1
|
Rahim Y, Reddy R, Naeem M, Tsaknis G. Medical thoracoscopy with talc pleurodesis for refractory hepatic hydrothorax: A case series of three successes. Respir Med Case Rep 2024; 50:102039. [PMID: 38817846 PMCID: PMC11137508 DOI: 10.1016/j.rmcr.2024.102039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/28/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024] Open
Abstract
Medical thoracoscopy with chemical pleurodesis is a last resort for managing patients who suffer. from recurrent hepatic hydrothorax. However, despite pleurodesis, the rapid fluid build-up can hinder the successful apposition of the pleural surfaces. To improve the chances of success, we investigated the effectiveness of abdominal paracentesis before chemical pleurodesis via medical thoracoscopy to reduce significant fluid shifts from the peritoneal to the pleural cavity. We present a series of three patients with liver cirrhosis complicated by hepatic hydrothorax who underwent medical thoracoscopy with talc pleurodesis. Before the procedure, we optimised medical treatment, and if needed, we performed large-volume paracentesis to prevent rapid reaccumulation of pleural fluid. All study subjects achieved treatment success, defined as relief of breathlessness and absence of pleural effusion at 12 months. Complications related to the treatment included hepatic encephalopathy and acute kidney injury, which were managed conservatively. To manage symptomatic and recurrent hepatic hydrothorax, medical thoracoscopy with talc pleurodesis, preceded by the evacuation of ascites, can be considered as a treatment option. This procedure should be considered early for those who do not respond to medical management and are not suitable candidates for TIPS or liver transplantation.
Collapse
Affiliation(s)
- Y. Rahim
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| | - R.V. Reddy
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| | - M. Naeem
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| | - G. Tsaknis
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| |
Collapse
|
2
|
Owda F, Mallah S, Ayyad M, Albandak M, Yousef S, Hmeedan A, Odeh M, Reid AM, Sleibi W, Azar J. A Very Uncommon Case of Transudative Chylothorax: A Case Report and Literature Review. Cureus 2023; 15:e38320. [PMID: 37261168 PMCID: PMC10227672 DOI: 10.7759/cureus.38320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/02/2023] Open
Abstract
The presence of chyle in the pleural cavity is referred to as chylothorax. Exudative chylothorax is usually related to damage or obstruction of the lymphatic vasculature with subsequent leakage into the pleural space. In contrast, transudative chylothorax is related to increased hydrostatic pressure caused by elevated intra-abdominal pressure, which leads to the translocation of chylous fluid into the pleural space. Cirrhosis is the most common cause of transudative chylothorax, commonly presenting with ascites and portal hypertension. To the best of our knowledge, isolated transudative chylothorax as a consequence of cirrhosis is exceptionally rare and has been scarcely reported in the literature. We herein report a female patient in her fifties who presented to our hospital with isolated unilateral transudative hepatic chylothorax, with no clinical evidence of cirrhosis or any stigmata of portal hypertension at the time of presentation.
Collapse
Affiliation(s)
- Fahed Owda
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Shatha Mallah
- Internal Medicine, An-Najah National University, Nablus, PSE
| | | | | | - Shahed Yousef
- School of Medicine, Al-Quds University, Jerusalem, PSE
| | - Alaa Hmeedan
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Mahmoud Odeh
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Adam M Reid
- Research, University of California Los Angeles, California, USA
| | - Wadi Sleibi
- Internal Medicine, Al-Quds University, Jerusalem, PSE
| | - Jehad Azar
- Respiratory Institute, Cleveland Clinic, Cleveland, USA
| |
Collapse
|
3
|
Akbar A, Hendrickson T, Vangara A, Marlowe S, Hussain A, Ganti SS. Hepatic Chylothorax: An Uncommon Pleural Effusion. J Investig Med High Impact Case Rep 2023; 11:23247096221150634. [PMID: 36644885 PMCID: PMC9846292 DOI: 10.1177/23247096221150634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
An 83-year-old male with chronic obstructive pulmonary disease and liver cirrhosis presented with confusion and dyspnea. On chest X-ray, he had the right mid to lower lung zone white out. Ultrasound-guided thoracentesis drained 1.5 L of milky white pleural fluid which was transudative according to chemical analysis. Transudative chylothorax in liver cirrhosis without ascites is rare, but can happen. When the flow of ascitic chylous fluid into the pleural space equals the rate of ascites production, clinical absence of detectable ascites will occur. Hepatic chylothorax is important and should be kept in differentials when evaluating patients with liver cirrhosis.
Collapse
Affiliation(s)
- Aelia Akbar
- Appalachian Regional Healthcare, Harlan, KY, USA
| | | | | | | | | | | |
Collapse
|
4
|
Banini BA, Alwatari Y, Stovall M, Ogden N, Gershman E, Shah RD, Strife BJ, Shojaee S, Sterling RK. Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology 2020; 72:1851-1863. [PMID: 32585037 DOI: 10.1002/hep.31434] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Bubu A Banini
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Yahya Alwatari
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Madeline Stovall
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Nathan Ogden
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Evgeni Gershman
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Brian J Strife
- Division of Interventional Radiology, Department of Radiology, Virginia Commonwealth University, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| |
Collapse
|
5
|
Sobotka LA, Spitzer C, Hinton A, Michaels A, Hanje AJ, Mumtaz K, Conteh LF. Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission. J Gastroenterol Hepatol 2020; 35:641-647. [PMID: 31441096 DOI: 10.1111/jgh.14842] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.
Collapse
Affiliation(s)
- Lindsay A Sobotka
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Carleen Spitzer
- Department of Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Anthony Michaels
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - A James Hanje
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Khalid Mumtaz
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Lanla F Conteh
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
6
|
Thoracoscopic diaphragm repair using abdominal insufflation in a patient with hepatic hydrothorax. Gen Thorac Cardiovasc Surg 2019; 68:302-305. [DOI: 10.1007/s11748-019-01117-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/24/2019] [Indexed: 12/21/2022]
|
7
|
Affiliation(s)
- Apurwa Karki
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Leonard Riley
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Hiren J Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 32610, United States.
| |
Collapse
|
8
|
The Outcome of Thoracentesis versus Chest Tube Placement for Hepatic Hydrothorax in Patients with Cirrhosis: A Nationwide Analysis of the National Inpatient Sample. Gastroenterol Res Pract 2017; 2017:5872068. [PMID: 29317865 PMCID: PMC5727694 DOI: 10.1155/2017/5872068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/24/2017] [Accepted: 10/10/2017] [Indexed: 02/07/2023] Open
Abstract
There are only a few studies with a small sample size of patients that have compared the risks of using chest tubes versus thoracentesis in hepatic hydrothorax. It has been shown that many complications may arise secondary to chest tube placement and is associated with increased morbidity and mortality. In this retrospective study, patients with cirrhosis were identified from the 2009 National Inpatient Sample by using ICD-9 codes; we evaluated the risk of chest tube versus thoracentesis in a largest population with hepatic hydrothorax to date to measure the mortality and the length of stay. A total of 140,573 patients with liver cirrhosis were identified. Of this, 1981 patients had a hepatic hydrothorax and ended up with either thoracentesis (1776) or chest tube (205). The mortality in those who received a chest tube was two times higher than that in thoracentesis group with a P value of ≤0.001 (CI 1.43–312). In addition, the length of hospital stay of the chest tube group was longer than that of the thoracentesis subset (7.2 days versus 3.8 days, resp.). We concluded that chest tube placement has two times higher mortality rate and longer hospital length of stay when compared to patients who underwent thoracentesis.
Collapse
|
9
|
Al-Zoubi RK, Abu Ghanimeh M, Gohar A, Salzman GA, Yousef O. Hepatic hydrothorax: clinical review and update on consensus guidelines. Hosp Pract (1995) 2016; 44:213-223. [PMID: 27580053 DOI: 10.1080/21548331.2016.1227685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rana Khazar Al-Zoubi
- a School of Medicine Ringgold standard institution - Pulmonary & Critical Care , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Mouhanna Abu Ghanimeh
- b School of Medicine Ringgold standard institution - Internal Medicine , University of Missouri Kansas City School of Medicine , Kansas City , MO , USA
| | - Ashraf Gohar
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Gary A Salzman
- c School of Medicine - Pulmonary and Critical Care Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| | - Osama Yousef
- d School of Medicine - Gastroenterology Medicine , University of Missouri-Kansas City School of Medicine , Kansas City , MO , USA
| |
Collapse
|
10
|
Abstract
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.
Collapse
|
11
|
Transjugular intrahepatic portosystemic shunt in refractory hydrothorax - a contribution to an unexplored indication. Eur J Gastroenterol Hepatol 2016; 28:661-6. [PMID: 27002676 DOI: 10.1097/meg.0000000000000623] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Hepatic hydrothorax is a rare complication of portal hypertension, but may be potentially severe. Although conservative therapy may be effective, it is not without risk and refractory cases are not rare. The portal decompression achieved by transjugular intrahepatic portosystemic shunts (TIPS) has shown positive results in the treatment of refractory ascites, and in that sense, the analysis of their value in other complications of portal hypertension becomes relevant. The aim of this study was to evaluate the efficacy and safety of TIPS in patients with refractory hydrothorax. METHODS This was a retrospective study including patients with refractory hydrothorax undergoing TIPS in a tertiary hospital in the period between 2000 and 2014, and evaluated the following: demographic characteristics, liver disease, and outcomes (efficacy and safety, including complications after TIPS, liver transplantation, 30-day, and 1-year mortality). RESULTS Nineteen patients with hydrothorax underwent TIPS; most had previously undergone multiple thoracocentesis and all had hypoalbuminemia. In all, 57.9% of the patients were men, with a mean age 63±9 years, and 84.2% had cirrhosis of alcoholic etiology and a mean Model for End-Stage Liver Disease-16, Child-Pugh B in 42.1%/Child-Pugh C in 47.4%. TIPS was effective in 73.3% of the cases. Portosystemic encephalopathy was recorded in 66.6% of the cases. Mortality was 25% at 30 days and 42.8% at 1 year with septic complications or progression of liver disease. Two patients underwent liver transplantation. The mean follow-up duration was 704 days (3-3485 days). CONCLUSION TIPS appears to be a relatively efficient method to control hydrothorax, making it a valid option in refractory cases despite the high risk of portosystemic encephalopathy and mortality.
Collapse
|
12
|
Yilmaz N, Zeybek A, Tharian B, Yilmaz UE. Efficacy of nonsurgical tigecycline pleurodesis for the management of hepatic hydrothorax in patients with liver cirrhosis. Surg Case Rep 2015; 1:62. [PMID: 26366359 PMCID: PMC4560132 DOI: 10.1186/s40792-015-0049-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 05/28/2015] [Indexed: 02/08/2023] Open
Abstract
Chemical pleurodesis is one of the therapeutic tools to control hepatic hydrothorax. Tetracycline and derivatives have been widely accepted as an effective and safe treatment for the purpose, but availability is the big concern. Tigecycline is an antibiotic derivative of tetracycline, which has demonstrated to be an effective pleurodesing agent in animal models. The aim of the study was to document two successful tigecycline pleurodesis in patients with decompensated liver cirrhosis, who were not candidates for liver transplantation. Both patients were undergoing palliative treatment for cirrhosis and developed massive pleural effusion on the right side. They underwent chemical pleurodesis in the first instance. Diagnostic thoracocentesis was done to rule out differentials and to confirm the clinical suspicion, following which, complete drainage of pleural fluids was achieved. Tigecycline of 3 mg/kg was instilled intrapleurally via the thoracic catheter, as per the protocol. The medical records and images were thoroughly reviewed. There was no recurrence of the effusion for at least 3 months, with no detected complications in the short- or long-term follow-up. In conclusion, pleurodesis with tigecycline seems to be effective and safe for the management of symptomatic hepatic hydrothorax and should therefore be promoted in the setting of liver cirrhosis at least for a short-term relief, especially in patients who do not meet the criteria for liver transplantation.
Collapse
Affiliation(s)
- Nevin Yilmaz
- />Transplant Hepatology, Mugla University School of Medicine, 48000 Mugla, Turkey
| | - Arife Zeybek
- />Thoracic Surgery, Mugla University School of Medicine, Mugla, Turkey
| | - Benjamin Tharian
- />Department of Medicine and Gastroenterology, NWAHS, Tasmania, Australia
| | - Ugur Eser Yilmaz
- />Royal College of Surgeons in Ireland Medicine School (RCSI) / Graduate Entry Program, Dublin, Ireland
| |
Collapse
|
13
|
Abstract
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.
Collapse
|
14
|
Lam ST, Johnson ML, Kwok RM, Bassett JT. Spontaneous bacterial empyema: not your average empyema. Am J Med 2014; 127:e9-e10. [PMID: 24530952 DOI: 10.1016/j.amjmed.2014.01.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 01/24/2014] [Accepted: 01/25/2014] [Indexed: 01/16/2023]
Affiliation(s)
- Sherrell T Lam
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Md.
| | - Michael L Johnson
- Department of Neurology, Walter Reed National Military Medical Center, Bethesda, Md
| | - Ryan M Kwok
- Division of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Md
| | - John T Bassett
- Division of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Md
| |
Collapse
|
15
|
Clinical significance of the dipstick test to detect empyema in hepatic hydrothorax with and without spontaneous bacterial peritonitis. EGYPTIAN LIVER JOURNAL 2014. [DOI: 10.1097/01.elx.0000440958.59548.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
16
|
Gaduputi V, Tariq H, Kanneganti K. A fascinating presentation of hepatic hydrothorax. World J Hepatol 2013; 5:589-591. [PMID: 24179619 PMCID: PMC3812462 DOI: 10.4254/wjh.v5.i10.589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/27/2013] [Accepted: 10/16/2013] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
17
|
Abstract
Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis without primary cardiac, pulmonary or pleural disease. It is a rare but important cause of unilateral-pleural effusion. The prevalence of this complication is 5-10% of the total number of patients with advanced stages of cirrhosis. In most cases (85%), the effusion is right-sided; however, in 13% of cases it can be left-sided and bilateral in 2% of the cases. We present a case of left-sided hepatic hydrothorax in the absence of ascites in a patient with primary biliary cirrhosis. The diagnosis of cirrhosis was confirmed by the biopsy;the patient didn't have any history or any signs or symptoms of cirrhosis prior to her presentation. In the case described, the patient was treated with spirnolactone, furosemide and ursodeoxycholic acid. At follow-up after six months since the diagnosis, she was responding to treatment with no complications. This case emphasizes the importance of considering hepatic hydrothorax as an etiology of a transudative pleural effusion regardless of the presence or absence of ascites inpatients with occult cirrhosis.
Collapse
Affiliation(s)
- Mohammad Alhaji
- 1 Department of Hospital Medicine, Saint Joseph Mercy Hospital, Ann Arbor, MI, USA
| | | |
Collapse
|
18
|
Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. ACTA ACUST UNITED AC 2013; 86:155-73. [PMID: 23571767 DOI: 10.1159/000346996] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 01/08/2013] [Indexed: 12/19/2022]
Abstract
Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.
Collapse
Affiliation(s)
- Amita Singh
- Department of Pulmonary and Critical Care, UF College of Medicine at Jacksonville, Jacksonville, FL 32209, USA.
| | | | | |
Collapse
|
19
|
Transjugular intrahepatic portosystemic shunt for treatment of cirrhosis-related chylothorax and chylous ascites: single-institution retrospective experience. Cardiovasc Intervent Radiol 2012. [PMID: 23207657 DOI: 10.1007/s00270-012-0530-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate the efficacy and safety of the use of transjugular intrahepatic portosystemic shunt (TIPS) creation to treat cirrhosis-related chylous collections (chylothorax and chylous ascites). METHODS We retrospectively reviewed data from four patients treated for refractory cirrhosis-related chylous collections with TIPS at our institution over an 8 year period. RESULTS One patient had chylothorax, and three patients had concomitant chylothorax and chylous ascites. There were no major complications, and the only procedure-related complications occurred in two patients who had mild, treatable hepatic encephalopathy. All patients had improvement as defined by decreased need for thoracentesis or paracentesis, with postprocedure follow-up ranging from 19 to 491 days. CONCLUSION TIPS is a safe procedure that is effective in the treatment of cirrhosis-related chylous collections.
Collapse
|
20
|
The Use of a PleurX Catheter in the Management of Recurrent Benign Pleural Effusion: A Concise Review. Heart Lung Circ 2012; 21:661-5. [DOI: 10.1016/j.hlc.2012.06.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 06/26/2012] [Accepted: 06/29/2012] [Indexed: 11/21/2022]
|
21
|
|
22
|
Makhlouf HA, Morsy KH, Makhlouf NA, Eldin EN, Khairy M. Spontaneous bacterial empyema in patients with liver cirrhosis in Upper Egypt: prevalence and causative organisms. Hepatol Int 2012. [DOI: 10.1007/s12072-012-9372-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
23
|
Abstract
Shortness of breath is a common complaint in those with chronic liver disease. The differential diagnosis for this complaint includes primary pulmonary disorders, systemic disorders that affect the liver and lungs, and extrahepatic manifestations of portal hypertension. Orthotopic liver transplant, when appropriate, is the most effective therapy for many patients with dyspnea and chronic liver disease, although therapies to treat the underlying complications of cirrhosis may provide relief. Shortness of breath in patients with cirrhosis often portends a poor prognosis, and these patients should be evaluated for orthotopic liver transplant because this therapy is most likely to provide long-lasting benefit.
Collapse
Affiliation(s)
- Paul Y Kwo
- Gastroenterology/Hepatology Division, Indiana University School of Medicine, Indianapolis, 46202-5121, USA.
| |
Collapse
|
24
|
Two cases of massive pleural effusion noted only after induction of anesthesia in living donor liver transplantation. J Anesth 2011; 25:418-21. [DOI: 10.1007/s00540-011-1110-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Accepted: 02/10/2011] [Indexed: 10/18/2022]
|
25
|
Ameneiros Lago E, Fernández Fernández F, Carballada Rico C, Sesma Sánchez P. [Spontaneous pleural empyema]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:124-125. [PMID: 21339016 DOI: 10.1016/j.gastrohep.2010.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Accepted: 09/29/2010] [Indexed: 05/30/2023]
|
26
|
Ford RM, Sakaria SS, Subramanian RM. Critical care management of patients before liver transplantation. Transplant Rev (Orlando) 2010; 24:190-206. [PMID: 20688502 DOI: 10.1016/j.trre.2010.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 02/07/2023]
Abstract
The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.
Collapse
Affiliation(s)
- Ryan M Ford
- Division of Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, GA, USA
| | | | | |
Collapse
|
27
|
The impact of preoperative hepatic hydrothorax on the outcome of adult liver transplantation. Eur J Gastroenterol Hepatol 2010; 22:207-12. [PMID: 19779352 DOI: 10.1097/meg.0b013e3283311140] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Hepatic hydrothorax is an uncommon, but severe complication of cirrhosis. Orthotopic liver transplantation (OLT) is the best option in case of end-stage liver disease. The impact of hepatic hydrothorax on pre-transplant and post-transplant courses has not been clearly investigated. PATIENTS AND METHODS Eleven patients (group 1) with hepatic hydrothorax and end-stage liver disease out of 346 consecutive patients who underwent OLT between January 2002 and December 2006 were studied. First, pretransplant and posttransplant symptoms and management of hepatic hydrothorax were compared in this group. Second, postoperative complications and survival were compared with two control groups of 11 patients, matched for age, sex, year of transplant, and severity of cirrhosis. Group 2 included patients with tense ascites, but no hepatic hydrothorax. Group 3 included patients without ascites. RESULTS In group 1, 73% of patients needed thoracentesis in the pre-transplant course (55% more than once) and none of the patients needed thoracenthesis in the post-transplant course. Comparing the postoperative period between the three groups, no significant differences in the duration of mechanical ventilation, intensive care unit stay, and in-hospital stay were observed. There were no significant differences in terms of incidence of sepsis and early postoperative death. One-year survival was also similar. CONCLUSION Liver transplantation is a good definitive therapeutic option for cirrhotic patients with hepatic hydrothorax and end-stage liver disease. The need of thoracentesis decreases in the posttransplant course, and the presence of preoperative hepatic hydrothorax did not have a significant negative influence on postoperative outcome.
Collapse
|
28
|
Northup PG, Harmon RC, Pruett TL, Schenk WG, Daniel TM, Berg CL. Mechanical pleurodesis aided by peritoneal drainage: procedure for hepatic hydrothorax. Ann Thorac Surg 2009; 87:245-50. [PMID: 19101306 DOI: 10.1016/j.athoracsur.2008.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 10/02/2008] [Accepted: 10/08/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hepatic hydrothorax in the setting of decompensated cirrhosis is a challenging and common clinical problem. Traditional therapies such as diuretics and transjugular intrahepatic portosystemic shunts can be effective therapies in selected patients but in patients ineligible for, or intolerant of, these traditional therapies, few effective therapeutic options remain for the management of hepatic hydrothorax. METHODS We present a series of 5 consecutive patients with refractory hepatic hydrothorax who underwent combined thorascopically guided mechanical and chemical pleurodesis aided by an intraperitoneal drain that prevented reaccumulation of the ascites while pleural inflammation and adhesion were progressing. We speculate that the prolonged contact between the parietal and visceral pleura allowed by prevention of reaccumulation of intraabdominal ascites and subsequent flux through the pleural space enhanced the efficacy of this procedure in comparison with those presented in the literature. RESULTS Despite the fact that all of our patients presented with decompensated cirrhosis, the surgical procedure and subsequent hospitalization were tolerated well by our entire cohort. Colonization of the pleural and peritoneal drainage fluid was a common complication of this procedure but was not associated with prolonged morbidity or mortality. CONCLUSIONS We present a therapy for the difficult clinical problem of refractory hepatic hydrothorax that may allow selected patients an opportunity for prolonged symptomatic control.
Collapse
Affiliation(s)
- Patrick G Northup
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Huang PM, Han YY, Kuo SW, Lee YC. Color Doppler ultrasonography in detecting transdiaphragmatic flow of hepatic hydrothorax: correlation with thoracoscopic findings. J Thorac Cardiovasc Surg 2008; 138:1251-2. [PMID: 19660259 DOI: 10.1016/j.jtcvs.2008.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 04/16/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Pei-Ming Huang
- Department of Traumatology and Surgery, National Taiwan University College of Medicine, National Taiwan University Hospital, No. 7 Chung-Shan S. Road, Taipei, Taiwan
| | | | | | | |
Collapse
|
30
|
Allam NAH. Spontaneous bacterial empyema in liver cirrhosis: an underdiagnosed pleural complication. Saudi J Gastroenterol 2008; 14:43-5. [PMID: 19568497 PMCID: PMC2702888 DOI: 10.4103/1319-3767.37809] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2007] [Accepted: 12/08/2007] [Indexed: 01/24/2023] Open
Abstract
Spontaneous bacterial empyema, defined as spontaneous infection of the pleural fluid, represents a distinct complication of hepatic hydrothorax with a different pathogenesis, clinical course and treatment strategy from those of empyema secondary to pneumonia. Nearly 40% of episodes of spontaneous empyema are not associated with spontaneous bacterial peritonitis (SBP) or even ascites. The condition portends a poor prognosis, and is frequently under-diagnosed. This article reviews the pathogenesis, diagnosis and management of spontaneous bacterial empyema.
Collapse
Affiliation(s)
- Naglaa A. H. Allam
- Lecturer of Hepatology, National Liver Institute, Menofeya University, Egypt,Address: Naglaa Allam, 4, Kafr Abdou St., Roshdy, Alexandria, Egypt. E-mail:
| |
Collapse
|
31
|
Roussos A, Philippou N, Mantzaris GJ, Gourgouliannis KI. Hepatic hydrothorax: pathophysiology diagnosis and management. J Gastroenterol Hepatol 2007; 22:1388-93. [PMID: 17645471 DOI: 10.1111/j.1440-1746.2007.05069.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
Collapse
|
32
|
Shiber JR. Complications and benefits from drainage of massive pleural effusions. Ann Emerg Med 2007; 49:544-5; author reply 545. [PMID: 17371715 DOI: 10.1016/j.annemergmed.2006.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 10/25/2006] [Accepted: 10/25/2006] [Indexed: 11/20/2022]
|
33
|
Ibrisim D, Cakaloglu Y, Akyuz F, Karadag A, Ozdil S, Besisik F, Mungan Z, Okten A. Treatment of hepatic hydrothorax with terlipressin in a cirrhotic patient. Scand J Gastroenterol 2006; 41:862-5. [PMID: 16785202 DOI: 10.1080/00365520500527441] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatic hydrothorax is a complication of cirrhosis that is uncommon and difficult to treat. Diuretic therapy, thoracentesis, transjugular intrahepatic portosystemic shunt and liver transplantation are the main therapeutic options. Here, we report on a 47-year-old man with decompensated liver cirrhosis related to hepatitis B and D virus infections and who had complications of hepatic hydrothorax and hepatorenal syndrome. In this case, the hepatic hydrothorax, which was refractory to thoracic tube drainage and octreotide treatment, could be controlled with 5 days of terlipressin therapy associated with albumin. Terlipressin administration resulted in both improvement in renal function and successful resolution of hepatic hydrothorax. Splanchnic vasoconstrictor agents that reduce splanchnic blood flow, increase both central volume and effective renal blood flow. Thus they improve renal function. In our case, terlipressin, known to be beneficial in hepatorenal syndrome, was also effective in the treatment of hepatic hydrothorax probably by similar mechanisms. This is the first case in the literature.
Collapse
Affiliation(s)
- Duygu Ibrisim
- Department of Internal Medicine, Division of Gastroenterohepatology, Istanbul University, Istanbul Medical Faculty, Capa, TR-34390 Istanbul, Turkey
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Hadsaitong D, Suttithawil W. Pleurovenous shunt in treating refractory nonmalignant hepatic hydrothorax: A case report. Respir Med 2005; 99:1603-5. [PMID: 16291082 DOI: 10.1016/j.rmed.2005.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2005] [Indexed: 11/20/2022]
Abstract
We report a case of successful, long-term pleurovenous shunt (PVS) in treating refractory nonmalignant hepatic hydrothorax. An 82-year-old woman with liver cirrhosis, hypertension complicated with chronic renal failure while on hemodialysis, presented with progressive dyspnea in association with a recurrent right-sided pleural effusion, occurring secondary to transdiaphragmatic migration of ascites. The diagnosis was established by a demonstration of (99m)Tc-sulphur colloid sequential scintigraphic scan. Despite repetitive thoracenteses and traditional medical treatment, she suffered dyspnea without relief. Denver peritoneovenous shunt was inserted into the right-sided pleural cavity to drain effusion into the subclavian vein without short- and long-term complications. Manually pumping schedule of 10 min was performed twice daily to remove pleural fluid into the venous circulation for maintaining shunt patency. After 19 months of follow-up, the patient is doing well and PVS remains patent without significant pleural effusion. PVS opens a window of opportunity and offers an alternative procedure with minimal invasiveness for high-risk patients with refractory hepatic hydrothorax. It could be an alternative treatment to other conventional surgical interventions.
Collapse
|
35
|
Abstract
PURPOSE OF REVIEW Recent papers relevant to the preoperative evaluation and optimization of patients with severe liver disease will be discussed. The emphasis will be placed on cardiovascular, pulmonary, and renal complications. Other aspects such as preoperative management of hepatitis B and C, other infectious issues, and liver cancer will not be discussed because this rarely involves the anesthesiologist. RECENT FINDINGS Dobutamine stress echocardiography has been the cornerstone of cardiac evaluation of liver transplant candidates. Combining liver transplantation with cardiac procedures has been shown to be feasible. While mild hepatopulmonary syndrome is well-tolerated, severe hepatopulmonary syndrome carries a fairly high mortality rate. New treatment modalities of severe portopulmonary hypertension have been introduced, and may have advantages over epoprostenol administration. Hepatic hydrothorax requires similar therapy to ascites [repeated thoracentesis or paracentesis, and transjugular intrahepatic portosystemic shunt (TIPS)], but refractory hydrothorax may require other interventions. Hepatorenal syndrome may improve by increasing renal blood flow through the use of vasoconstrictors (vasopressin, norepinephrine) in combination with albumin administration. Interventional radiologists can now change the flow through an established TIPS. Hepatic encephalopathy may result in some irreversible changes in the brain. It remains difficult to predict whether a patient with acute fulminant failure will recover spontaneously. Support devices that include hepatocytes show early promising results. The coagulation changes in living donors are incompletely understood. Finally, autonomic neuropathy as a complication of severe liver disease results in more hemodynamic instability. SUMMARY Recent advances in preoperative evaluation and optimization are presented and discussed.
Collapse
Affiliation(s)
- Andre M De Wolf
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611-2908, USA.
| |
Collapse
|
36
|
Castellote J, Lopez C, Gornals J, Domingo A, Xiol X. Use of reagent strips for the rapid diagnosis of spontaneous bacterial empyema. J Clin Gastroenterol 2005; 39:278-81. [PMID: 15758619 DOI: 10.1097/01.mcg.0000155125.74548.28] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS To assess the utility of reagent strips for rapid diagnosis of spontaneous bacterial empyema in cirrhotic patients with hepatic hydrothorax. BACKGROUND Analysis of ascitic fluid using reagent strips is a useful diagnostic test for spontaneous bacterial peritonitis. METHODS A reagent strip for leukocyte esterase designed for the testing of urine was used to evaluate pleural fluid analysis in 47 nonselected thoracenteses in 28 cirrhotic patients with hepatic hydrothorax. RESULTS Twelve spontaneous bacterial empyemas were diagnosed. Simultaneous spontaneous bacterial peritonitis was present in 7 of 10 cases in which ascites fluid was analyzed. When a test result of 3 or 4 was considered positive, sensitivity was 83% (10 of 12), specificity was 100% (35 of 35), and positive predictive value was 100%. When result of 2 or more was considered positive, sensitivity was 92% (11 of 12), specificity was 80% (28 of 35), and negative predictive value was 97%. CONCLUSION Analysis of pleural fluid with reagent strips is a rapid, easy to use, and inexpensive tool for the diagnosis of spontaneous bacterial empyema in cirrhotic patients. A positive result should be considered an indication for antibiotic therapy.
Collapse
Affiliation(s)
- Jose Castellote
- Servicio de Aparato Digestivo, IDIBELL Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
| | | | | | | | | |
Collapse
|