Spontaneous neutrocytic hepatic hydrothorax without ascites

Hepatic hydrothorax: clinical review and update on consensus guidelines

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.

Evaluation of liver transplant candidates: A pulmonary perspective

Chronic liver disease is one of the leading causes of mortality and morbidity in the worldwide adult population. Liver transplant is the gold standard therapy for end-stage liver disease and many patients are on the waiting list for a transplant. A variety of pulmonary disorders are encountered in cirrhotic patients. Pleura, lung parenchyma, and pulmonary vasculature may be affected in these patients. Hypoxemia is relatively common and can be asymptomatic. Hepatopulmonary syndrome should be investigated in hypoxic cirrhotic patients. Gas exchange abnormalities are common and are generally correlated with the severity of liver disease. Both obstructive and restrictive types of airway disease can be present. Abnormal diffusion capacity is the most frequently observed pulmonary function disorder in patients with cirrhosis. Hepatic hydrothorax is another finding which is usually seen in conjunction with, but occasionally without ascites. Portopulmonary hypertension is a complication of long standing liver dysfunction and when severe, is accepted as a containdication to liver transplant. Since respiratory disorders are common and have significant impact on postoperative outcome in patients undergoing liver transplant, a careful preoperative pulmonary assessment is important.

Hepatic hydrothorax: pathophysiology diagnosis and management

Hepatic hydrothorax is defined as a significant pleural effusion (usually greater than 500 ml) in a cirrhotic patient, without an underlying pulmonary or cardiac disease. The diagnosis of hepatic hydrothorax should be suspected in a patient with established cirrhosis and portal hypertension, presenting with a unilateral pleural effusion, most commonly right-sided. In the vast majority of cases, patients with hepatic hydrothorax have end-stage liver disease. Therefore, they should be considered potential candidates for orthotopic liver transplantation. Until the performance of transplantation, other therapeutic modalities should be applied in order to relieve symptoms and prevent pulmonary complications.

The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding

BACKGROUND

Until now, the pathophysiology of hepatic hydrothorax has been moot. We discuss (on the basis of gross videothoracoscopy findings in 11 cases and the literature) the pathogenesis and clinical presentation of this complex condition.

METHODS

We prospectively studied 11 patients (age, 31-73 years; 6 men and 5 women) with refractory hepatic hydrothorax (Child-Pugh class B-C) who underwent thoracoscopic repair of diaphragmatic defects. The diaphragmatic defects were examined intraoperatively.

RESULTS

The diaphragmatic defects stemming from hepatic hydrothorax were classified into 4 morphologic types: type I, no obvious defect (1 patient); type II, blebs lying on the diaphragm (4 patients); type III, broken defects (fenestrations) in the diaphragm (8 patients); and type IV, multiple gaps in the diaphragm (1 patient). The type of diaphragmatic defect did not correlate with the volume occupied by the pleural effusion in the preoperative chest radiograms.

CONCLUSIONS

The finding of this study allowed hepatic hydrothorax pathophysiology to be directly visualized, and further studies concerning the treatment of hepatic hydrothorax might be based on these mechanisms.

Hepatic hydrothorax: pathophysiology, diagnosis, and management

Hepatic hydrothorax occurs in approximately 5 to 12% of patients with cirrhosis and portal hypertension. Various therapeutic modalities ranging from dietary and pharmacologic interventions to surgical approaches are available for the management of this condition. Treatment must be individualized based on the patient's response to conservative management as well as the severity of the underlying liver disease. Hepatic hydrothorax may be complicated by spontaneous bacterial empyema, which portends a poor prognosis with a mortality rate of up to 20%. All patients with hepatic hydrothorax should be evaluated for possible liver transplantation.

Hepatic hydrothorax

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.

Hepatic hydrothorax: a retrospective case study

PURPOSE

To present the pathophysiology, differential diagnoses, assessment techniques, and treatment options for hepatic hydrothorax.

DATA SOURCES

A case study is presented with supporting material from current medical literature.

CONCLUSIONS

Hepatic hydrothorax is a pleural effusion caused by the flow of ascitic fluid into the pleural space through an actual defect in the diaphragm. Successful outcomes depend on early detection and timely referral of often-subtle lung involvement.

IMPLICATIONS FOR PRACTICE

Although incidence is reported to be as high as 12% in cirrhotic patients, standard medical references attach little importance to pulmonary risks in this population. Hepatic hydrothorax should always be considered in the cirrhotic patient with a pleural effusion.

Hepatic hydrothorax: pathogenesis, diagnosis, and management

Hepatic hydrothorax is defined as a pleural effusion in a patient with cirrhosis of the liver and no cardiopulmonary disease. The estimated prevalence of this often debilitating complication in patients with liver cirrhosis is 4% to 10%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. As a result patients are at increased risk of respiratory infection. Initial management consists of sodium restriction, diuretics, and thoracentesis. A transjugular intrahepatic portosystemic shunt may be required. Because most patients with hepatic hydrothorax have end-stage liver disease, a liver transplant should be considered if these options fail.

Isolated pleural effusion in severe ovarian hyperstimulation: A case report

Assisted reproductive technology programs use controlled ovarian hyperstimulation to maximize pregnancy rates. Severe ovarian hyperstimulation syndrome is a well-known risk. Pleural effusion often accompanies severe ovarian hyperstimulation syndrome. We describe 2 cases of isolated hydrothorax without concomitant ascites and review the literature of this rare finding.