The use of the diagnostic radionuclide ascites scan to facilitate treatment decisions for hepatic hydrothorax

The Role of SPECT/CT in Peritoneal Scintigraphy in the Era of Low-Dose Imaging: A Case Report

Peritoneal scintigraphy, although rarely used, plays a vital role in the diagnosis of peritoneal dialysis catheter complications. Reported complications include spontaneous hydrothorax secondary to a pleuroperitoneal fistula, which requires the abandonment of peritoneal dialysis, given that a delay in diagnosis can lead to worsening clinical status. Previously reported peritoneal scintigraphy protocols recommended intraperitoneal instillation of radiotracer and moderate-to-large volumes of dialysate or sterile saline ranging from 350 to 2,000 mL. However, smaller volumes, in conjunction with the use of single-photon emission computed tomography/computed tomography, are not verified in patients receiving peritoneal scintigraphy imaging.

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.

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.

Pitfalls in the Performance and Interpretation of Scintigraphic Imaging for Pleuroperitoneal Shunt

Ascites can cause pleural effusions when the peritoneal fluid crosses the diaphragm through a pleuroperitoneal shunt in the setting of hepatic cirrhosis (hepatic hydrothorax) or malignant ascites. Scintigraphic imaging for pleuroperitoneal shunt requires intraperitoneal injection of Tc-SC or Tc-macroaggregated albumin followed by planar imaging of the chest and abdomen. Pleuroperitoneal shunt is confirmed by identifying radiotracer crossing the diaphragm from the peritoneal to pleural space. An atlas of pleuroperitoneal shunt imaging pitfalls is presented to facilitate optimal performance and interpretation of nuclear pleuroperitoneal shunt examinations. Examples include cases of nondiagnostic radiotracer injections, processing errors, and nontarget uptake.

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.

Optimal Time Points for Scintigraphic Imaging of Pleuroperitoneal Shunts

OBJECTIVE

Nuclear imaging can confirm pleuroperitoneal shunt as the cause of pleural effusion. No society guidelines exist for scintigraphic pleuroperitoneal shunt detection. Our institutional protocol was evaluated to determine optimal imaging time points for shunt detection.

METHODS

Pleuroperitoneal shunt studies over 4 years were blindly reviewed by 2 nuclear radiologists. Data from blinded review included presence or absence of pleuroperitoneal shunt, laterality of shunt and time points for shunt detection.

RESULTS

Chart review yielded 30 studies. Three cases were excluded because of improper injection. Imaging was positive for pleuroperitoneal shunt in 81% (22/27) of cases. In positive cases, activity was identified in the right hemithorax in 82% (18/22), left hemithorax in 9% (2/22), and bilaterally in 9% (2/22). One-hour imaging demonstrated 91% (20/22) of positive cases. The remaining 2 positive cases were negative at 1 hour but positive after 4 hours. No study was negative at 1 and 4 hours and positive at 24 hours. All negative cases (5/27) were confirmed on 24-hour imaging.

CONCLUSIONS

The majority of positive pleuroperitoneal shunt examinations will demonstrate activity in the right hemithorax on 1-hour imaging. Although no case was negative at 1 and 4 hours and positive at 24 hours, imaging at 24 hours may still be necessary to confirm absence of shunt. Therefore, optimal imaging time points consist of early 1-hour and delayed 24-hour images if the 1-hour time point was negative. The 4-hour time point may be considered optional, thereby potentially optimizing patient safety and resource utilization.

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.

Role of the peritoneopleural pressure gradient in the genesis of hepatic hydrothorax. An isotopic study

SUMMARY

Hepatic hydrothorax is defined as the development of significant pleural effusion in a patient with cirrhosis without primary pulmonary or cardiac disease. This complication is seen in 4-10% of patients with cirrhosis. The pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm. We report two patients with posthepatitis cirrhosis presenting with a significant pleural effusion. The peritoneopleural communication was demonstrated by peritoneal scintigraphy. The role of the peritoneopleural pressure gradient is discussed.

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.

Endometriosis associated with hemothorax

Bloody pleural effusion is rarely associated with endometriosis. To effectively treat this condition, it is important to differentiate the malady from other common diseases such as malignancy or tuberculosis. We describe the case of a 40-year-old multiparous female featuring right-sided hemothorax presenting with right shoulder pain and progressive shortness of breath for the preceding 2 months. Thoracoscopy disclosed grossly negative findings apart from multiple small pores in the right hemi-diaphragm with blood clots within them. Examination of the thoracoscopic biopsy specimens showed chronic pleuritis without evidence of malignancy or tuberculosis. Pelvic endometriosis was considered a possible diagnosis according to the results of abdominal computed tomography (CT) scan, transvaginal sonography, and the results of dilatation and curettage. Periodic episodes of symptoms concurrent with menstruation led to the suspicion of a relationship between these conditions in our patient. Despite the patient undergoing an abdominal total hysterectomy and adhesiolysis without salpingo-oophorectomy, recurrent right-sided bloody pleural effusion developed 1.5 months subsequent to surgery. As a consequence, danazol (400 mg/day) was maintained because of the endometriosis associated with pleural effusion. One year of regular follow-up later, there was no evidence of recurrent pleural effusion. We considered that the bloody pleural fluid arose via seepage from the pelvic endometriosis through the pores of the right hemi-diaphragm during menstruation.

Large diaphragmatic defect as the cause of hydrothorax in a cirrhotic patient: demonstration with peritoneal scintigraphy and magnetic resonance imaging

A 52-year-old man with history of post-hepatitic cirrhosis presented with ascitis and respiratory distress. Chest X-ray on admission showed a large right hydrothorax. Thoracentesis yielded a large volume of a clear transudate fluid. Peritoneal scintigraphy showed rapid migration of radiotracer into the right pleural cavity, confirming the abdominal origin of the pleural fluid and suspecting a large diaphragmatic defect. MR imaging study using ultrafast sequences confirmed the large diaphragmatic defect.

Isotopic exploration of hepatic hydrothorax: ten cases

OBJECTIVE

The aim of this retrospective study was to evaluate the performance of peritoneal scintigraphy for the diagnosis of peritoneopleural communication in patients with cirrhosis and to discuss its role in therapeutic management.

PATIENTS AND METHODS

Ten patients with cirrhosis and pleural effusion were included in this study. Cirrhosis was due to viral hepatitis in eight patients, auto-immune disease in one patient and of unknown origin in one. The pleural effusion was right-sided in nine patients and bilateral in one. 99m-technetium sulfur colloid peritoneal scintigraphy was performed in all patients.

RESULTS

Scintigraphy revealed peritoneopleural communication in nine patients. In four patients, radioactivity appeared in the pleural cavity within a few minutes after injection of the radiotracer. In three of them, a large diaphragmatic defect was demonstrated by ultrasonography, magnetic resonance imaging or thoracoscopy. Complete response to medical treatment was observed in four patients. Scintigraphy revealed rapid radioactivity migration in four patients; diuretic treatment led to resolution of the hydrothorax in one of them. Three patients whose hydrothorax was refractory to medical treatment were treated by pleurodesis with talc. Resolution of the hydrothorax was achieved in one of them.

CONCLUSION

Peritoneal scintigraphy is a simple non-invasive method enabling confirmation of peritoneopleural communication in cirrhotic patients. The importance of the diaphragmatic defect can also be evaluated, providing a significant contribution to therapeutic decision-making.

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.

Chemical pleurodesis for hepatic hydrothorax

BACKGROUND

Ascites can occur after hepatic diseases causing dyspnea, coughing and pain. When associated with pleural effusion it can also increase respiratory distress. In a bibliographic survey hydrothorax has been observed in up to 20% of the patients and the kind of treatment is still being discussed.

OBJECTIVE

This case report shows the occurrence of a large volume of ascites and pleural effusion in a cirrhotic patient and his treatment.

METHODS

Report the case of a patient with hepatic cirrhosis due to chronic alcoholism and massive pleural effusion and ascites. He was submitted to several pleural paracenteses without success. Scintigraphy showed the presence of ascites and confirmed a possible pleuroperitoneal communication. The thoracic surgery group was called and after evaluation it was decided to submit the patient to a pulmonary decortication and chemical pleurodesis.

RESULTS

These procedures were carried out with success. The pleural effusion was solved and the treatment of ascites was decided upon because the patient did not accept any surgical procedure.

CONCLUSION

This treatment could be applied to patients with hydrothorax who could not be submitted to a liver transplantation.