Hepatic hydrothorax in the absence of ascites (original) (raw)
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Hepatic Hydrothorax without Apparent Ascites and Dyspnea - A Case Report
JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 2018
A 78-year-old female with a past medical history of alcoholic cirrhosis was hospitalised with recurrent lower gastrointestinal bleeding due to rectal ulcers. The ulcers were successfully treated with cautery and placement of clips. However, a recurrent large right-sided pleural effusion without apparent ascites and dyspnea were found incidentally during the hospitalisation. The initial fluid analysis was exudate based on Light's criteria with high protein. The fluid analysis was repeated five days later, after rapid reaccumulation which revealed transudates. Other causes of pleural effusion like heart failure, renal failure or primary pulmonary diseases were excluded. Hepatic hydrothorax was considered and the patient was started with the treatment of Furosemide and Spironolactone. The atypical presentation of hepatic hydrothorax may disguise the diagnosis and delay the treatment. Therefore, for a patient with recurrent, unexplained unilateral pleural effusions, even with atypical fluid characterisation and in the absence of ascites, hepatic hydrothorax should still remain on the top differential with underlying cirrhosis to ensure optimal treatment.
Hepatic hydrothorax: an uncommon cause of pleural effusion (Atena Editora)
Hepatic hydrothorax: an uncommon cause of pleural effusion (Atena Editora), 2024
Hepatic hydrothorax is the accumulation of transudate in the pleural space of patients with decompensated cirrhosis, in the absence of cardiac, pulmonary, or pleural disease. This condition affects approximately 5 to 15% of patients with cirrhosis and is associated with complications such as ascites, hepatic encephalopathy, and increased mortality. The objective of this study is to present a case report of a patient with hepatic hydrothorax due to alcoholic cirrhosis, carried out through electronic medical records and a literature review.
A fascinating presentation of hepatic hydrothorax
World journal of hepatology, 2013
We report this case of a 43-year-old woman with hepatitis-C cirrhosis who presented with a large right sided pleural effusion complicated by hypoxic respiratory failure and altered mentation necessitating dependence on mechanical ventilation. The pleural effusion spontaneously resolved upon initiation of mechanical positive pressure ventilation and recurred almost immediately after weaning the patient off the ventilator. The pre-ventilation, ventilation and post-ventilation chest X-ray films in chronological order present a striking visual demonstration of fluid dynamics and pathophysiology of hepatic hydrothorax, thereby obviating the need for a dedicated diagnostic test. We also report this case to highlight the treatment strategies for this often intractable complication.
Hepatic Hydrothorax in the Background of Minimal or No Ascites: A Case Report
2024
The examination findings were corroborated by the chest X-ray, which showed the presence of pleural effusion in the right middle and lower zones (Fig. 1). Direct microscopy of the pleural fluid showed 150 cells/mL 3 with a neutrophilic predominance of 80%. The culture of the pleural fluid grew Pseudomonas aeruginosa. On biochemical analysis, glucose levels in the pleural fluid were 77.0 mg/dL, the pleural protein/serum protein ratio was <0.5, and the pleural lactate dehydrogenase (LDH)/serum LDH ratio was <0.6, suggesting the transudative nature of the fluid according to the modified light's criteria. 5 The biochemical analysis results have been summarized in Table 1. Ultrasonography (USG) of the abdomen showed a normal-sized liver with coarse echotexture a dilated portal vein (14 mm) and splenomegaly (13.8 cm), which were suggestive of CLD with portal hypertension (Fig. 2). Minimal ascites was noted, which could not 1-4
Hepatic hydrothorax - complication of end-stage hepatic cirrhosis
Advances in Palliative Medicine, 2008
A 62-year-old woman admitted to the hospital with dyspnoea, elevated body temperature, cough for two days. Patient has been treated for alcoholic hepatic sclerosis for 12 years and hepatitis C infection for 5 years. The chest X-ray revealed hydrothorax of right pleura. Continuous drainage of the right pleura was applied. In spite of intensive treatment effusion excuded 1000 ml/day making pleurodesis impossible, and eventually pleuro-peritoneal shunt was performed. Shunt drainage however turned out to be insufficient to evacuate the pleural fluid. The shunt was removed and continuous pleural drainage was reopen. Due to subsequent disseminated intravascular coagulation, patient was treated with fresh frozen plasma, heparin, blood and platelets. The clinical status alleviated, but patient still required chest tube because of the refractory hydrothorax.
CHEST Journal, 2011
H epatic hydrothorax results from pathologic transdiaphragmatic migration of ascitic fl uid in patients with cirrhosis of the liver. It is diagnosed clinically after excluding primary pulmonary or cardiac causes of the pleural effusion in a cirrhotic patient with transudative pleural fl uid. A defi nitive diagnosis can be established by demonstrating peritoneal-pleural communication at thoracoscopy, at nuclear medicine scan with radiolabeled albumin, or on contrast-enhanced ultrasonography. 1-3 The prevalence of hepatic hydrothorax ranges from 4% to 6% in patients with cirrhosis. 4,5 Hepatic hydrothorax most commonly presents as a right-sided pleural effusion but can result in a unilateral left effusion or bilateral pleural effusions. Although ascites is usually evident at presentation, hepatic hydrothorax can present without clinically detectable ascites. 8 Patients may be asymptomatic or may present with dyspnea, cough, or hypoxemia. They are prone to recurrent bouts of spontaneous bacterial pleuritis with or without concurrent spontaneous bacterial peritonitis. The initial evaluation of this effusion should be pleural fl uid analysis. Complete pleural fl uid analysis will establish the transudative nature of the fl uid and Background: There are limited published data defi ning complete pleural fl uid analysis, echocardiographic characteristics, or the presence or absence of ascites on sonographic or CT imaging in patients with hepatic hydrothorax. Methods: We reviewed pleural fl uid analysis and radiographic, sonographic, and echocardiographic fi ndings in 41 consecutive patients with hepatic hydrothorax referred to the Pleural Procedure Service for thoracentesis. Results: Ascites was detected on sonographic or CT imaging in 38 of 39 patients (97%). Diastolic dysfunction was found in 11 of 21 patients (52%). Contrast echocardiography with agitated saline demonstrated an intrapulmonary shunt in 18 of 23 cases (78%). Solitary hepatic hydrothorax had a median pleural fl uid pH of 7.49 (fi fth to 95th percentile, 7.40-7.57), total protein level of 1.5 g/dL (0.58-2.34), and lactate dehydrogenase (LDH) level of 65 IU/L (36-138). The median pleural fluid/serum protein ratio and pleural LDH/upper limit of normal serum LDH ratio were 0.25 (0.10-0.43) and 0.27 (0.14-0.57), respectively. The median absolute neutrophil count (ANC) was 26 cells/ m L . Only a single patient had a protein discordant exudate despite 83% of patients receiving diuretics. When comparing solitary hepatic hydrothorax and spontaneous bacterial pleuritis, there was no statistically signifi cant difference among pleural fl uid total protein ( P 5 .99), LDH ( P 5 .33), and serum albumin ( P 5 .47). ANC was higher in patients with spontaneous bacterial pleuritis ( P , .0001). Conclusions: Hepatic hydrothorax virtually always presents with ascites that is detectable on sonographic or CT imaging. The development of an "exudate" from diuretic therapy is a rare phenomenon in hepatic hydrothorax. In contrast, diastolic dysfunction and intrapulmonary shunting are common in patients with hepatic hydrothorax. There was no statistically signifi cant change in pleural fl uid parameters with spontaneous bacterial pleuritis, except an increased ANC.
Hepatic hydrothorax: An update and review of the literature
World journal of hepatology, 2017
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. Th...
Hepatic hydrothorax: Case report and literature review
Revista Colombiana de Gastroenterologia
Hepatic hydrothorax is a rare complication that occurs in patients with liver cirrhosis. We report the case of a patient with NASH cirrhosis and evidence of portal hypertension who was admitted to the emergency department with coughing and chest pain. Transudative pleural effusions (according to Light's criteria) were found in association with ascites, but no cardiac cause, pleural effusion or pulmonary effusion could be found. Treatment with diuretics was begun, but was suspended because the patient developed signifi cant renal dysfunction. Fluid was drained with a thoracostomy but additional loss of fl uid led to further deterioration of renal function. It was decided to insert a transjugular portosystemic shunt (TIPS) to signifi cantly decrease portal pressure and to progressively decrease ascitic fl uid and pleural effusion. A subsequent review of the patient and radiological follow-up found no recurrence of symptoms, pleural effusion or ascites.
Review article: hepatic hydrothorax
Patients with cirrhosis and portal hypertension often have abnormal extracellular fluid volume regulation, resulting in accumulation of fluid as ascites, oedema or pleural effusion. These complications carry a poor prognosis with nearly half of the patients with ascites dying in the ensuing 2-3 years. In contrast to what happens in the abdominal cavity where large amounts of fluid (5-8 L) accumulate with the patient only experiencing only mild symptoms, in the thoracic cavity smaller amounts of fluid (1-2 L) cause severe symptoms such as shortness of breath, cough and hypoxaemia. Hepatic hydrothorax is defined as a pleural effusion, usually >500 mL, in patients with cirrhosis without cardiopulmonary disease. The pathophysiology involves the direct movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. The estimated prevalence among cirrhotic patients is 5-10%. The effusion, which is a transudate, most commonly occurs in the right hemithorax. The mainstay of therapy is similar to that of portal hypertensive ascites and includes sodium restriction and administration of diuretics. Refractory hydrothorax can be managed with transjugular intrahepatic portosystemic shunt in selected cases. Pleurodesis is not routinely recommended. Suitable patients with hepatic hydrothorax should be considered candidates for liver transplantation.