hepatic hydrothorax hepatic hydrothorax.p… · thoracentesis •30% other cause: spontaneous...
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Hepatic hydrothorax
Sasinee Tongprasert, MD
Samitivej Srinakarin Hospital
Ramathibodi Hospital
DEFINITION
• Significant pleural effusion, usually greater than 500 mL, in a cirrhotic patient, without an underlying pulmonary or cardiac disease
• Prevalence 5–12%
• 85% Rt, 13% Lt, 2% bilateral
Sawant P, et al. International Journal of Hepatology 2011:1-11 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
PATHOGENESIS
• Hypoalbuminemia—decreased colloid osmotic pressure
• Azygos veins hypertension
• Transdiaphragmatic migration of fluid via lymphatic channels
• Leakage of ascitic fluid via diaphragmatic defects
Roussos A, et al. Journal of Gastroen Hepatol 2007;22: 1388–1393 Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320
Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141
PATHOGENESIS
• Hypoalbuminemia—decreased colloid osmotic pressure
• Azygos veins hypertension
• Transdiaphragmatic migration of fluid via lymphatic channels
• Leakage of ascitic fluid via diaphragmatic defects
Roussos A, et al. Journal of Gastroen Hepatol 2007;22: 1388–1393 Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320
Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141
Truninger K, et al. Schweiz Med Wochenschr 2000;130: 1706
PATHOGENESIS
PATHOGENESIS
CLINICAL MANIFESTATIONS
• Shortness of breath, cough, hypoxemia, and/or chest discomfort
• Acute tension hydrothorax (less common)
DIAGNOSIS
CXR
Woo Jin Lee, et al. The Korean J Hepatol 2011;17(4):292-298
Thoracentesis
• 30% other cause: spontaneous bacterial empyema (SBEM), tuberculosis, adenocarcinoma, parapneumonic empyema
• 85% of right side and 35% of left side is simple hepatic hydrothorax
• Cell count, Gram stain and culture in blood culture bottles, and serum and fluid protein, albumin, and LDH
Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
DIAGNOSIS
• Cell count < 500/mm3
• PMN count < 250/mm3
• Protein concentration < 2.5 g/dL
• Pleural fluid/serum total protein ratio < 0.5
• Pleural fluid/serum LDH ratio < 0.6
• Pleural fluid/serum albumin gradient > 1.1
• pH >7.4
• Pleural fluid glucose concentration similar to that of serum
DIAGNOSIS
Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
Criteria
• PMN > 250 cells/mm3 and positive culture or
• PMN > 500 cells/mm3 and negative culture
• Absence of pneumonia on CXR
Siddappa PK , et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
Spontaneous bacterial empyema (SBEM)
• Incidence 13-16%
• 40% not associated with SBP
• Direct spread of the infection through the diaphragmatic defects and enteric microorganisms reach the pleural space through bacteremia
• Fever and pleuritic chest pain, encephalopathy or unexplained deterioration in renal function
Spontaneous bacterial empyema (SBEM)
Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
• The etiologic agents: E. coli, Streptococcus, Enterococcus, Klebsiella
• Rx: Third-generation cephalosporin
Albumin, antibiotic prophylaxis
• Risk factors: low levels of pleural fluid C3 or total protein, and a high Child-Pugh score
• Mortality 20%
Spontaneous bacterial empyema (SBEM)
Siddappa PK, et al. Trop Gastroenterol 2009;30(3): 135–141 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
Intraperitoneal injection of 99mTc-sulphur colloid or 99mTc-human serum albumin
• Gold standard: sensitivity 71%, performing a thoracentesis prior increase sensitivity nearly 100% and specificity 100%
DIAGNOSIS
Kiafar C, et al. Ann of Hepatol 2008;7(4):313-320 Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
• Investigation for primary cardiopulmonary disorders: CT chest, Echocadiography
Radiology March 2011;258(3):776-784
DIAGNOSIS
MANAGEMENT
Candidates for orthotopic liver transplantation
• Definitive treatment
Medical management
• Sodium-restricted diet: 2 g/ day
• Diuretics: renal excretion of Na > 120 mEq/day
MANAGEMENT
Therapeutic thoracentesis
• "2 L rule"
• Risk of pulmonary edema and hypotension
• Complication: pneumothorax, hemothorax
• Coagulopathy: not contraindication
• Cr > 6 mg/dl increase risk bleeding
• Placement of chest tubes in patients with hepatic hydrothorax can result in massive protein and electrolyte depletion, infection, renal failure, and bleeding
• Relative contraindication
Orman ES, Lok ASF. Hepatol Int 2009;3:582–586
MANAGEMENT Transjugular intrahepatic portosystemic shunts • Response rates 70-80% • Largest study by Dhanasekaran 73 patient: 59% CR, 20% PR and 21% NR short term survival 30, 60,90 d: 81, 78, 72% long term survival 1, 3, 5 yr: 48, 26, 15%
• Standard treatment for refractory hepatic hydrothorax
• Contraindications: age > 70, significant hepatic encephalopathy, large portal vein thrombosis, right-sided heart failure, elevated pulmonary arterial pressures, and MELD score > 18
Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
MANAGEMENT
Surgical interventions
• Surgical repair of diaphragmatic defects: small report from Milanez: 21 Patients
Success 48% Morbidity 57.1% Mortality 38.9%
• Pleurodesis—injection of a sclerosing agent, Video-assisted thoracoscopy (VATS): limit data
Krok KL, et al. Semin Respir Crit Care Med 2012;33:3–10
Improve clinical 72.7% but mortality 45.5%
• Other treatment options — Splanchnic vasoconstrictor drugs (Octreotide, Terlipressin): case report
MANAGEMENT
SUMMARY
• Pleural effusion in a cirrhotic patient, without an underlying pulmonary or cardiac disease
• Most right side
• Leakage of ascitic fluid via diaphragmatic defects
• Thoracentesis should perform
• SBEM
• Intraperitoneal injection of 99mTc-sulphur colloid or 99mTc-human serum albumin: gold standard
SUMMARY