of the last follow-up or death. Patients with refractory HH had the lowest median survival of only 0.26 years. Within the HH group, having a refractory HH group was significantly associated with an increased risk of mortality (HR 1.73; 95% CI 1.06-2.81; p -value 0.03). Refractory HH was also significantly associated with mortality when evaluated in the entire cohort and after adjusting for other covariates (HR 1.48, 95% CI 1.03-2.11; p -value 0.03). Patients with refractory HH had the highest 1-year survival benefit with LT (0.48 y), followed by patients with non-refractory HH (0.28 y), then patients with other complications of cirrhosis (0.19 y). In this large study evaluating the prognostic impact of HH on patients with cirrhosis, refractory HH was an independent predictor of mortality. LT provides an additional survival benefit to patients with HH compared with those without HH.
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Affiliation(s)
- Karim T Osman
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Anastasia Naritsin
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Brenda Amuchi
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Amir A Qamar
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Division of Transplant and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
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8
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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] [Accepted: 12/23/2023] [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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9
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Cadranel JFD, Ollivier-Hourmand I, Cadranel J, Thevenot T, Zougmore H, Nguyen-Khac E, Bureau C, Allaire M, Nousbaum JB, Loustaud-Ratti V, Causse X, Sogni P, Hanslik B, Bourliere M, Peron JM, Ganne-Carrie N, Dao T, Thabut D, Maitre B, Debzi N, Smadhi R, Sombie R, Kpossou R, Nouel O, Bissonnette J, Ruiz I, Medmoun M, Dastis SN, Deltenre P, Artru F, Raherison C, Elkrief L, Lemagoarou T. International survey among hepatologists and pulmonologists on the hepatic hydrothorax: plea for recommendations. BMC Gastroenterol 2023; 23:305. [PMID: 37697230 PMCID: PMC10496231 DOI: 10.1186/s12876-023-02931-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/23/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND The Hepatic hydrothorax is a pleural effusion related to portal hypertension; its diagnosis and therapeutic management may be difficult. The aims of this article are which follows: To gather the practices of hepatogastroenterologists or pulmonologists practitioners regarding the diagnosis and management of the hepatic hydrothorax. METHODS Practitioners from 13 French- speaking countries were invited to answer an online questionnaire on the hepatic hydrothorax diagnosis and its management. RESULTS Five hundred twenty-eight practitioners (80% from France) responded to this survey. 75% were hepatogastroenterologists, 20% pulmonologists and the remaining 5% belonged to other specialities. The Hepatic hydrothorax can be located on the left lung for 64% of the responders (66% hepatogastroenterologists vs 57% pulmonologists; p = 0.25); The Hepatic hydrothorax can exist in the absence of clinical ascites for 91% of the responders (93% hepatogastroenterologists vs 88% pulmonologists; p = 0.27). An Ultrasound pleural scanning was systematically performed before a puncture for 43% of the responders (36% hepatogastroenterologists vs 70% pulmonologists; p < 0.001). A chest X-ray was performed before a puncture for 73% of the respondeurs (79% hepatogastroenterologists vs 54% pulmonologists; p < 0.001). In case of a spontaneous bacterial empyema, an albumin infusion was used by 73% hepatogastroenterologists and 20% pulmonologists (p < 0.001). A drain was used by 37% of the responders (37% hepatogastroenterologists vs 31% pulmonologists; p = 0.26).An Indwelling pleural catheter was used by 50% pulmonologists and 22% hepatogastroenterologists (p < 0.01). TIPS was recommended by 78% of the responders (85% hepatogastroenterologists vs 52% pulmonologists; p < 0.001) and a liver transplantation, by 76% of the responders (86% hepatogastroenterologists vs 44% pulmonologists; p < 0.001). CONCLUSIONS The results of this large study provide important data on practices of French speaking hepatogastroenterologists and pulmonologists; it appears that recommendations are warranted.
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Affiliation(s)
| | | | | | | | - Honoré Zougmore
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Manon Allaire
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | | | | | | | | | - Marc Bourliere
- Hepatogastroenterology department, Saint-Joseph, Marseille, France
| | | | | | - Thong Dao
- Hepatogastroenterology department, CHU Caen, Caen, France
| | - Dominique Thabut
- Hepatogastroenterology Department, La Pitié Salpétrière, Paris, France
| | | | - Nabil Debzi
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Ryad Smadhi
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
- Hepatology Department CHU Mustapha, Alger, Algérie, Algeria
| | - Roger Sombie
- Gastroenterology Department, CHU Yalgado Ouedraogo Ouagadougou, Ouagadougou, Burkina Faso
| | - Raimi Kpossou
- Hepatogastroenterology Deparment, National Hospital and University Center Hubert Koutoukou Maga, Cotonou, Benin
| | - Olivier Nouel
- Hepatogastroenterology Department, St Brieuc, France
| | - Julien Bissonnette
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Isaac Ruiz
- Department of Hepatology and Liver Transplantation, University of Montreal Hospital, Montreal, Canada
| | - Mourad Medmoun
- Hepatogastroenterology and Nutrition Department GHPSO Boulevard Laennec, 60100, Creil, France
| | | | | | - Florent Artru
- Hepatogastroenterology Department, Lausanne, Suisse, Switzerland
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10
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Mandorfer M, Aigner E, Cejna M, Ferlitsch A, Datz C, Gräter T, Graziadei I, Gschwantler M, Hametner-Schreil S, Hofer H, Jachs M, Loizides A, Maieron A, Peck-Radosavljevic M, Rainer F, Scheiner B, Semmler G, Reider L, Reiter S, Schoder M, Schöfl R, Schwabl P, Stadlbauer V, Stauber R, Tatscher E, Trauner M, Ziachehabi A, Zoller H, Fickert P, Reiberger T. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023:10.1007/s00508-023-02229-w. [PMID: 37358642 DOI: 10.1007/s00508-023-02229-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Abstract
The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.
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Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Elmar Aigner
- First Department of Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Manfred Cejna
- Department of Radiology, LKH Feldkirch, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine I, KH Barmherzige Brüder Wien, Vienna, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tilmann Gräter
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, KH Hall in Tirol, Hall, Austria
| | - Michael Gschwantler
- Division of Gastroenterology and Hepatology, Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Stephanie Hametner-Schreil
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University of Innbsruck, Innsbruck, Austria
| | - Andreas Maieron
- Department of Internal Medicine II, University Hospital St. Pölten, St. Pölten, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Silvia Reiter
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Maria Schoder
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Tatscher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Ziachehabi
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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11
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Alhabeeb FF, Carle-Talbot K, Rakocevic N, Zhang T, Mitchell M, Amjadi K, Kwok C. Indwelling tunneled pleural catheters in patients with hepatic hydrothorax: A single-center analysis for outcomes and complications. CANADIAN JOURNAL OF RESPIRATORY, CRITICAL CARE, AND SLEEP MEDICINE 2022. [DOI: 10.1080/24745332.2022.2125459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Katia Carle-Talbot
- Respirology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | | | - Tinghua Zhang
- Ottawa Methods Centre, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Mitchell
- Schulich School of Medicine and Dentistry, Department of Medicine, Division of Respirology, Western University, London, Ontario, Canada
| | | | - Chanel Kwok
- Respirology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
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12
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Pippard B, Bhatnagar M, McNeill L, Donnelly M, Frew K, Aujayeb A. Hepatic Hydrothorax: A Narrative Review. Pulm Ther 2022; 8:241-254. [PMID: 35751800 PMCID: PMC9458779 DOI: 10.1007/s41030-022-00195-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.
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Affiliation(s)
- Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lisa McNeill
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katie Frew
- Department of Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, Northumbria Way, Northumberland, Cramlington, NE23 6NZ, UK.
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13
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Avula A, Acharya S, Anwar S, Narula N, Chalhoub M, Maroun R, Thapa S, Friedman Y. Indwelling Pleural Catheter (IPC) for the Management of Hepatic Hydrothorax: The Known and the Unknown. J Bronchology Interv Pulmonol 2022; 29:179-185. [PMID: 34753862 DOI: 10.1097/lbr.0000000000000823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 09/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hepatic hydrothorax (HH) is described as pleural effusion secondary to liver cirrhosis after ruling out other etiologies. We aim to assess the efficacy of an indwelling pleural catheter (IPC) placement in refractory HH in this systematic review and meta-analysis. METHODS A comprehensive search of literature was performed from inception to December 2020. The authors reviewed, selected, and abstracted the data from eligible studies into Covidence, a systematic review software. Cochrane criteria was used to rate each study for the risk of bias. The data abstracted were described using a random-effects model. Heterogeneity was evaluated using the I2 test. RESULTS Ten studies involving a total of 269 patients were included. The studies were analyzed for the proportion of pleurodesis achieved, the average time to pleurodesis, total complication rate, pleural infection rate, and mortality. A proportion of 47% of the total subjects included achieved spontaneous pleurodesis in an average duration of 104.3 days. The frequency of total complication rate was noted to be 30.36%. The incidence of pleural cavity infection was described to be 12.4% and death resulting from complications of IPC was 3.35%. CONCLUSION The current management options for the refractory pleural effusion in HH include repeated thoracenteses, transjugular intrahepatic portosystemic shunt, surgical repair of defects in the diaphragm, and liver transplantation. However, the cost, eligibility, and availability can be some of the major concerns with these treatment modalities. With this meta-analysis, we conclude that IPCs can provide an alternative therapeutic option for spontaneous pleurodesis.
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Affiliation(s)
- Akshay Avula
- Staten Island University Hospital, Northwell Health, New York, NY
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14
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Craciun R, Mocan T, Procopet B, Nemes A, Tefas C, Sparchez M, Mocan LP, Sparchez Z. Pulmonary complications of portal hypertension: The overlooked decompensation. World J Clin Cases 2022; 10:5531-5540. [PMID: 35979136 PMCID: PMC9258359 DOI: 10.12998/wjcc.v10.i17.5531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/22/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Rares Craciun
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Tudor Mocan
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Bogdan Procopet
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Andrada Nemes
- Intensiv Care Unit I, Cluj County Emergency Hosptial, Cluj-Napoca 400006, Romania
| | - Cristian Tefas
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Mihaela Sparchez
- 2nd Paediatric Clinic, ”Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca 400126, Please enter the state or province, Romania
| | - Lavinia-Patricia Mocan
- Department of Histology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400349, Romania
| | - Zeno Sparchez
- 3rd Medical Clinic, Department of Internal Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca 400162, Romania
- Gastroenterology Clinic, "Prof. Dr. O. Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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15
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Cuk N, Melamed KH, Vangala S, Salah R, Miller WD, Swanson S, Dai D, Antongiorgi Z, Wang T, Agopian VG, Dinorcia J, Farmer DG, Yanagawa J, Kaldas FM, Barjaktarevic I. Postoperative Trapped Lung After Orthotopic Liver Transplantation is a Predictor of Increased Mortality. Transpl Int 2022; 35:10387. [PMID: 35592450 PMCID: PMC9110663 DOI: 10.3389/ti.2022.10387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/10/2022] [Indexed: 12/10/2022]
Abstract
Pleural effusions are a common complication of orthotopic liver transplantation (OLT), and chronic post-OLT pleural effusions have been associated with worse outcomes. Furthermore, “trapped lung” (TL), defined as a restrictive fibrous visceral pleural peel preventing lung re-expansion, may have prognostic significance. We performed a retrospective analysis of adult OLT recipients over a 9-year period at UCLA Medical Center. Post-OLT patients with persistent pleural effusions, defined by the presence of pleural fluid requiring drainage one to 12 months after OLT, were included for analysis. Outcomes for patients with and without TL were compared using univariate and multivariate analysis. Of the 1722 patients who underwent OLT, 117 (7%) patients met our criteria for persistent postoperative pleural effusion, and the incidence of TL was 21.4% (25/117). Compared to patients without TL, those with TL required more surgical pleural procedures (OR 59.8, 95%CI 19.7–181.4, p < 0.001), spent more days in the hospital (IRR 1.56, 95%CI 1.09–2.23, p = 0.015), and had a higher risk of mortality (HR 2.47, 95%CI 1.59–3.82, p < 0.001) following transplant. In sum, we found that post-OLT TL was associated with higher morbidity, mortality, and healthcare utilization. Future prospective investigation is warranted to further clarify the risk factors for developing postoperative pleural effusions and TL.
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Affiliation(s)
- Natasha Cuk
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kathryn H. Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Kathryn H. Melamed,
| | - Sitaram Vangala
- Clinical and Translational Science Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ramy Salah
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - W. Dwight Miller
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Sarah Swanson
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - David Dai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Zarah Antongiorgi
- Division of Critical Care Medicine, Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Vatche G. Agopian
- Division of Transplant Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Joseph Dinorcia
- Division of Transplant Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Douglas G. Farmer
- Division of Transplant Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Jane Yanagawa
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Fady M. Kaldas
- Division of Transplant Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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16
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Ota K, Katagiri Y, Katakura M, Maemura T, Takahashi T, Morita M. Porous diaphragm syndrome presenting as hemothorax secondary to hemoperitoneum after laparoscopic myomectomy: A case report and literature review. J Obstet Gynaecol Res 2022; 48:1039-1045. [PMID: 35168301 DOI: 10.1111/jog.15175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 12/16/2021] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
Porous diaphragm syndrome includes all pleural cavity conditions, including pleural effusion, hemothorax, or pneumothorax, that occur secondary to peritoneal cavity disorders through defects in the diaphragm. In this report, we describe the first known case of porous diaphragm syndrome presenting as hemothorax after laparoscopic myomectomy. A 46-year-old nulliparous woman underwent laparoscopic myomectomy for multiple fibroids. Eight hours after surgery, the patient developed exertional dyspnea followed by hemoptysis. Radiological diagnosis revealed massive hemothorax in the right thoracic cavity. Thoracoscopic findings showed the presence of small fenestrae at the center of the right diaphragm, which were repaired thoracoscopically. Hence, quick postoperative diagnosis resulted in successful treatment. In this case, porous diaphragm syndrome is believed to be caused by retention of intraoperative bleed and saline from intra-abdominal lavage, in the abdominal cavity. Porous diaphragm syndrome is a potential life-threatening condition that gynecological surgeons should consider in this era of laparoscopic surgery.
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Affiliation(s)
- Kuniaki Ota
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan.,Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
| | - Yukiko Katagiri
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Masafumi Katakura
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | | | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
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17
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Husnain SMN, Shojaee S. Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion. Clin Chest Med 2021; 42:625-635. [PMID: 34774170 DOI: 10.1016/j.ccm.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.
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Affiliation(s)
| | - Samira Shojaee
- Department of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, Virginia Commonwealth University Health System, 1200 East Broad Street, PO Box 980050, Richmond, VA 23298, USA.
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18
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Selvan M, Collins H, Griffiths W, Gelson W, Herre J. Case Report: Indwelling Pleural Catheter Based Management of Refractory Hepatic Hydrothorax as a Bridge to Liver Transplantation. Front Med (Lausanne) 2021; 8:695977. [PMID: 34322505 PMCID: PMC8311019 DOI: 10.3389/fmed.2021.695977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Liver transplantation is the treatment of choice for decompensated liver disease, and by extension for hepatic hydrothorax. Persistent pleural effusions make it challenging for patients to maintain physiological fitness for transplantation. Indwelling pleural catheters (IPCs) provide controlled pleural fluid removal, including peri-operatively. The immune dysfunction of cirrhosis heightens susceptibility to bacterial infection and concerns exist regarding the sepsis potential from a tunnelled drain. Method: Six patients were identified who underwent IPC insertion for hepatic hydrothorax before successful liver transplantation, between November 2016 and November 2017. Results: All patients had recurrent transudative right sided pleural effusions. Mean age was 49 years (range 24–64) and mean United Kingdom Model for End-Stage Liver Disease score was 58. Four patients required correction of coagulopathy before insertion. There were no complications secondary to bleeding. Three patients were taught self-drainage at home of up to 1 litre (L) daily. A protocol was developed to ensure weekly review, pleural fluid culture and drainage of larger volumes in hospital. For every 2–3 L of pleural fluid drained, 100 mls of 20% Human Albumin Solution (HAS) was administered. On average an IPC was in situ for 58 days before surgery and drained 19 L of fluid in hospital. There was a small increase in average BMI (0.2) and serum albumin (2.1 g/L) at transplantation. There was one episode of stage one acute kidney injury secondary to high volume drainage. No further ascitic or pleural procedures were needed while an IPC was in situ. One thoracentesis was required after IPC removal. On average IPCs remained in situ for 7 days post transplantation and drained a further 2 L of fluid. Pleural fluid sampling was acquired on 92% of drainages in hospital. Of 44 fluid cultures, 2 cultured bacteria. Two patients had their IPCs and all other lines removed post transplantation due to suspected infection. Conclusion: Our case series describes a novel protocol and successful use of IPCs in the management of refractory hepatic hydrothorax as a bridge to liver transplantation. The protocol includes albumin replacement during pleural drainage, regular clinical review and culture of pleural fluid, with the option of self-drainage at home.
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Affiliation(s)
- Mayurun Selvan
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Hannah Collins
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - William Griffiths
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - William Gelson
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
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19
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Jung Y, Song SY, Na KJ, Chon SH, Jun CH, Choi SK. Minimally invasive surgical strategy for refractory hepatic hydrothorax. Eur J Cardiothorac Surg 2021; 57:881-887. [PMID: 31958113 DOI: 10.1093/ejcts/ezz342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/25/2019] [Accepted: 11/13/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Treatment of refractory hepatic hydrothorax, a complication of liver cirrhosis, is complex. We aimed to investigate the usefulness of the '4-step approach', which is a minimally invasive surgical strategy combining 4 therapeutic modalities: (i) pneumoperitoneum to localize diaphragmatic defects; (ii) thoracoscopic pleurodesis; (iii) postoperative positive-pressure ventilation; and (iv) peritoneal drainage for abdominal decompression. METHODS We retrospectively analysed the medical records of 12 patients with hepatic hydrothorax who underwent surgical treatment using the 4-step approach from January 2013 to December 2017. Nine of them (75.0%) were Child C cases; the median model for end-stage liver disease score was 20.5. The diaphragmatic defects localized after forming a pneumoperitoneum were treated with primary closure followed by thoracoscopic pleurodesis, postoperative positive-pressure ventilation and peritoneal drainage. RESULTS Diaphragmatic defects were localized in all patients except one. The median postoperative positive-pressure ventilation duration was 20.1 h. Peritoneal drainage was performed for a median duration of 5 days; the peritoneal drains were removed at a median of 8 postoperative days. The median duration of postoperative hospital stay until discharge/transfer was 9.5 days. No operative mortalities occurred. The median duration of follow-up was 10.9 months. Eight deaths (66.7%) occurred during the follow-up period; however, no deaths were surgery-associated. Ipsilateral pleural effusion recurred in 3 patients (25%), among whom reoperation was performed in 1 without recurrence at the 13-month follow-up. CONCLUSIONS The 4-step approach seems to be a safe and effective minimally invasive surgical strategy for treating refractory hepatic hydrothorax.
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Affiliation(s)
- Yochun Jung
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, South Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Soon-Ho Chon
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Jeju, South Korea
| | - Chung Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, South Korea
| | - Sung Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, South Korea
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20
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Melamed KH, Dai D, Cuk N, Markovic D, Follett R, Wang T, Lopez RC, Shirali AS, Yanagawa J, Busuttil R, Kaldas F, Barjaktarevic I. Preoperative Trapped Lung Is Associated With Increased Mortality After Orthotopic Liver Transplantation. Prog Transplant 2020; 31:47-54. [PMID: 33280518 DOI: 10.1177/1526924820978604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Trapped lung, characterized by atelectatic lung unable to reexpand and fill the thoracic cavity due to a restricting fibrous visceral pleural peel, is occasionally seen in patients with end-stage liver disease complicated by hepatic hydrothorax. Limited data suggest that trapped lung prior to orthotopic liver transplantation may be associated with poor outcomes. RESEARCH QUESTION What is the clinical significance of trapped lung in patients receiving orthotopic liver transplantation? DESIGN We performed a retrospective analysis of patients who underwent liver transplantation over an 8-year period. Baseline clinical characteristics and postoperative outcomes of adult patients with trapped lung were analyzed and compared to the overall cohort of liver transplant recipients and controls matched 3:1 based on age, sex, Model for End-Stage Liver Disease (MELD) score, and presence of pleural effusion. RESULTS Of the 1193 patients who underwent liver transplantation, we identified 20 patients (1.68%) with trapped lung. The probability of 1 and 2-year survival were 75.0% and 57.1%, compared to 85.6% and 80.4% (p = 0.02) in all liver transplant recipients and 87.9% and 81.1% (p = 0.03) in matched controls respectively. Patients with trapped lung had a longer hospital length of stay compared to the total liver transplant population (geometric mean 54.9 ± 8.4 vs. 27.2 ± 0.7 days, p ≤ 0.001), when adjusted for age and MELD score. DISCUSSION Patients with trapped prior to orthotopic liver transplantation have increased probability of mortality as well as increased health care utilization. This is a small retrospective analysis, and further prospective investigation is warranted.
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Affiliation(s)
- Kathryn H Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - David Dai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Natasha Cuk
- Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Daniela Markovic
- Department of Biostatistics, 8783University of California at Los Angeles, Los Angeles, CA, USA
| | - Robert Follett
- Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA.,8783UCLA Clinical and Translational Science Institute, Los Angeles, CA, USA
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Roxana Cortes Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Aditya S Shirali
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Jane Yanagawa
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Ronald Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
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21
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Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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22
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Jackson K, Johnston R, Mackay L, Aujayeb A. A difficult pleural effusion in a cirrhotic patient. Breathe (Sheff) 2020; 16:200049. [PMID: 33304406 PMCID: PMC7714551 DOI: 10.1183/20734735.0049-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Failure of medical management of hepatic hydrothoraces will require pleural interventions. Indwelling pleural catheters and medical thoracoscopy can help. Careful liaison with liver transplantation teams is required. https://bit.ly/2XO1naG.
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Affiliation(s)
- Karl Jackson
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Robert Johnston
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Laura Mackay
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
| | - Avinash Aujayeb
- Respiratory Dept, Northumbria HealthCare NHS Trust, North Shields, UK.,These authors contributed equally
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23
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Olson JC. Palliative Interventions in Patients With Cirrhosis With Refractory Ascites and Hepatic Hydrothorax: Who, What, and When? Clin Liver Dis (Hoboken) 2020; 16:63-65. [PMID: 32922752 PMCID: PMC7474139 DOI: 10.1002/cld.953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/14/2020] [Accepted: 03/06/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jody C. Olson
- Departments of Medicine and SurgeryUniversity of Kansas Medical CenterKansas CityKS
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24
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Benz F, Mohr R, Tacke F, Roderburg C. Pulmonary Complications in Patients with Liver Cirrhosis. J Transl Int Med 2020; 8:150-158. [PMID: 33062591 PMCID: PMC7534492 DOI: 10.2478/jtim-2020-0024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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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Affiliation(s)
- Fabian Benz
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Raphael Mohr
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Frank Tacke
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Christoph Roderburg
- Charité University Medicine Berlin, Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany
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25
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Harimoto H, Kanazawa H, Narahara Y, Kidokoro H, Fukuda T, Hayama T, Kawamoto T, Iwakiri K. Transjugular intrahepatic portosystemic shunt for the treatment of refractory hepatic hydrothorax. KANZO 2020; 61:399-409. [DOI: 10.2957/kanzo.61.399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Affiliation(s)
- Hirotomo Harimoto
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | - Hidenori Kanazawa
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | | | - Hideko Kidokoro
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | - Takeshi Fukuda
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | - Tadanobu Hayama
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | - Tomoaki Kawamoto
- Department of Gastroenterology and Hepatology, Nippon Medical School
| | - Katsuhiko Iwakiri
- Department of Gastroenterology and Hepatology, Nippon Medical School
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26
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Hein YP, Ekladious A. Hepatic hydrothorax as the first sign of decompensated cirrhosis of liver in the absence of clinical ascites. Intern Med J 2020; 50:639-640. [PMID: 32431043 DOI: 10.1111/imj.14826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/04/2019] [Accepted: 10/15/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Yee P Hein
- Department of General Medicine, South West Health Campus, Bunbury, Western Australia, Australia
| | - Adel Ekladious
- Department of General Medicine, South West Health Campus, Bunbury, Western Australia, Australia
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27
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Sobotka LA, Spitzer C, Hinton A, Michaels A, Hanje AJ, Mumtaz K, Conteh LF. Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission. J Gastroenterol Hepatol 2020; 35:641-647. [PMID: 31441096 DOI: 10.1111/jgh.14842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.
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Affiliation(s)
- Lindsay A Sobotka
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Carleen Spitzer
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Anthony Michaels
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - A James Hanje
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Lanla F Conteh
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
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28
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Soulaidopoulos S, Goulis I, Cholongitas E. Pulmonary manifestations of chronic liver disease: a comprehensive review. Ann Gastroenterol 2020; 33:237-249. [PMID: 32382226 PMCID: PMC7196609 DOI: 10.20524/aog.2020.0474] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/06/2019] [Indexed: 12/14/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
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Affiliation(s)
- Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration General Hospital, National and Kapodistrian University of Athens (Stergios Soulaidopoulos)
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Hippokration General Hospital, Medical School of Aristotle University of Thessaloniki (Ioannis Goulis)
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School of National and Kapodistrian University of Athens (Evangelos Cholongitas), Greece
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29
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Walker S, Shojaee S. Nonmalignant pleural effusions: are they as benign as we think? PLEURAL DISEASE 2020. [DOI: 10.1183/2312508x.10024119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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30
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Abstract
The most common pulmonary complications of chronic liver disease are hepatic hydrothorax, hepatopulmonary syndrome, and portopulmonary hypertension. Hepatic hydrothorax is a transudative pleural effusion in a patient with cirrhosis and no evidence of underlying cardiopulmonary disease. Hepatic hydrothorax develops owing to the movement of ascitic fluid into the pleural space. Hepatopulmonary syndrome and portopulmonary hypertension are pathologically linked by the presence of portal hypertension; however, their pathophysiologic mechanisms are significantly different. Hepatopulmonary syndrome is characterized by low pulmonary vascular resistance secondary to intrapulmonary vascular dilatations and hypoxemia; portopulmonary hypertension features elevated pulmonary vascular resistance and constriction/obstruction within the pulmonary vasculature.
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Affiliation(s)
- Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic Rochester, 200 1st Street SW, Rochester, MN 55905, USA
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31
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Hopkins D, Pattman S, Jones R, Aujayeb A. A left-sided cerebrospinal fluid hydrothorax and a right ventricular-peritoneal shunt: a unique clinical case study. BMJ Case Rep 2019; 12:12/9/e230236. [PMID: 31540921 DOI: 10.1136/bcr-2019-230236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
We describe the case of a 84-year-old woman with a right ventricular-peritoneal shunt and a left-sided pleural effusion, the analysis of which was positive for cerebrospinal fluid. We consider the potential causative mechanisms. Our patient was managed conservatively due to her frailty, the effusion being asymptomatic and her preference not to pursue further invasive diagnostic testing. This case report is unique due to the contralateral nature of the effusion to the shunt, which has not been described before in the literature.
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Affiliation(s)
- David Hopkins
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Stewart Pattman
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Rhian Jones
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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32
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Piano S, Tonon M, Angeli P. Ascites, Hyponatremia, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome. EVIDENCE‐BASED GASTROENTEROLOGY AND HEPATOLOGY 4E 2019:662-675. [DOI: 10.1002/9781119211419.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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33
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Silva Cruz C, Tosatto V, Nascimento PO, Barata Moura R. Hepatic hydrothorax: indwelling catheter-related Acinetobacter radioresistens infection. BMJ Case Rep 2019; 12:12/3/e227635. [PMID: 30878955 DOI: 10.1136/bcr-2018-227635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Hepatic hydrothorax, a rare and debilitating complication of cirrhosis, carries high morbidity and mortality. First-line treatment consists of dietary sodium restriction and diuretic therapy. Some patients, mainly those who are refractory to medical management, will require invasive pleural drainage. The authors report the case of a 76-year-old man in a late cirrhotic stage of alcoholic chronic liver disease, presenting with recurrent right-sided hepatic hydrothorax, portal hypertension, hepatosplenomegaly and thrombocytopaenia. After recurrent admissions and complications, the potential for adjusting diuretic therapy was limited. After unsuccessful talc pleurodesis, an indwelling tunnelled pleural catheter was placed with effective symptomatic control. One month later, the patient was readmitted with empyema due to Acinetobacter radioresistens Despite optimised medical and surgical treatment, the patient died 4 weeks later.
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Affiliation(s)
- Cristiano Silva Cruz
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Valentina Tosatto
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Paula Oliveira Nascimento
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
| | - Rita Barata Moura
- Department of Internal Medicine, Centro Hospitalar de Lisboa Central, EPE - Hospital de Santa Marta, Lisboa, Portugal
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34
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Lépine PA, Thomas R, Nguyen S, Lacasse Y, Cheah HM, Creaney J, Muruganandan S, Martel S, Lee YCG, Delage A. Simplified Criteria Using Pleural Fluid Cholesterol and Lactate Dehydrogenase to Distinguish between Exudative and Transudative Pleural Effusions. Respiration 2019; 98:48-54. [PMID: 30826806 DOI: 10.1159/000496396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/19/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An important part of the investigation of pleural effusion is the identification of markers that help separate exudate from transudate. OBJECTIVES The purposes of this study were to compare the accuracy of published and new sets of criteria to distinguish between exudative and transudative pleural effusions, and to determine whether serum biochemical analysis is necessary. METHODS An externally validated cohort study was performed. Pleural effusions were determined to be transudative or exudative on the basis of an assessment of the medical record by two clinicians blinded to biochemical results. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the receiver operating characteristic curve were determined for each proposed combination of criteria. RESULTS Pleural fluid analysis was available for 311 thoracenteses in the main cohort and for 112 thoracenteses in the validation cohort. The best sensitivity (97% [95% CI 94-99]) and negative likelihood ratio (0.04 [95% CI 0.02-0.08]) for identifying exudative effusions were observed with criteria combining pleural fluid lactate dehydrogenase greater than 0.6 the upper limit of normal serum lactate dehydrogenase and pleural fluid cholesterol greater than 1.04 mmol/L (40 mg/dL). The overall diagnostic accuracy was similar to Light's criteria. Findings were similar in the validation cohort. CONCLUSIONS Our proposed criteria using simultaneously pleural fluid lactate dehydrogenase and pleural fluid cholesterol can identify an exudate with a sensitivity and an overall diagnostic accuracy similar to Light's criteria. It avoids simultaneous blood sampling, thus reducing patient discomfort and potential costs.
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Affiliation(s)
- Pierre-Alexis Lépine
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, Québec, Canada,
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, University of Western Australia, Perth, Washington, Australia
| | - Sébastien Nguyen
- Université de Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Québec, Canada
| | - Yves Lacasse
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, Québec, Canada
| | - Hui Min Cheah
- Institute for Respiratory Health, University of Western Australia, Perth, Washington, Australia
| | - Jenette Creaney
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, University of Western Australia, Perth, Washington, Australia
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, University of Western Australia, Perth, Washington, Australia
| | - Simon Martel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, Québec, Canada
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, University of Western Australia, Perth, Washington, Australia
| | - Antoine Delage
- Université de Sherbrooke, Hôpital Charles-Lemoyne, Greenfield Park, Québec, Canada
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35
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Ota T, Hasegawa Y, Okabe T, Okimura A, Fukuoka M. Porous diaphragm syndrome with recurrent thymoma. Respirol Case Rep 2019; 7:e00391. [PMID: 30519470 PMCID: PMC6261833 DOI: 10.1002/rcr2.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 11/10/2022] Open
Abstract
Porous diaphragm syndrome describes a defect in the diaphragm in which substances pass from the peritoneal cavity to the pleural space. Defects may be congenital or acquired. Acquired defects are caused by the thinning and eventual splitting of collagen fibres in the tendinous part of the diaphragm. We report a case of porous diaphragm syndrome with recurrent thymoma that presented with massive ascites. Increasing intra-abdominal pressure by ascites and diaphragmatic thinning due to malnutrition by malignancies resulted in the formation of an artificial hole. Thoracentesis changed the balance of hydrostatic pressure, which initiated the influx of a large volume of ascites to the pleural cavity through a hole in the diaphragm.
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Affiliation(s)
- Takayo Ota
- Department of Medical OncologyIzumi City General HospitalIzumiJapan
| | | | - Takafumi Okabe
- Department of Medical OncologyNara Hospital Kindai Faculty of MedicineIkomaJapan
| | - Akira Okimura
- Department of PathologyIzumi City General HospitalIzumiJapan
| | - Masahiro Fukuoka
- Department of Medical OncologyIzumi City General HospitalIzumiJapan
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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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Affiliation(s)
- Apurwa Karki
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Leonard Riley
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Hiren J Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States.
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38
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KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
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Shojaee S, Rahman N, Haas K, Kern R, Leise M, Alnijoumi M, Lamb C, Majid A, Akulian J, Maldonado F, Lee H, Khalid M, Stravitz T, Kang L, Chen A. Indwelling Tunneled Pleural Catheters for Refractory Hepatic Hydrothorax in Patients With Cirrhosis: A Multicenter Study. Chest 2018; 155:546-553. [PMID: 30171863 DOI: 10.1016/j.chest.2018.08.1034] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/03/2018] [Accepted: 08/15/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The outcome of indwelling pleural catheter (IPC) use in hepatic hydrothorax (HH) is unclear. This study aimed to review the safety and feasibility of the IPC in patients with refractory HH. METHODS A retrospective multicenter study of patients with HH from January 2010 to December 2016 was performed. Inclusion criteria were refractory HH treated with an IPC and an underlying diagnosis of cirrhosis. Records were reviewed for patient demographics, operative reports, and laboratory values. The Kaplan-Meier method was used to estimate catheter time to removal. The Cox proportional hazard model was used to evaluate for independent predictors of pleurodesis and death. RESULTS Seventy-nine patients were identified from eight institutions. Indication for IPC placement was palliation in 58 patients (73%) and bridge to transplant in 21 patients (27%). The median in situ dwell time of all catheters was 156 days (range, 16-1,978 days). Eight patients (10%) were found to have pleural space infection, five of whom also had catheter-site cellulitis. Two patients (2.5%) died secondary to catheter-related sepsis. Catheter removal secondary to spontaneous pleurodesis was achieved in 22 patients (28%). Median time from catheter insertion to pleurodesis was 55 days (range, 10-370 days). Older age was an independent predictor of mortality on multivariate analysis (hazard ratio, 1.05; P = .01). CONCLUSIONS We present, to our knowledge, the first multicenter study examining outcomes related to IPC use in HH. Ten percent infection risk and 2.5% mortality were identified. IPC placement may be a reasonable clinical option for patients with refractory HH, but it is associated with significant adverse events in this morbid population.
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Affiliation(s)
- Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA.
| | - Najib Rahman
- Nuffield Department of Medicine, Oxford Center for Respiratory Medicine, University of Oxford, Oxford, England; Oxford National Institute of Health Research Biomedical Center, Oxford, England
| | - Kevin Haas
- Division of Pulmonary and Critical Care Medicine, University of Illinois, Chicago, IL
| | - Ryan Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mohammed Alnijoumi
- Division of Pulmonary and Critical Care Medicine, University of Missouri, Columbia, MO
| | - Carla Lamb
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Lynnfield, MA
| | - Adnan Majid
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jason Akulian
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Hans Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Center, Baltimore, MD
| | - Marwah Khalid
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, MO
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Baig MA, Majeed MB, Attar BM, Khan Z, Demetria M, Gandhi SR. Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature. Cureus 2018; 10:e3110. [PMID: 30338185 PMCID: PMC6175258 DOI: 10.7759/cureus.3110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/06/2018] [Indexed: 12/26/2022] Open
Abstract
Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria. The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion. We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.
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Affiliation(s)
- Muhammad A Baig
- Medicine, John H Stroger J. Hospital of Cook County, Chicago, USA
| | | | - Bashar M Attar
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Zubair Khan
- Internal Medicine, University of Toledo Medical Center, Toledo, USA
| | - Melchor Demetria
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Seema R Gandhi
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
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Comparison of treatment of hepatic hydrothorax with catheter drainage versus serial thoracentesis. Curr Opin Pulm Med 2018. [PMID: 29521656 DOI: 10.1097/mcp.0000000000000484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Flamm SL. Complications of Cirrhosis in Primary Care: Recognition and Management of Hepatic Encephalopathy. Am J Med Sci 2018; 356:296-303. [PMID: 30286824 DOI: 10.1016/j.amjms.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/24/2018] [Accepted: 06/08/2018] [Indexed: 12/13/2022]
Abstract
Approximately 3.7% of patients in primary care settings have chronic liver disease, and 18% with chronic liver disease in the specialty care setting have cirrhosis. For cirrhotic patients without complications, prognosis is generally favorable; increased morbidity and mortality are observed when complications (i.e., hepatic encephalopathy [HE]) occur. HE occurs in up to 70% of patients with cirrhosis. Neurologic signs in HE span a wide spectrum, from those not easily apparent (covert) to more clinically obvious signs (overt). Providers should consider overt HE in patients with cirrhosis and signs of impaired cognition, confusion, consciousness and/or personality changes, and/or impaired memory. Overt HE treatment includes identifying and treating precipitating factors and reducing bacterial-derived toxin loads. For acute overt HE, lactulose is first-line treatment. To prevent HE recurrence, lactulose plus rifaximin is recommended. Patients with cirrhosis and HE often present in primary care; recognizing and properly managing HE are important in this setting.
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Affiliation(s)
- Steven L Flamm
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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43
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Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World J Hepatol 2017; 9:1197-1204. [PMID: 29152039 PMCID: PMC5680207 DOI: 10.4254/wjh.v9.i31.1197] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 09/17/2017] [Accepted: 10/15/2017] [Indexed: 02/06/2023] Open
Abstract
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.
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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45
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Indwelling tunneled pleural catheters for the management of hepatic hydrothorax. Curr Opin Pulm Med 2017; 23:351-356. [DOI: 10.1097/mcp.0000000000000386] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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46
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Hung TH, Tseng CW, Tsai CC, Hsieh YH, Tseng KC, Tsai CC. Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion. Dig Dis Sci 2017; 62:1080-1085. [PMID: 28130709 DOI: 10.1007/s10620-017-4463-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/16/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion. AIMS In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients. METHODS The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching. RESULTS The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality. CONCLUSION In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan. .,School of Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi County, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No. 2, Minsheng Rd., Dalin Township, Chiayi County, 62247, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
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47
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Monastesse A, Girard F, Massicotte N, Chartrand-Lefebvre C, Girard M. Lung Ultrasonography for the Assessment of Perioperative Atelectasis. Anesth Analg 2017; 124:494-504. [DOI: 10.1213/ane.0000000000001603] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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49
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Al-Zoubi RK, Abu Ghanimeh M, Gohar A, Salzman GA, Yousef O. Hepatic hydrothorax: clinical review and update on consensus guidelines. Hosp Pract (1995) 2016; 44:213-223. [PMID: 27580053 DOI: 10.1080/21548331.2016.1227685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatic Hydrothorax (HH) is defined as a pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. It is an uncommon complication of cirrhosis, most frequently seen in association with decompensated liver disease. The development of HH remains incompletely understood and involves a complex pathophysiological process with the most acceptable explanation being the passage of the ascetic fluid through small diaphragmatic defects. Given the limited capacity of the pleural space, even the modest pleural effusion can result in significant respiratory symptoms. The diagnosis of HH should be suspected in any patient with established cirrhosis and portal hypertension presenting with unilateral pleural effusion especially on the right side. Diagnostic thoracentesis should be performed in all patients with suspected HH to confirm the diagnosis and rule out infection and alternative diagnoses. Spontaneous bacterial empyema and spontaneous bacterial pleuritis can complicate HH and increase morbidity and mortality. HH can be difficult to treat and in our review below we will list the therapeutic modalities awaiting the evaluation for the only definitive therapy, which is liver transplantation.
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Affiliation(s)
- Rana Khazar Al-Zoubi
- a School of Medicine Ringgold standard institution - Pulmonary & Critical Care , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Mouhanna Abu Ghanimeh
- b School of Medicine Ringgold standard institution - Internal Medicine , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Ashraf Gohar
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Gary A Salzman
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Osama Yousef
- d School of Medicine - Gastroenterology Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
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50
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Jung Y. Surgical Treatment of Hepatic Hydrothorax: A "Four-Step Approach". Ann Thorac Surg 2016; 101:1195-7. [PMID: 26897210 DOI: 10.1016/j.athoracsur.2015.04.110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/17/2015] [Accepted: 04/23/2015] [Indexed: 02/08/2023]
Abstract
Recently, various video-assisted thoracoscopic surgical techniques have been reported with occasional success in treating hepatic hydrothorax (HH). In 2 patients with refractory HH, we applied a combination of four therapeutic modalities as a single procedure named as a "four-step approach": (1) pneumoperitoneum for localization of diaphragmatic defects, (2) thoracoscopic pleurodesis, (3) postoperative continuous positive airway pressure, and (4) drainage of ascites for abdominal decompression. The treatment was successful in both patients, without recurrence during the follow-up period of 24 and 3 months, respectively.
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Affiliation(s)
- Yochun Jung
- Department of Thoracic and Cardiovascular Surgery, Cheju Halla General Hospital, Jeju, Korea.
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