1
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Aujayeb A. JTD special series 'Malignant and benign pleural disease'. J Thorac Dis 2024; 16:1750-1752. [PMID: 38617759 PMCID: PMC11009571 DOI: 10.21037/jtd-24-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/04/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
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2
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Panackel C, Fawaz M, Jacob M, Raja K. Pulmonary Assessment of the Liver Transplant Recipient. J Clin Exp Hepatol 2023; 13:895-911. [PMID: 37693254 PMCID: PMC10483013 DOI: 10.1016/j.jceh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.
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Affiliation(s)
| | - Mohammed Fawaz
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Jacob
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Kaiser Raja
- King's College Hospital London, Dubai Hills, Dubai, United Arab Emirates
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3
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Bai X, Liu X, Shi Y, Li W, Li Q, Du W. Risk factors for hepatic hydrothorax in patients with cirrhosis: a clinical retrospective study. Front Med (Lausanne) 2023; 10:1165604. [PMID: 37332757 PMCID: PMC10268603 DOI: 10.3389/fmed.2023.1165604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
Aims and background Hepatic hydrothorax, which presents as an unexplained pleural effusion, is one of the important complications in patients with end-stage cirrhosis. It has a significant correlation with prognosis and mortality. The aim of this clinical study was to detect the risk factors for hepatic hydrothorax in patients with cirrhosis and to better understand potentially life-threatening complications. Methods Retrospectively, 978 cirrhotic patients who were hospitalized at the Shandong Public Health Clinical Center from 2013 to 2021 were involved in this study. They were divided into the observation group and the control group based on the presence of hepatic hydrothorax. The epidemiological, clinical, laboratory, and radiological characteristics of the patients were collected and analyzed. ROC curves were used to evaluate the forecasting ability of the candidate model. Furthermore, 487 cases in the experimental group were divided into left, right, and bilateral groups, and the data were analyzed. Results The patients in the observation group had a higher proportion of upper gastrointestinal bleeding (UGIB), a history of spleen surgery, and a higher model for end-stage liver disease (MELD) scores compared with the control group. The width of the portal vein (PVW) (P = 0.022), prothrombin activity (PTA) (P = 0.012), D-dimer (P = 0.010), immunoglobulin G (IgG) (P = 0.007), high-density lipoprotein cholesterol (HDL) (P = 0.022), and the MELD score were significantly associated with the occurrence of the hepatic hydrothorax. The AUC of the candidate model was 0.805 (P < 0.001, 95% CI = 0.758-0.851). Portal vein thrombosis was more common in bilateral pleural effusion compared with the left and right sides (P = 0.018). Conclusion The occurrence of hepatic hydrothorax has a close relationship with lower HDL, PTA, and higher PVW, D-dimer, IgG, and MELD scores. Portal vein thrombosis is more common in cirrhotic patients with bilateral pleural effusion compared to those with unilateral pleural effusion.
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Affiliation(s)
- Xue Bai
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyan Liu
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Yanhui Shi
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Qiang Li
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Wenjun Du
- Department of Liver Diseases, Shandong Public Health Clinical Center, Shandong University, Jinan, China
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4
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Patel BH, Melamed KH, Wilhalme H, Day GL, Wang T, DiNorcia J, Farmer D, Agopian V, Kaldas F, Barjaktarevic I. Implications of Pleural Fluid Composition in Persistent Pleural Effusion following Orthotopic Liver Transplant. Med Sci (Basel) 2023; 11:medsci11010024. [PMID: 36976532 PMCID: PMC10058754 DOI: 10.3390/medsci11010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We evaluated the clinical, biochemical, and cellular characteristics of post-OLT PPEf and assessed their relationship with longitudinal outcomes. We performed a retrospective cohort study of OLT recipients between 2006 and 2015. Included patients had post-OLT PPEf, defined by effusion persisting >30 days after OLT and available pleural fluid analysis. PPEf were classified as transudates or exudates (ExudLight) by Light's criteria. Exudates were subclassified as those with elevated lactate dehydrogenase (ExudLDH) or elevated protein (ExudProt). Cellular composition was classified as neutrophil- or lymphocyte-predominant. Of 1602 OLT patients, 124 (7.7%) had PPEf, of which 90.2% were ExudLight. Compared to all OLT recipients, PPEf patients had lower two-year survival (HR 1.63; p = 0.002). Among PPEf patients, one-year mortality was associated with pleural fluid RBC count (p = 0.03). While ExudLight and ExudProt showed no association with outcomes, ExudLDH were associated with increased ventilator dependence (p = 0.03) and postoperative length of stay (p = 0.03). Neutrophil-predominant effusions were associated with increased postoperative ventilator dependence (p = 0.03), vasopressor dependence (p = 0.02), and surgical pleural intervention (p = 0.02). In summary, post-OLT PPEf were associated with increased mortality. Ninety percent of these effusions were exudates by Light's criteria. Defining exudates using LDH only and incorporating cellular analysis, including neutrophils and RBCs, was useful in predicting morbidity.
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Affiliation(s)
- Bhavesh H Patel
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Kathryn H Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Gwenyth L Day
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Joseph DiNorcia
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Douglas Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Vatche Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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Affiliation(s)
- Aelia Akbar
- Appalachian Regional Healthcare, Harlan, KY, USA
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Han SK, Kang SH, Kim MY, Na SK, Kim T, Lee M, Jun BG, Kim TS, Choi DH, Suk KT, Kim YD, Cheon GJ, Yim HJ, Kim DJ, Baik SK. Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax. J Clin Med 2022; 11. [PMID: 36498795 DOI: 10.3390/jcm11237221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/21/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Background/Aims: The management of hepatic hydrothorax (HH) remains a challenging clinical scenario with suboptimal options. We investigated the effect and safety of pigtail catheter drainage compared to intermittent thoracentesis. Methods: This multicenter, retrospective study included 164 cirrhotic patients with recurrent pleural effusion from March 2012 to June 2017. Patients with neoplasms, cardiopulmonary disease, and infectious conditions were excluded. We compared the clinical outcomes of pigtail catheter drainage versus thoracentesis for variables including complications related to procedures, overall survival, and re-admission rates. Results: A total of 164 patients were divided into pigtail catheter (n = 115) and thoracentesis (n = 49) groups. During the follow-up period of 6.93 months after discharge, 98 patients died (pigtail; n = 47 vs. thoracentesis; n = 51). The overall survival (p = 0.61) and 30-day mortality (p = 0.77) rates were similar between the pigtail catheter and thoracentesis groups. Only MELD scores were associated with overall survival (adjusted HR, 1.08; p < 0.01) in patients with HH. Spontaneous pleurodesis occurred in 59 patients (51.3%) in the pigtail catheter group. Re-admission rates did not differ between the pigtail catheter and thoracentesis groups (13.2% vs 19.6% p = 0.7). A total of five complications occurred, including four total cases of bleeding (one patient in the pigtail catheter group and three in the thoracentesis group) and one case of empyema in the pigtail catheter group. Conclusions: Pigtail catheter drainage is not inferior to that of intermittent thoracentesis for the management of HH, proving it may be an effective and safe clinical option.
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Jung Y, Song SY, Yun JS, Na KJ. Minimally Invasive Surgical Treatment of Hepatic Hydrothorax Complicated by Empyema: A Case Report. Innovations (Phila) 2022; 17:445-448. [PMID: 35960503 DOI: 10.1177/15569845221113574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hepatic hydrothorax complicated by empyema is difficult to manage. A 53-year-old man with liver cirrhosis was admitted for refractory right pleural effusion. He had a pleural catheter inserted 2 months prior. Pleural fluid appeared as exudate, and bacteria were identified in the pleural fluid culture. After confirming full ipsilateral lung expansion, minimally invasive surgery was performed. A diaphragmatic defect found by creating a pneumoperitoneum was closed, followed by talc pleurodesis. Postoperatively, overnight positive-pressure ventilation and 5-day peritoneal drainage were performed; chest tube drainage dramatically reduced over this time. At the 10-month follow-up, no recurrence of pleural effusion or signs of infection were observed.
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Affiliation(s)
- Yochun Jung
- Department of Thoracic and Cardiovascular Surgery, 65416Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, South Korea
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, 65722Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Ju Sik Yun
- Department of Thoracic and Cardiovascular Surgery, 65722Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, 65722Chonnam National University Hwasun Hospital, Chonnam National University School of Medicine, Hwasun, South Korea
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Awwad A, Berman Z, Minocha J. Pleurovenous Shunt Placement for the Management of Nonmalignant Pleural Effusion. Semin Intervent Radiol 2022; 39:248-252. [PMID: 36062223 PMCID: PMC9433146 DOI: 10.1055/s-0042-1751296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Therapeutic thoracentesis is a first-line therapy in the management of patients with medically refractory, nonmalignant pleural effusion. However, when required in short intervals, serial thoracenteses can lead to increased procedure-related complications and negatively impact quality of life. Alternative treatment options vary depending on the etiology of fluid accumulation. Hepatic hydrothorax secondary to cirrhosis is a common cause of medically refractory pleural effusion encountered by interventional radiologists. In select patients in whom surgical pleurodesis, transjugular intrahepatic portosystemic shunt placement, and/or tunneled pleural catheter placement cannot be performed or provide inadequate relief, implantation of a pleurovenous (Denver) shunt may assist in palliation. The Denver shunt system allows decompression of pleural fluid into the central venous circulation by utilizing unidirectional valves and a manually operated subcutaneous pump. Though limited reports have described favorable technical and clinical success, more research is required to determine the safety and efficacy of this procedure. This article discusses pleurovenous shunt placement, postprocedure shunt evaluation, and potential associated complications.
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Affiliation(s)
- Andy Awwad
- Division of Interventional Radiology, University of California San Diego School of Medicine, San Diego, California
| | - Zach Berman
- Division of Interventional Radiology, University of California San Diego School of Medicine, San Diego, California
| | - Jeet Minocha
- Division of Interventional Radiology, University of California San Diego School of Medicine, San Diego, California
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9
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Abstract
BACKGROUND Spontaneous bacterial empyema (SBE) is an infection of a preexisting hepatic hydrothorax (HH). We aim to describe the experience in managing SBE in a liver transplant (LT) referral center and assessing the incidence and mortality rates of SBE after conducting a systematic review. METHODS 992 patients with cirrhosis were retrospectively reviewed from 2015 to 2020. SBE was diagnosed by (i) positive microbiological culture and polymorphonuclear leukocyte count >250 cells/µL or (ii) negative microbiological culture, compatible clinical course, and polymorphonuclear count >500 cells/µL in pleural fluid. Furthermore, we conducted a comprehensive literature search of MEDLINE, EMBASE, and Google Scholar for studies evaluating SBE. RESULTS Twelve patients (10.4%) had spontaneous bacterial empyema out of 115 patients with HH. Five patients underwent LT, 6 had died, and 1 did not get transplanted and was alive throughout the duration of follow-up. Ten studies were included in the systematic review. Pooled incidence in patients with HH was 19.03%. Only 20.69% of the patients received a LT. Pooled mortality rate was 46.45%, with only 3.45% of the patients dying post-transplant. CONCLUSION SBE is a severe complication of cirrhosis and HH. LT may provide a survival benefit. Thus, patients should be considered for early transplant.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Neev Mehta
- Department of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Carol Spencer
- Department of Library Services, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Amir A Qamar
- Department of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA
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10
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Jiménez-Gutiérrez JM, García-Juárez I, Olivas-Martinez A, Ruiz I. One-year outcome of patients with cirrhosis who developed spontaneous bacterial empyema: A cohort study. J Dig Dis 2021; 22:714-720. [PMID: 34738327 DOI: 10.1111/1751-2980.13066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 09/19/2021] [Accepted: 11/02/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aimed to evaluate outcomes in cirrhotic patients diagnosed with spontaneous bacterial empyema (SBE) compared with those without this complication. METHODS We performed a retrospective cohort study of cirrhotic patients from a tertiary care center. The primary outcome was time to death or liver transplantation (LT) within one year after diagnosis of infection. We integrated three groups: patients with SBE (group A), patients with spontaneous bacterial peritonitis (SBP; group B), and cirrhotic patients without SBP or SBE (group C), matched by age, model for end-stage liver disease-sodium (MELD-Na) score and year of infection. Outcomes were analyzed using a Cox regression model adjusted for cardiovascular risk factors and MELD-Na score. RESULTS Between January 1999 and February 2019, 4829 cirrhotic patients were identified. Among them, 73 (1.5%) had hepatic hydrotorax, of whom 22 (30.1%) were diagnosed with SBE. Median age in group A was 58 years, 50% were men, and median MELD-Na was 21.5. Compared with group C, the hazard ratio of death or LT during the first year after infection was 2.98 (95% confidence interval [CI] 1.43-6.22, P = 0.004) for group A and 1.23 (95% CI 0.65-2.32, P = 0.522) for group B. CONCLUSIONS Our results suggest that patients with SBE have a worse outcome during the first year after infection is diagnosed. Patients who develop SBE should be promptly referred for transplant evaluation. SBE may emerge as new indication that could benefit from MELD exception points.
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Affiliation(s)
- José M Jiménez-Gutiérrez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico
| | | | - Isaac Ruiz
- Department of Hepatology and Liver Transplantation, Centre Hospitalier de l'Université de Montréal, Montréal, Canada.,Institut Mondor de Recherche Biomédicale INSERM U955 Team 18, Hôpital Henri Mondor, Université Paris-Est, Créteil, France
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11
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Matei D, Craciun R, Crisan D, Procopet B, Mocan T, Pasca S, Zaharie R, Popovici B, Sparchez Z. Hepatic Hydrothorax-An Independent Decompensating Event Associated with Long-Term Mortality in Patients with Cirrhosis. J Clin Med 2021; 10:3688. [PMID: 34441984 PMCID: PMC8396982 DOI: 10.3390/jcm10163688] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background: Hepatic hydrothorax (HH) is an understudied complication of decompensated cirrhosis. We aimed to evaluate the long-term prognosis of patients with HH by comparing them with a matched non-HH group. Methods: This retrospective study included 763 consecutive patients hospitalized for decompensated cirrhosis and ascites. Ninety-seven patients with HH were matched for survival analysis with non-HH patients based on liver disease severity. Results: The prevalence of HH was 13.1%. Patients with HH had significantly worse overall liver function. Upon matching, patients with HH had a lower long-term survival (15.4% vs. 30.9% at 5 years) with a mean overall survival of 22.2 ± 2.2 months for the HH group vs. 27.1 ± 2.6 months for the non-HH group (Log Rank-0.05). On multivariate survival analysis using Cox regression, the MELD-Na score, ALBI grade, hepato-renal syndrome, and grade III ascites had a significant impact on mortality in patients with HH. In patients with HH, a MELD-Na score ≥ 16, ALBI grade III, hepato-renal syndrome, or severe ascites delineated high-mortality risk groups. Conclusions: HH is consistently associated with more advanced liver disease. Patients with HH have worse long-term survival, their prognosis being closely intertwined with overlapping decompensating events.
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Affiliation(s)
- Daniela Matei
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Rares Craciun
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Dana Crisan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Department of Gastroenterology, Cluj-Napoca Municipal Hospital, 400139 Cluj-Napoca, Romania
| | - Bogdan Procopet
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Tudor Mocan
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Sergiu Pasca
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
| | - Roxana Zaharie
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Bogdan Popovici
- Department of Thoracic Surgery, “Leon Daniello” Pulmonology Hospital, 400371 Cluj-Napoca, Romania;
| | - Zeno Sparchez
- Department of Internal Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (D.M.); (R.C.); (B.P.); (T.M.); (S.P.); (R.Z.); (Z.S.)
- Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
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12
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Gilbert CR, Shojaee S, Maldonado F, Yarmus LB, Bedawi E, Feller-Kopman D, Rahman NM, Akulian JA, Gorden JA. Pleural Interventions in the Management of Hepatic Hydrothorax. Chest 2021; 161:276-283. [PMID: 34390708 DOI: 10.1016/j.chest.2021.08.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.
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Affiliation(s)
- Christopher R Gilbert
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA.
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Eihab Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jason A Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jed A Gorden
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
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13
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Selvan M, Collins H, Griffiths W, Gelson W, Herre J. Case Report: Indwelling Pleural Catheter Based Management of Refractory Hepatic Hydrothorax as a Bridge to Liver Transplantation. Front Med (Lausanne) 2021; 8:695977. [PMID: 34322505 PMCID: PMC8311019 DOI: 10.3389/fmed.2021.695977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Liver transplantation is the treatment of choice for decompensated liver disease, and by extension for hepatic hydrothorax. Persistent pleural effusions make it challenging for patients to maintain physiological fitness for transplantation. Indwelling pleural catheters (IPCs) provide controlled pleural fluid removal, including peri-operatively. The immune dysfunction of cirrhosis heightens susceptibility to bacterial infection and concerns exist regarding the sepsis potential from a tunnelled drain. Method: Six patients were identified who underwent IPC insertion for hepatic hydrothorax before successful liver transplantation, between November 2016 and November 2017. Results: All patients had recurrent transudative right sided pleural effusions. Mean age was 49 years (range 24–64) and mean United Kingdom Model for End-Stage Liver Disease score was 58. Four patients required correction of coagulopathy before insertion. There were no complications secondary to bleeding. Three patients were taught self-drainage at home of up to 1 litre (L) daily. A protocol was developed to ensure weekly review, pleural fluid culture and drainage of larger volumes in hospital. For every 2–3 L of pleural fluid drained, 100 mls of 20% Human Albumin Solution (HAS) was administered. On average an IPC was in situ for 58 days before surgery and drained 19 L of fluid in hospital. There was a small increase in average BMI (0.2) and serum albumin (2.1 g/L) at transplantation. There was one episode of stage one acute kidney injury secondary to high volume drainage. No further ascitic or pleural procedures were needed while an IPC was in situ. One thoracentesis was required after IPC removal. On average IPCs remained in situ for 7 days post transplantation and drained a further 2 L of fluid. Pleural fluid sampling was acquired on 92% of drainages in hospital. Of 44 fluid cultures, 2 cultured bacteria. Two patients had their IPCs and all other lines removed post transplantation due to suspected infection. Conclusion: Our case series describes a novel protocol and successful use of IPCs in the management of refractory hepatic hydrothorax as a bridge to liver transplantation. The protocol includes albumin replacement during pleural drainage, regular clinical review and culture of pleural fluid, with the option of self-drainage at home.
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Affiliation(s)
- Mayurun Selvan
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Hannah Collins
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - William Griffiths
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - William Gelson
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
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Malangu B, Shaikh A. Acute Tension Hydrothorax in a Cirrhotic Patient With Hepatic Hydrothorax Without Ascites. Cureus 2021; 13:e13941. [PMID: 33868866 PMCID: PMC8051170 DOI: 10.7759/cureus.13941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
We describe a case of a 50-year-old man with alcohol cirrhosis status post transjugular intrahepatic portosystemic shunt (TIPS) who presented with dyspnea, refractory hepatic hydrothorax (HH), and no ascites who subsequently developed acute tension hydrothorax (TH). Urgent ultrasound-guided thoracentesis was performed with a significant improvement of symptoms. Further management consisted of a chest tube placement, subsequently removed with a plan for intermittent thoracentesis as needed, diuretic therapy, and salt restriction. HH occurs in 5%-10% of patients with cirrhosis, and TH in these patients is a rare entity that requires prompt recognition and drainage as it may be life-threatening.
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Affiliation(s)
- Boniface Malangu
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Amjad Shaikh
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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15
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Magendiran B, Viswanathan S, Selvaraj J, Pillai V. Empyema Tube or No Tube? Cureus 2021; 13:e12829. [PMID: 33633873 PMCID: PMC7899129 DOI: 10.7759/cureus.12829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report the case of a 36-year-old man with cirrhosis who presented with recurrent infection of his right-sided hepatic hydrothorax in the form of fever, dyspnea, and cough. The pleural fluid analysis showed transudative fluid with normal pH, lactic acid dehydrogenase, and glucose, but with Escherichia coli growth. An uncommon diagnosis of high mortality, spontaneous bacterial empyema was made. Criteria for chest tube drainage were met, but he was managed without one. He developed hospital-acquired pneumonia during his stay, but his pleural fluid showed the same characteristics. His empyema and pneumonia were managed with antibiotics and other supportive measures. On follow-up, he was readmitted on three other occasions with similar complaints and succumbed to upper gastrointestinal bleed during the fifth admission. A chest tube is not indicated in patients with spontaneous bacterial empyema unless frank pus is present.
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Affiliation(s)
- Bhoobalan Magendiran
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Stalin Viswanathan
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Jayachandran Selvaraj
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
| | - Vivekanandan Pillai
- General Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, IND
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Melamed KH, Dai D, Cuk N, Markovic D, Follett R, Wang T, Lopez RC, Shirali AS, Yanagawa J, Busuttil R, Kaldas F, Barjaktarevic I. Preoperative Trapped Lung Is Associated With Increased Mortality After Orthotopic Liver Transplantation. Prog Transplant 2020; 31:47-54. [PMID: 33280518 DOI: 10.1177/1526924820978604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Trapped lung, characterized by atelectatic lung unable to reexpand and fill the thoracic cavity due to a restricting fibrous visceral pleural peel, is occasionally seen in patients with end-stage liver disease complicated by hepatic hydrothorax. Limited data suggest that trapped lung prior to orthotopic liver transplantation may be associated with poor outcomes. RESEARCH QUESTION What is the clinical significance of trapped lung in patients receiving orthotopic liver transplantation? DESIGN We performed a retrospective analysis of patients who underwent liver transplantation over an 8-year period. Baseline clinical characteristics and postoperative outcomes of adult patients with trapped lung were analyzed and compared to the overall cohort of liver transplant recipients and controls matched 3:1 based on age, sex, Model for End-Stage Liver Disease (MELD) score, and presence of pleural effusion. RESULTS Of the 1193 patients who underwent liver transplantation, we identified 20 patients (1.68%) with trapped lung. The probability of 1 and 2-year survival were 75.0% and 57.1%, compared to 85.6% and 80.4% (p = 0.02) in all liver transplant recipients and 87.9% and 81.1% (p = 0.03) in matched controls respectively. Patients with trapped lung had a longer hospital length of stay compared to the total liver transplant population (geometric mean 54.9 ± 8.4 vs. 27.2 ± 0.7 days, p ≤ 0.001), when adjusted for age and MELD score. DISCUSSION Patients with trapped prior to orthotopic liver transplantation have increased probability of mortality as well as increased health care utilization. This is a small retrospective analysis, and further prospective investigation is warranted.
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Affiliation(s)
- Kathryn H Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - David Dai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Natasha Cuk
- Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Daniela Markovic
- Department of Biostatistics, 8783University of California at Los Angeles, Los Angeles, CA, USA
| | - Robert Follett
- Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA.,8783UCLA Clinical and Translational Science Institute, Los Angeles, CA, USA
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Roxana Cortes Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Aditya S Shirali
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Jane Yanagawa
- Division of Thoracic Surgery, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Ronald Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at 8783UCLA, Los Angeles, CA, USA
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Gallo A, Dedionigi C, Civitelli C, Panzeri A, Corradi C, Squizzato A. Optimal Management of Cirrhotic Ascites: A Review for Internal Medicine Physicians. J Transl Int Med 2020; 8:220-236. [PMID: 33511049 PMCID: PMC7805288 DOI: 10.2478/jtim-2020-0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clinical history of liver cirrhosis is characterised by two phases: the asymptomatic phase, also termed 'compensated cirrhosis', and the phase of complications due to the development of portal hypertension and liver dysfunction, also termed 'decompensated cirrhosis', in which patients may develop ascites, the most frequent and clinically relevant complication of liver cirrhosis. Ascites can be classified into uncomplicated and complicated according to the development of refractoriness, spontaneous bacterial peritonitis (SBP) or the association with hepatorenal syndrome (HRS). In this narrative review, we will extensively discuss the optimal pharmacological and non-pharmacological management of cirrhotic ascites with the aim to offer an updated practical guide to Internal Medicine physicians. According to the amount of fluid in the abdominal cavity, uncomplicated ascites is graded from 1 to 3, and the cornerstone of its management consists of restriction of salt intake, diuretics and large-volume paracentesis (LVP); in recent years, long-term administration of human albumin has acquired a new interesting role. Refractory ascites is primarily managed with LVP and transjugular intrahepatic portosystemic shunt (TIPS) placement in selected patients. The occurrence of renal impairment, especially HRS, worsens the prognosis of patients with cirrhotic ascites and deserves a specific treatment. Also, the management of SBP faces the rising and alarming spread of antibiotic resistance. Hepatic hydrothorax may even complicate the course of the disease and its management is a challenge. Last but not least, liver transplantation (LT) is the ultimate and more effective measure to offer to patients with cirrhotic ascites, particularly when complications occur.
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Affiliation(s)
- Andrea Gallo
- Department of Medicine and Surgery, University of Insubria, Como/Varese, Italy
| | - Cristina Dedionigi
- Department of Medicine and Surgery, University of Insubria, Como/Varese, Italy
| | - Chiara Civitelli
- Department of Medicine and Surgery, University of Insubria, Como/Varese, Italy
| | - Anna Panzeri
- Department of Medicine and Surgery, University of Insubria, Como/Varese, Italy
- Hepatology Center, Ospedale Sant’Anna, Como, Italy
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18
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Abstract
Patients with advanced chronic liver diseases, particularly with decompensated liver cirrhosis, can develop specific pulmonary complications independently of any pre-existing lung disease. Especially when dyspnea occurs in combination with liver cirrhosis, patients should be evaluated for hepato-pulmonary syndrome (HPS), porto-pulmonary hypertension (PPHT), hepatic hydrothorax and spontaneous bacterial empyema, which represent the clinically most relevant pulmonary complications of liver cirrhosis. Importantly, the pathophysiology, clinical features, diagnosis and the corresponding therapeutic options differ between these entities, highlighting the role of specific diagnostics in patients with liver cirrhosis who present with dyspnea. Liver transplantation may offer a curative therapy, including selected cases of HPS and PPHT. In this review article, we summarize the pathogenesis, clinical features, diagnostic algorithms and treatment options of the 4 specific pulmonary complications in patients with liver cirrhosis.
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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20
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Shojaee S, Rahman N, Haas K, Kern R, Leise M, Alnijoumi M, Lamb C, Majid A, Akulian J, Maldonado F, Lee H, Khalid M, Stravitz T, Kang L, Chen A. Indwelling Tunneled Pleural Catheters for Refractory Hepatic Hydrothorax in Patients With Cirrhosis: A Multicenter Study. Chest 2018; 155:546-553. [PMID: 30171863 DOI: 10.1016/j.chest.2018.08.1034] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/03/2018] [Accepted: 08/15/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The outcome of indwelling pleural catheter (IPC) use in hepatic hydrothorax (HH) is unclear. This study aimed to review the safety and feasibility of the IPC in patients with refractory HH. METHODS A retrospective multicenter study of patients with HH from January 2010 to December 2016 was performed. Inclusion criteria were refractory HH treated with an IPC and an underlying diagnosis of cirrhosis. Records were reviewed for patient demographics, operative reports, and laboratory values. The Kaplan-Meier method was used to estimate catheter time to removal. The Cox proportional hazard model was used to evaluate for independent predictors of pleurodesis and death. RESULTS Seventy-nine patients were identified from eight institutions. Indication for IPC placement was palliation in 58 patients (73%) and bridge to transplant in 21 patients (27%). The median in situ dwell time of all catheters was 156 days (range, 16-1,978 days). Eight patients (10%) were found to have pleural space infection, five of whom also had catheter-site cellulitis. Two patients (2.5%) died secondary to catheter-related sepsis. Catheter removal secondary to spontaneous pleurodesis was achieved in 22 patients (28%). Median time from catheter insertion to pleurodesis was 55 days (range, 10-370 days). Older age was an independent predictor of mortality on multivariate analysis (hazard ratio, 1.05; P = .01). CONCLUSIONS We present, to our knowledge, the first multicenter study examining outcomes related to IPC use in HH. Ten percent infection risk and 2.5% mortality were identified. IPC placement may be a reasonable clinical option for patients with refractory HH, but it is associated with significant adverse events in this morbid population.
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Affiliation(s)
- Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA.
| | - Najib Rahman
- Nuffield Department of Medicine, Oxford Center for Respiratory Medicine, University of Oxford, Oxford, England; Oxford National Institute of Health Research Biomedical Center, Oxford, England
| | - Kevin Haas
- Division of Pulmonary and Critical Care Medicine, University of Illinois, Chicago, IL
| | - Ryan Kern
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mohammed Alnijoumi
- Division of Pulmonary and Critical Care Medicine, University of Missouri, Columbia, MO
| | - Carla Lamb
- Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Lynnfield, MA
| | - Adnan Majid
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jason Akulian
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Hans Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medical Center, Baltimore, MD
| | - Marwah Khalid
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University in St Louis, St Louis, MO
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21
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Baig MA, Majeed MB, Attar BM, Khan Z, Demetria M, Gandhi SR. Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature. Cureus 2018; 10:e3110. [PMID: 30338185 PMCID: PMC6175258 DOI: 10.7759/cureus.3110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/06/2018] [Indexed: 12/26/2022] Open
Abstract
Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH, many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. A literature search was conducted using the electronic database engines MEDLINE, PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trials and Cochrane Database of Systematic Reviews) from inception to April 2018 to identify published articles and reports addressing outcomes in patients treated for HH with IPCs. The risk of bias was rated for each study using the Cochrane criteria. The search strategy retrieved 370 papers, of which four case series were selected with a total of 111 patients. After the insertion of IPCs for HH, spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients at a mean duration of 73-222 days. As far as secondary outcomes were concerned, the frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage two (2.9%) out of 68 patients, pleural fluid infection five (4.5%) out of 111 patients and catheter-site cellulitis one (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study, wherein 12 (20%) out of 60 patients developed recurrence of pleural effusion. We conclude IPCs as an acceptable therapeutic option for the management of refractory pleural effusion in patients with HH. Although trans-jugular intrahepatic portosystemic shunt (TIPS) and liver transplantation are the gold standards for the management of pleural effusion in these patients, cost and availability are the major concerns with these treatment modalities. IPCs are a safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.
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Affiliation(s)
- Muhammad A Baig
- Medicine, John H Stroger J. Hospital of Cook County, Chicago, USA
| | | | - Bashar M Attar
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Zubair Khan
- Internal Medicine, University of Toledo Medical Center, Toledo, USA
| | - Melchor Demetria
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
| | - Seema R Gandhi
- Gastroenterology and Hepatology, John H. Stroger Jr. Hospital of Cook County, Chicago, USA
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22
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Kniese C, Diab K, Ghabril M, Bosslet G. Indwelling Pleural Catheters in Hepatic Hydrothorax: A Single-Center Series of Outcomes and Complications. Chest 2018; 155:307-314. [PMID: 29990479 DOI: 10.1016/j.chest.2018.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/11/2018] [Accepted: 07/02/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Treatment of hepatic hydrothorax (HH) generally involves sodium restriction, diuretics, and serial thoracentesis. In more advanced cases, transjugular intrahepatic portosystemic shunt and liver transplantation may be required. Previously, indwelling tube drainage has been avoided due to concerns regarding high complication rates and overall poor outcomes. Recently, indwelling pleural catheters (IPCs) have been proposed as a novel treatment option for HH. METHODS This study was a retrospective review of patients who had undergone IPC placement for HH over a 10-year period at a large liver transplant referral center. We tracked outcomes, including complication rates and liver transplantation, as well as biomarkers of nutritional status. RESULTS Sixty-two patients underwent IPC placement between 2007 and 2017, with 33 IPCs (53%) placed as a bridge to liver transplantation. Complications were recorded in 22 patients (36%); empyema was the most common, diagnosed in 10 patients (16.1%). Ten patients evaluated for liver transplantation underwent successful transplantation following IPC placement. There were statistically significant decreases in both BMI and serum albumin levels following IPC placement. CONCLUSIONS IPCs represent a potential treatment for refractory HH and should be used with caution in patients eligible for liver transplantation. Ideally, IPC use for these patients would be evaluated by a multidisciplinary team. IPC use may lead to small decreases in BMI and serum albumin levels in patients over time.
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Affiliation(s)
- Christopher Kniese
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN.
| | - Khalil Diab
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Gabriel Bosslet
- Department of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
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23
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Abstract
Respiratory complications before and after liver transplant are common, diverse, and potentially have a negative impact on patient outcomes. In this review, we discuss the most frequent respiratory conditions that patients may develop in the perioperative period. Their prevention and/or treatment may help to maximize the benefit these patients may derive from liver transplant. This review examines diagnostic and therapeutic approaches to these complications for hepatologists, surgeons, and critical care physicians.
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Affiliation(s)
- Filipe S Cardoso
- 1 Gastroenterology and Intensive Care Divisions, Hospital Curry Cabral, Central Lisbon Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Constantine J Karvellas
- 2 Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
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24
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Abstract
BACKGROUND/AIM A pleural effusion is an abnormal collection of fluid in the pleural space and may cause related morbidity or mortality in cirrhotic patients. Currently, there are insufficient data to support the long-term prognosis for cirrhotic patients with pleural effusion. In this study, we investigated the short- and long-term effects of pleural effusion on mortality in cirrhotic patients and evaluated the benefit of liver transplantation in these patients. PATIENTS AND METHODS The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify 3,487 cirrhotic patients with pleural effusion requiring drainage between January 1, 2007 and December 31, 2010. The proportional hazards Cox regression model was used to control for possible confounding factors. RESULTS The 30-day, 90-day, 1-year, and 3-year mortalities were 20.1%, 40.2%, 59.1%, and 75.9%, respectively, in the cirrhotic patients with pleural effusion. After Cox proportional hazard regression analysis adjusted by patient gender, age, complications of cirrhosis and comorbid disorders, old age, esophageal variceal bleeding, hepatocellular carcinoma, hepatic encephalopathy, pneumonia, renal function impairment, and without liver transplantation conferred higher risks for 3-year mortality in the cirrhotic patients with pleura effusion. Liver transplantation is the most important factor to determine the 3-year mortalities (HR: 0.17, 95% CI 0.11- 0.26, P < 0.001). The 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortalities were 5.7%, 13.4%, 20.4%, and 21.7% respectively, in the liver transplantation group, and 20.5%, 41.0%, 61.2%, and 77.5%, respectively, in the non-liver transplantation group. CONCLUSION In cirrhotic patients, the presence of pleural effusion predicts poor long-term outcomes. Liver transplantation could dramatically improve the survival and should be suggested as soon as possible.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan,Address for correspondence: Dr. Chih-Wei Tseng, Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan. E-mail:
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chen-Chi Tsai
- School of Medicine, Tzu Chi University, Hualien, Taiwan,Division of Infectious Disease, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Kuo-Chih Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Hualien, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
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25
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Murphy DL, Condino AE, Gittinger MJ, Vrablik ME. Right Atrial Collapse With Hepatic Hydrothorax in Advanced Liver Disease. J Med Ultrasound 2017; 25:55-57. [PMID: 30065456 PMCID: PMC6029287 DOI: 10.1016/j.jmu.2017.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/09/2017] [Indexed: 11/09/2022] Open
Abstract
Cardiac chamber collapse secondary to extrapericardial causes is rare. Focused cardiac ultrasound (FoCUS) in the emergency department can rapidly yield important clinical information and guide management in patients presenting with dyspnea, hypotension, or other cardiopulmonary complaints of uncertain etiology. We report a case of newly-diagnosed cirrhosis with massive ascites and large pleural effusions that distorted normal cardiac anatomy and venous return, in which FoCUS was essential in differentiating underlying pathology of this sick patient and guiding therapy.
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Affiliation(s)
- David L Murphy
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Anna E Condino
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Matthew J Gittinger
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - Michael E Vrablik
- Harborview Medical Center, Division of Emergency Medicine, Seattle, WA, USA.,University of Washington, Division of Emergency Medicine, Seattle, WA, USA
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26
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Kim JS, Kim CW, Nam HS, Cho JH, Ryu JS, Lee HL. Hepatic hydrothorax without ascites as the first sign of liver cirrhosis. Respirol Case Rep 2015; 4:16-8. [PMID: 26839695 PMCID: PMC4722098 DOI: 10.1002/rcr2.140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 12/21/2022] Open
Abstract
A 60‐year‐old woman without a history of liver diseases, but with a history of regular alcohol consumption, presented with a right‐sided transudative pleural effusion. Neither parenchymal lung lesion nor pleural thickening was seen on a chest computed tomography. On abdominal ultrasonography, the liver size and contour were normal, and ascites was not noted. Despite performing imaging and laboratory studies, we could not find a cause of the pleural effusion. Thus, due to her history of regular alcohol consumption, we decided to measure liver stiffness using a transient elastography (Fibroscan®, EchosensTM, Paris, France), which showed a value of 35.3 kPa suggestive of liver cirrhosis. An intraperitoneal injection of a radioisotope demonstrated the transdiaphragmatic flow of fluid from peritoneal cavity to pleural cavity. The diagnosis was confirmed as hepatic hydrothorax. Management consisting of restricted salt and water intake with diuretics resulted in resolution of the hepatic hydrothorax.
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Affiliation(s)
- Jung Soo Kim
- Division of Pulmonary and Critical Care Medicine Inha University College of Medicine Incheon Republic of Korea
| | - Cheol-Woo Kim
- Division of Allergy Medicine, Department of Internal Medicine Inha University College of Medicine Incheon Republic of Korea
| | - Hae-Seong Nam
- Division of Pulmonary and Critical Care Medicine Inha University College of Medicine Incheon Republic of Korea
| | - Jae Hwa Cho
- Division of Pulmonary and Critical Care Medicine Inha University College of Medicine Incheon Republic of Korea
| | - Jeong-Seon Ryu
- Division of Pulmonary and Critical Care Medicine Inha University College of Medicine Incheon Republic of Korea
| | - Hong Lyeol Lee
- Division of Pulmonary and Critical Care Medicine Inha University College of Medicine Incheon Republic of Korea
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27
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Abstract
Pleural effusions arise from a variety of systemic, inflammatory, infectious and malignant conditions. Their precise etiological diagnosis depends on a combination of medical history, physical examination, imaging tests and pertinent pleural fluid analyses; including specific biomarkers (e.g., natriuretic peptides for heart failure, adenosine deaminase for tuberculosis, or mesothelin for mesothelioma). Invasive procedures, such as pleuroscopic biopsies, may be required for persistently symptomatic effusions which remain undiagnosed after the analysis of one or more pleural fluid samples. However, whenever parietal pleural nodularity or thickening exist, image-guided biopsies should first be attempted. This review addresses the current diagnostic approach to pleural effusions secondary to heart failure, pneumonia, cancer, tuberculosis and other less frequent conditions.
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Affiliation(s)
- José M Porcel
- a Pleural Medicine Unit, Department of Internal Medicine , Arnau de Vilanova University Hospital, Biomedical Research Institute of Lleida , Lleida , Spain
| | - M Azzopardi
- b Respiratory Department , Sir Charles Gairdner Hospital , Perth , Western Australia
| | - C F Koegelenberg
- c Division of Pulmonology, Department of Medicine , Stellenbosch University and Tygerberg Academic Hospital , Cape Town , South Africa
| | - F Maldonado
- d Division of Allergy, Pulmonary and Critical Care Medicine , Vanderbilt University , Nashville , TN , USA
| | - N M Rahman
- e Oxford Centre for Respiratory Medicine , Oxford University Hospitals NHS Trust , Oxford , UK
| | - Y C G Lee
- b Respiratory Department , Sir Charles Gairdner Hospital , Perth , Western Australia
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28
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Shimbo A, Matsuda S, Tejima K, Yamahira K, Naka K, Arai M, Fujita S. Induced negative pressure proposed as a new method for diagnosing hepatic hydrothorax involving minor leaks. Clin Case Rep 2014; 2:296-302. [PMID: 25548633 PMCID: PMC4270713 DOI: 10.1002/ccr3.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 01/01/2023] Open
Abstract
Key Clinical Message Hepatic hydrothorax is known as pleural effusion of hepatic origin, and is difficult to diagnose. We herein report the novel strategy combining radioisotope scintigraphy with chest drainage to definitively diagnose hepatic hydrothorax of an 85-year-old patient which would have been missed with conventional diagnostic methods.
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Affiliation(s)
- Asami Shimbo
- Department of General Medicine, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Satoshi Matsuda
- Department of Respiratory Disease, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Kazuaki Tejima
- Department of Gastroenterology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Koh Yamahira
- Department of Radiology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Kenichi Naka
- Department of Radiology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Masahiro Arai
- Department of Gastroenterology, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
| | - Shuhei Fujita
- Department of General Medicine, Toshiba General Hospital Shinagawa-ku, Tokyo, Japan
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29
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Abstract
Refractory ascites represents a devastating complication of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an efficacious option for patients for whom transplant is not an immediate option. Techniques to optimize the hepatic venous pressure gradient and the use of covered stents have reduced rates of hepatic encephalopathy and stent occlusion, respectively. Patients with a Model for End-Stage Liver Disease score less than 15, serum creatinine less than 2 mg/dL, and serum bilirubin less than 2 mg/dL are particularly suited for TIPS placement. TIPS is also effective for hepatic hydrothorax and for massive ascites in the posttransplant setting, although future investigations are necessary to elucidate risk factors and establish the effect on transplant-free survival.
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Affiliation(s)
- Zachary L Bercu
- Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aaron M Fischman
- Department of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
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30
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Krowka MJ, Wiesner RH, Heimbach JK. Pulmonary contraindications, indications and MELD exceptions for liver transplantation: a contemporary view and look forward. J Hepatol 2013; 59:367-74. [PMID: 23557870 DOI: 10.1016/j.jhep.2013.03.026] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 12/11/2022]
Abstract
Pulmonary concerns in liver transplant candidates have intraoperative and outcome implications. Evolving MELD exception policies address transplant priority for problems such as hepatopulmonary syndrome, portopulmonary hypertension, and hemorrhagic hereditary telangiectasia. Other pulmonary issues such as refractory hepatic hydrothorax, advanced chronic obstructive lung disease (including alpha-1 antitrypsin deficiency) and indeterminate pulmonary nodules may affect liver transplant consideration. Herein, we discuss current pulmonary-related contraindications, indications and MELD exception policies for liver transplantation, suggesting future considerations.
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31
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Abstract
Hepatic hydrothorax secondary to transdiaphragmatic spread of peritoneal fluid can cause respiratory discomfort to the patient. Draining of hydrothorax helps relieve these symptoms. Pleurovenous shunt (Denver shunt) is a relatively non-invasive method of shunting the pleural fluid to the central venous system. Reported complications of pleurovenous shunts are shunt failure, pulmonary edema, post shunt coagulopathy, deep vein thrombosis, and infection. We report a rare case of a leak at the venous end of the catheter that was placed within the right internal jugular vein, resulting in a large collection in the neck.
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Affiliation(s)
- Eranga Perera
- Department of Radiology, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
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32
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Helmy N, Akl Y, Kaddah S, Hafiz HAE, Makhzangy HE. A case series: Egyptian experience in using chemical pleurodesis as an alternative management in refractory hepatic hydrothorax. Arch Med Sci 2010; 6:336-42. [PMID: 22371768 PMCID: PMC3282509 DOI: 10.5114/aoms.2010.14252] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2009] [Revised: 05/30/2009] [Accepted: 06/08/2009] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Nariman Helmy
- Chest Diseases Department, Cairo University, Cairo, Egypt
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33
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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.
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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:
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