Diagnosis and Management of Hepatic Hydrothorax.

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).

[Indocyanine Green Fluorescence Intraoperative Imaging for Fistula Identification of Pleuroperitoneal Communication by Continuous Ambulatory Peritoneal Dialysis:Report of a Case].

A 64-year-old female with chronic renal failure had been receiving continuous ambulatory peritoneal dialysis (CAPD). She developed acute hydrothorax in the right pleural cavity 1 year after the commencement of CAPD. Scintigraphy revealed a diagnosis of pleuroperitoneal communication, and we performed video-assisted thoracoscopic surgery. We infused a dialysis solution containing indocyanine green (ICG) through CAPD catheter. Near-infrared fluorescence thoracoscopy revealed a fistula that could not be identified by white light. We sutured the fistula covered with a polyglycolic acid sheet and fibrin glue. The CAPD was able to be resumed 8 days after surgery, and there was no recurrence of pleural effusion 10 months since surgery. Identification of the diaphragmatic fistula is important in the treatment of pleuroperitoneal communication. This technique using near-infrared fluorescence thoracoscopy with ICG was useful in identifying the fistula, and it emitted sufficient fluorescence even at low concentration ICG.

[Early Resuming of Continuous Ambulatory Peritoneal Dialysis on the Following Day After Surgery for Pleuroperitoneal Communication:Report of a Case].

A 72-year-old man was introduced continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure. Five months later, he was pointed out a massive right pleural effusion. Being diagnosed with pleuroperitoneal communication, he was referred to our department for surgery. Dialysis fluid and indocyanine green were injected through a peritoneal catheter for CAPD 30 minutes before surgery. A small fistula was detected by pressing the abdomen and using infrared thoracoscopy. The fistula was sutured and covered with polyglycolic acid sheet and fibrin glue. A day after surgery, CAPD was resumed. He was discharged on the post operative sixth day without any complications.

Hepatic Hydrothorax and Congestive Heart Failure Induced Pleural Effusion.

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.

Indwelling Tunneled Pleural Catheters for Refractory Hepatic Hydrothorax in Patients With Cirrhosis: A Multicenter Study.

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.

Rare complication of central venous catheter placement: bilateral hydrothorax.

Central venous catheters (CVCs) are very useful tools in clinical medicine. It is important not only for the administration of medications or fluids but also the measurement of haemodynamic variables, especially in intensive care patients. CVC placement is a relatively safe procedure but may occasionally be associated with complications, such as pneumothorax, haemothorax, cardiac tamponade, sepsis and thrombosis. We aim to report an extraordinary case of bilateral hydrothorax due to CVC placement.

Hepatic Hydrothorax.

Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.

Indwelling tunneled pleural catheters for the management of hepatic hydrothorax.

PURPOSE OF REVIEW: Hepatic hydrothorax is a complication of end-stage liver disease that may have significant associated morbidity. Sodium restriction and diuretic therapy are the mainstays of treatment, though up to a quarter of patients will become refractory to this and will require a pleural drainage procedure. Thoracentesis, transjugular intrahepatic portosystemic shunt, and chemical pleurodesis all have variable success rates and associated complications in the management of hepatic hydrothorax. Indwelling tunneled pleural catheters (ITPC) have been successfully used to manage recurrent symptomatic malignant pleural effusions, and there is growing interest regarding their use in the management of hepatic hydrothorax. RECENT FINDINGS: Evidence regarding the use of ITPC for nonmalignant pleural effusions has been limited to retrospective studies and small feasibility trials. A recent meta-analysis regarding the use of IPTC for nonmalignant pleural effusions demonstrated a rate of spontaneous pleurodesis of 51%, whereas a small, prospective study demonstrated spontaneous pleurodesis rates of 33% and an infection rate of 16.7% in 24 patients with ITPC placed for hepatic hydrothorax in patients suitable for liver transplant evaluation. SUMMARY: ITPC may be an acceptable treatment option for the management of hepatic hydrothorax which are refractory to conventional medical management. Larger, randomized controlled trials are needed to further evaluate the safety and efficacy of these catheters for the management of nonmalignant pleural effusions.

Hypertonic glucose pleurodesis and surgical diaphragmatic repair for tension hydrothorax complicating continuous ambulatory peritoneal dialysis.

We herein describe a case of tension hydrothorax that occurred on continuous ambulatory peritoneal dialysis (CAPD), highlighting the problems of diagnosis and a novel management. A 38-year-old male with end-stage renal disease (ESRD) due to diabetes mellitus developed dyspnea and poor drainage after 13 months of CAPD. Chest X-ray revealed massive right-sided hydrothorax and mediastinal shift. He underwent emergency thoracentesis and pleural fluid showed a high level of glucose. Pleuroperitoneal communication was strongly suspected, although the methylene blue test was negative. We temporarily performed hemodialysis. Two weeks later, PD was resumed but failed with recurrent right-side hydrothorax in 4 months. The pleuroperitoneal leakage was definitively confirmed by video-assisted thoracoscopic surgery (VATS). Diaphragmatic repair and pleurodesis with hypertonic glucose were performed. There was no recurrence of hydrothorax after treatment.

An Unusual Presentation in Urinothorax.

Urinothorax is defined as the presence of urine in the pleural cavity. Leakage from the urinary tract can cause urinoma with retroperitoneal urine collection, and secondarily, urinothorax. We report the case of a 35-year-old female who presented with dyspnoea and right-sided chest pain. Chest radiograph revealed a right-sided pleural effusion. The patient had undergone left-sided ovarian cystectomy three months ago, had sustained a left-sided ureteric injury that required ureteric stent placement. Urinothorax was suspected as a consequence of ureteric injury; pleural fluid to serum creatinine ratio was found to be greater than one, confirming the diagnosis.

[Detection of the communication site by dye injection method at the surgery for pleuroperitoneal communication].

A 65-year-old male with end stage renal failure due to IgA nephritis commenced continuous ambulatory peritoneal dialysis (CAPD). Three weeks after initiation of CAPD, right hydrothorax developed. Then, we strongly assumed pleuroperitoneal communication( PPC) although the pleural effusion did not show high concentration of glucose. He underwent thoracoscopic surgery for PPC. On the inner, central tendons part of the diaphragm, there were a few blebs. One hour after 3 l of peritoneal dialysis solution containing 15 ml indigocarmine was instilled into the abdomen through a CAPD catheter, the blebs were tense and colored blue by the dye solution. The blebs were directly sutured and diaphragm was covered by polyglycolic acid sheet and fibrin glue all over. Since then, he resumed CAPD, without recurrence of hydrothorax. Then we investigated the treatment outcome of video-assisted thoracic surgery (VATS) for PPC in Japan. The outcome was poorer in cases in which communication was not detected intraoperatively. These patients should be given sufficient consideration for surgical procedure.

Hepatic hydrothorax.

Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The estimated prevalence among patients with liver cirrhosis is approximately 5-6%. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. The diagnosis is made from clinical presentation and confirmed by diagnostic thoracentesis with pleural fluid analysis. The initial medical management is sodium restriction and diuretics, but liver transplantation provides the only definitive therapy. For patients who are not transplant candidates and those who await organ availability, other therapeutic modalities that are to be considered include transjugular intrahepatic portosystemic shunt placement, videoassisted thoracoscopic surgery repair, pleurodesis, and vasoconstrictors (eg, octreotide and terlipressin). The primary therapeutic goals are to reduce ascitic fluid production and improve symptoms to bridge the time for liver transplantation.

A 62-year-old female patient with left-sided pleural effusion.

Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis without primary cardiac, pulmonary or pleural disease. It is a rare but important cause of unilateral-pleural effusion. The prevalence of this complication is 5-10% of the total number of patients with advanced stages of cirrhosis. In most cases (85%), the effusion is right-sided; however, in 13% of cases it can be left-sided and bilateral in 2% of the cases. We present a case of left-sided hepatic hydrothorax in the absence of ascites in a patient with primary biliary cirrhosis. The diagnosis of cirrhosis was confirmed by the biopsy;the patient didn't have any history or any signs or symptoms of cirrhosis prior to her presentation. In the case described, the patient was treated with spirnolactone, furosemide and ursodeoxycholic acid. At follow-up after six months since the diagnosis, she was responding to treatment with no complications. This case emphasizes the importance of considering hepatic hydrothorax as an etiology of a transudative pleural effusion regardless of the presence or absence of ascites inpatients with occult cirrhosis.

Thoracoscopic surgical treatment for pleuroperitoneal communication.

Hydrothorax as a result of pleuroperitoneal communication (PPC) is an uncommon but a well-known complication of continuous ambulatory peritoneal dialysis (CAPD). In this paper, we present a 60-year old man with diabetic renal failure who underwent CAPD. Two weeks after starting CAPD, chest radiographs showed a right-sided hydrothorax. Radioscintigraphy was performed and PPC was diagnosed. Eight days after the diagnosis, thoracoscopic surgery was performed. The leakage points were closed by direct suturing with absorbable polyglycolic acid felt and fibrin glue. The patient resumed CAPD 2 weeks later, and there was no recurrence of the right hydrothorax. Video-assisted thoracic surgery with direct suturing represents a feasible method for treating PPC with confirmed fistulae.

Hidrotórax hepático: cuando la evolución es la evidencia / Hepatic hydrothorax: when the patient's course is the evidence you need

Se analiza el caso clínico de un paciente de 61 años, alcoholista, con hidrotórax unilateral derecho y signos clínicos de insuficiencia hepatocítica crónica planteándose como etiología del derrame el hidrotórax hepático. A propósito de este caso clínico se discuten los criterios diagnósticos de esta entidad, forma de estudio, patrones evolutivos, complicaciones y la eficacia de las distintas opciones terapéuticas

[Progredient dyspnea and poor drainage in a peritoneal dialysis patient - case 2/2012]. / Zunehmende Dyspnoe und geringes Auslaufvolumen bei einem Peritonealdialysepatienten - Fall 2/2012.

HISTORY AND ADMISSION FINDINGS: We report on a peritoneal dialysis patients who presented with dyspnea, poor drainage and weight gain. INVESTIGATIONS: A chest x-ray showed a large pleural effusion on the right side. Thoracocentesis revealed a clear protein-devoid fluid with a glucose concentration greater than that of plasma. By intraperitoneal administration of toluidine blue, a pleuroperitoneal leakage was proven. DIAGNOSIS, TREATMENT AND COURSE: The patient underwent video-assisted thoracoscopy revealing a total of four spots of pleuroperitoneal leakage on the diaphragm after intraperitoneal administration of toluidine blue. Closure was attempted with the aid of a prolene patch which was stiched onto the diaphragm inducing adhesion to the lung. After three months bridging with hemodialysis, the peritoneal dialysis was commenced again without a recurrence of the leakage. CONCLUSIONS: Pleuroperitoneal leakage can occur during the course of peritoneal dialysis treatment leading to hydrothorax. Video-assisted thoracoscopy and patching of the diaphragm with a prolene mesh can be used to treat these patients.

Angiogenic and antiangiogenic factors before and after resolution of maternal mirror syndrome.

Mirror syndrome is a rare condition that involves fetal hydrops, placentomegaly and severe maternal edema. The pathogenesis of this syndrome mimics endothelial dysfunction observed in pre-eclampsia. We report a case of maternal mirror syndrome caused by bilateral fetal hydrothorax that resolved after intrauterine pleuroamniotic shunt placement. At the time of the clinical manifestation there was an antiangiogenic state similar to that seen in pre-eclampsia, which resolved after fetal treatment. Our findings suggest that mirror syndrome is a manifestation of a broad spectrum of pathological conditions that induces an antiangiogenic state.