Current status of transjugular intrahepatic portosystemic shunts

A case series: Egyptian experience in using chemical pleurodesis as an alternative management in refractory hepatic hydrothorax

INTRODUCTION

Chemical pleurodesis is an effective treatment for malignant effusion and pneumothorax. Although this mode of therapy is less widely accepted in treatment of patients with hepatic hydrothorax, the need for palliative treatment in such patients encouraged us to do this work. The aim of study was analysing the outcome of chemical pleurodesis using bovoiodine, Vibramycin and talc slurry in treatment of hepatic hydrothorax.

MATERIAL AND METHODS

A case series randomized study including 23 patients with symptomatic right side hepatic hydrothorax not responding to medical treatment and repeated thoracocentesis was conducted. From March 2007 to March 2008, 19 men and 4 women with a mean age of 54.3 ±8.1 years (range 42-70 years) underwent medical thoracoscopies to achieve pleurodesis by application of 3 sclerosing agents.

RESULTS

Out of the 23 patients pleurodesis was repeated in 20 cases. Three cases did not attend their follow-up so their responses to pleurodesis are not known. The follow-up period of the study was 3 months. The procedure was effective in 15 of 20 patients (75%): 7/8 cases treated with bovoiodine (87.5%), and 4/6 cases with Vibramycin and talc slurry (66.7%) for each. There were 4 recurrences (20%) and a single case of mortality (5%) due to hepatic coma which can be attributed to the course of the disease. We detected minimal morbidity during the follow-up period of 3 months.

CONCLUSIONS

The procedure appears to be indicated for these fragile patients especially when medical therapy fails. Chemical pleurodesis deserves to be considered as an alterative therapy in such patients.

Advances in research on portal hypertensive enteropathy

Portal hypertensive enteropathy, whose fundamental pathologic change is a vasculopathy characterized histopathologically by mucosal and submucosal vessel dilatation, oedema and congestion, mainly results from a combination of increased intrahepatic vascular resistance and increased blood flow through the portal venous system. Though portal hypertensive enteropathy usually has non-specific clinical manifestations, it is a major cause of lower gastrointestinal bleeding. Up to now, there has been no standard for the diagnosis and grading of portal hypertensive enteropathy. Unfortunately, the experience of treatment for portal hypertensive enteropathy only comes from some small-sample trials. For these reasons, an in-depth study of portal hypertensive enteropathy is still necessary. In this article, we will review the advances in research on portal hypertensive enteropathy.

Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide

Hepatic hydrothorax is a dreaded complication in patients with liver cirrhosis. Placement of chest tubes can alleviate respiratory distress, but patients often succumb due to excessive fluid and protein loss via the open drain. Our case illustrates that high-dose octreotide can strongly reduce hepatic hydrothorax drainage volume. This allows removal of the chest tube, which would otherwise not have been possible.

Clinical aspects of bleeding complications in cirrhotic patients

Liver disease is a frequent cause of haemostatic abnormalities, which may lead to overt or occult bleeding. Clinical manifestations of hepatic coagulopathy include upper and lower gastrointestinal haemorrhage, easy bruising and bleeding from gums, nose or the female genital tract. The most significant bleeding problem among patients with chronic liver disease is blood loss due to portal hypertension. About 30% of subjects with oesophageal or gastric varices resulting from cirrhosis have an episode of gastrointestinal bleeding in their lifetime. Risk factors for the first episode of variceal bleeding include the severity of liver dysfunction, large varices, and the presence of endoscopic red colour signs. Bacterial infection in patients with variceal haemorrhage may be critical in triggering bleeding. Nongastrointestinal bleeding events, either spontaneous or induced by minor trauma, are also a common complication of advanced cirrhosis. In women, for instance, dysfunctional uterine bleeding may become so severe that hysterectomy is required. In addition, invasive diagnostic tests (mostly solid tissue biopsies) and surgical procedures have a high risk of haemorrhage and are sometimes withheld in cirrhotic patients for fear of complications. In patients with portal hypertension, surgical procedures aggravate the injury of the hepatic parenchyma and may worsen the condition.