Management of refractory hepatic hydrothorax: a report of two cases and review of the literature.

Hepatic hydrothorax is a transudative pleural effusion in patients with cirrhosis. A 56-year-old cirrhotic patient presented with dyspnea and desaturation; his chest images showed a right pleural effusion. Another 66-year-old woman with cirrhosis, developed during her hospitalization acute respiratory failure, and her chest X- ray showed left pleural effusion. Initially, both patients were prescribed a dietary sodium restriction and diuretics. Nevertheless, they didn't have a good response so a chest tube was placed, and an octreotide infusion partially reduced the volume of the pleural drainage allowing a pleurodesis. We report two cases of refractory hepatic hydrothorax with multiple treatments including octreotide and pleurodesis.

Pulmonary Complications of Portal Hypertension.

Portopulmonary hypertension (POPH), hepatopulmonary syndrome, and hepatic hydrothorax constitute significant complications of portal hypertension, with important implications for management and liver transplantation (LT) candidacy. POPH is characterized by obstruction and remodeling of the pulmonary resistance arterial bed. Hepatopulmonary syndrome is the most common pulmonary vascular disorder, characterized by intrapulmonary vascular dilatations causing impaired gas exchange. LT may improve prognosis in select patients with POPH. LT is the only effective treatment of hepatopulmonary syndrome. Hepatic hydrothorax is defined as transudative pleural fluid accumulation that is not explained by primary cardiopulmonary or pleural disease. LT is the definitive cure for hepatic hydrothorax.

Complications of Peritoneal Dialysis Part I: Mechanical Complications.

Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in many countries. However, it can be associated with unexpected interruptions to or discontinuation of therapy. Timely diagnosis and resolution are required to minimize preventable modality change to hemodialysis. This review covers mechanical complications, including leaks, PD hydrothorax, hernias, dialysate flow problems, PD-related pain, and changes in respiratory mechanics. Most mechanical complications occur early, either as a result of PD catheter insertion or the introduction of dialysate and consequent increased intra-abdominal pressure. Late mechanical complications can also occur and may require different treatment.

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).

Hepatic Hydrothorax Without Ascites: A Diagnostic And Management Challenge.

Hepatic hydrothorax refers to the presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis who does not have other reasons to have a pleural effusion (e.g., cardiac, pulmonary, or pleural disease). Hepatic hydrothorax occurs in approximately 5-6% of patients with cirrhosis. It results from the ascitic fluid draining into the pleural cavity through the diaphragmatic defects. The presentation of patients with hepatic hydrothorax includes chest pain, hypoxemia, cough, shortness of breath and fatigue. The atypical feature, in this case, is the presence of hepatic hydrothorax in a patient with chronic liver disease without ascites. The management of hepatic hydrothorax is difficult. The initial treatment should be a low-salt diet plus diuretics. The best diuretic regimen is probably the combination of furosemide and spironolactone. However, about 25% of patients are refractory to this regimen, and additional therapy is indicated. This patient underwent thoracentesis, however, considering the re-accumulation of fluid, a pigtail catheter was placed which drained up to 8 liters of fluid.

Hidrotórax hepático: presentación de 3 casos con diferentes enfoques terapéuticos / Hepatic hydrothorax: presentation of 3 cases with different therapeutic approaches

El hidrotórax hepático (HH) se define como un derrame pleural mayor de 500 ml en pacientes con cirrosis e hipertensión portal. Representa una complicación infrecuente por lo general asociada con ascitis y su origen se relaciona con el paso de líquido ascítico a través de pequeños defectos en el diafragma de predominio en el hemitórax derecho. Una vez establecido el diagnóstico por imágenes, la toracentesis diagnostica permite confirmar un trasudado. La terapia inicial está basada en la restricción de sodio y el uso combinado de diuréticos. El 20-25% de los pacientes desarrolla un HH refractario, el cual requiere intervenciones invasivas tales como la derivación percutánea portosistémica intrahepática (DPPI), la reparación de los defectos diafragmáticos por videotoracoscopia asistida asociada a pleurodésis química y el uso de un catéter pleural tunelizado. No se recomienda la inserción de un tubo de tórax por su elevada morbilidad y mortalidad. El tratamiento definitivo del HH es el trasplante hepático el cual alcanza una excelente sobrevida. Presentamos tres casos de hidrotórax hepático con diferentes enfoques terapéuticos que incluyeron el manejo conservador con dieta y diuréticos, la inserción fallida de un tubo de tórax con pleurodesis y una DPPI.

Hepatic hydrothorax is uncommon transudative pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. Ascites is also present in most of the patients and the pathophysiology include the passage of ascites fluid through small diaphragmatic defects. After diagnostic thoracentesis studies, the first line management is restricting sodium intake and diuretics combination including stepwise dose of spironolactone plus furosemide. Therapeutic thoracentesis is a simple and effective procedure to relief dyspnea. Hepatic hydrothorax is refractory in approximately 20-25% and treatments options include repeated thoracentesis, transjugular intrahepatic portosystemic shunts (TIPS) placement, chemical pleurodesis with repair diaphragmatic defects using video-assisted thoracoscopy surgery (VATS), and insertion of an indwelling pleural catheter. Chest tube insertion carries significant morbidity and mortality with questionable benefit. Hepatic transplantation remains the best treatment option with long term survival. We present three cases of hepatic hydrothorax with different therapeutic approach including first line management, failed chest tube insertion and TIPS placement.

Secuestro pulmonar asociado a hidrotórax, un hallazgo infrecuente: caso clínico / Sequestration pulmonary associated to hydrotorax, an infrequent find

Pulmonary sequestration is a rare lung congenital malformation that can be diagnosed in the rutine prenatal ultrasound scan. It has a wide spectrum of clinical manifestations, that range from asymptomatic fetuses to hydrops fetalis. Although prenatal Ultrasound (US) has been the traditional diagnostic tool in these cases, fetal magnetic resonance imaging (MRI) may prove useful in differential diagnosis with cistic adenomatous malformation (CCAM) and also in the evaluation of the mass efect exerted by the malformation. We present a case of a 38 year old pregnant woman with a diagnosis of fetal hydrothorax in the 29th week of gestation. Ultrasound and MRI evaluation revealed pulmonary sequestration. Management involved prenatal thoracocentesis, planned delivery and neonatal support. This case highlights the importance of a multidisciplinary approach when encountering fetal lung anomalies including radiologists and pediatricians, a thorough assessment of the lesion using US, MRI and planned delivery in a tertiary center with adecuate neonatal support.

El secuestro pulmonar es una malformación congénita pulmonar infrecuente que puede ser diagnosticada mediante el ultrasonido durante una evaluación prenatal de rutina. Sus manifestaciones clínicas van desde fetos asintomáticos hasta el hidrops fetal. Si bien la ultrasonografía ha sido el método tradicional de evaluación de estas malformaciones, la utilización de resonancia puede demostrar utilidad, en especial en el diagnóstico diferencial con malformación adenomatosa quística, como también en evaluar el efecto de compresión ejercido por la lesión, y estimar el volumen pulmonar residual. Se presenta un caso de una paciente embarazada de 38 años con diagnóstico de secuestro pulmonar a las 29 semanas y que a las 32semanas evolucionó con hidrotórax que requirió toracocentesis, interrupción programada y soporte neonatal. Este caso resalta la importancia de usar un enfoque multidisciplinario al enfrentarse con lesiones pulmonares fetales que incluya neonatólogo, radiólogo, obstetra, y una evaluación detallada de la lesión utilizando ultrasonografía y resonancia magnética como también interrupción programada en un centro terciario con adecuado soporte neonatal.

Tratamento de hidrotórax com shunt portossistêmico transjugular intra-hepático (TIPS) / Treatment of hydrothorax with transjugular intrahepatic portosystemic shunt (TIPS)

O hidrotórax hepático caracteriza-se pelo derrame pleural secundário a ascite volumosa em pacientes com cirrose descompensada. É complicação rara em hepatopatas com hipertensão portal e de difícil reversão com o manejo clínico convencional para o tratamento da ascite. A introdução do shunt portossistêmico transjugular intra-hepático (TIPS) como opção terapêutica para esses pacientes mostrou-se procedimento bastante eficaz e com pequena morbidade associada. O objetivo deste trabalho é relatar o caso de uma paciente hepatopata crônica, com ascite volumosa e hidrotórax refratários ao tratamento clínico, a qual foi submetida à colocação de TIPS para tratamento. Pacientes com cirrose descompensada e ascite são candidatos a complicações como peritonite bacteriana espontânea, síndrome hepatorrenal e hidrotórax. O tratamento definitivo nestes casos é o transplante hepático – nem sempre viável e de rápido acesso. O TIPS é opção terapêutica temporária e de baixo risco para esses pacientes e que vem mostrando altas taxas de sucesso.

Liver hydrothorax is characterized by pleural effusion secondary to voluminous ascites in patients with uncompensated cirrhosis. It is a rare complication in hepatopaths with portal hypertension, one not easily reverted through the standard clinical management for the treatment of ascites. The introduction of transjugular intrahepatic portosystemic shunt (TIPS) as a therapeutic option for these patients proved to be quite efficacious and with little associated morbidity. The aim of this work is to report the case of a chronic female hepatopath with voluminous ascites and hydrothorax refractory to clinical treatment, who was submitted to TIPS. Patients with uncompensated cirrhosis and ascites are candidates to complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and hydrothorax. Definitive treatment in these cases is the hepatic transplant – not always viable and easily accessed. TIPS is the temporary, low-risk therapeutic option for such patients, which has shown high rates of success.

TIPS--anastomose portossistêmica intra-hepática transjugular. Revisao / TIPS - Transjugular intrahepatic portosystemic shunt. A review

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.

Hidrotórax como complicaçäo de cirrose hepática: diagnóstico pelo método cintilográfico / Hydrothorax as complication of hepatic cirrhosis: diagnosis by scintigraphic method

Os autores apresentam um caso de hidrotórax secundário a insuficiência hepatocelualr e ascite. O diagnóstico foi estabelecido através da injeçäo intraperitoneal de Tc-enxofre coloidal, evidenciando-se passagem do radiofármaco para a cavidade pleural. Após administraçäo intrapleural do radiotraçador, näo se observou sua passgem para a cavidade peritoneal. Portanto, o método radioisotópico demonstrou de maneira simples, rápida e näo invasiva a natureza do derrame pleural

Hidrotórax hepático na ausência de ascite: relato de caso / Hepatic hydrothorax in absence of ascites: report of case

Hidrotórax hepático ocorre em cerca de 5 por cento a 7 por cento dos cirróticos com ascite, porém na ausência de ascite é um evento raro. Relatamos caso de paciente portador de hepatopatia crônica por álcool e vírus B que evoluiu com volumoso derrame pleural na ausência de ascite clinicamente detectável e revisamos a fisopatologia, diagóstico e tratamento desta condiçäo clínica.