THE HIDING HEPATIC HYDROTHORAX

Abstract

TOPIC: Lung Pathology TYPE: Fellow Case Reports INTRODUCTION: Hepatic Hydrothorax is excessive accumulation of pleural fluid in patients with decompensated liver cirrhosis without pulmonary or cardiac disease. Radioisotope diagnostic techniques are used to confirm doubtful cases of hepatic hydrothorax. [1] Here we describe an unusual case of pleural chylothorax secondary to hepatic hydrothorax(HH). CASE PRESENTATION: 68 yr-old-female with history of NASH liver cirrhosis, portal hypertension, RCC of the kidney s/p right partial nephrectomy, chronic kidney disease and MGUS presented with shortness of breath and abdominal distention. On examination she had diminished breath sounds and abdominal ascites with fluid thrill. Initial CT chest, abdomen and pelvis showed moderate right pleural effusion with liver cirrhosis and moderate ascites. During the course of her hospitalization, she underwent multiple diagnostic and therapeutic paracentesis and thoracentesis. Analysis of the pleural fluid was consistent with chylothorax, ascitic fluid had elevated triglycerides however was not diagnostic of chylous ascites. Microbiological work up was negative. No malignant cells were identified. She was started on optimal diuretic therapy. A peritoneum shunting study with SPECT/CT using technetium 99m MAA was performed with evidence of hepatic hydrothorax, following which she underwent a Transjugular intrahepatic portosystemic shun (TIPS) procedure. DISCUSSION: Spontaneous chylothorax after liver cirrhosis is a known entity. Triglyceride levels >200 mg/dl in ascitic fluid [2] and >110 mg/dl in pleural fluid is consistent with a chylous effusion. Migration of intraperitoneally infused 99mTc-labeled microspheres of human serum albumin or a sulfur colloid into the pleural cavity confirms the diagnosis of hepatic hydrothorax in unequivocal cases. The rate of isotope movement indicates the size of defects in the diaphragm. Ditah et al provided a systematic review and meta-analysis of a total of 198 patients suffering from HH where TIPS successfully eliminated the symptoms of refractory HH in 73% of cases. [3] CONCLUSIONS: In conclusion patient developed chylothorax from her ascites which was not evident on initial pleural and ascetic analysis. REFERENCE #1: [1] Dmitry Victorovich Garbuzenko, Nikolay Olegovich Arefyev, Hepatic hydrothorax: An update and review of the literature, World J Hepatol 2017 November 8; 9(31): 1197-1204 REFERENCE #2: [2] Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment Richa Bhardwaj*1, Haleh Vaziri1, Arun Gautam1, Enrique Ballesteros2, David Karimeddini3 and George Y. Wu1 1 Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA; 2 Department of Pathology and Lab Medicine, UCONN Health, Farmington, CT, USA; 3 Department of Diagnostic Imaging and Therapeutics, UCONN Health, Farmington, CT, USA REFERENCE #3: [3]Ditah IC, Al Bawardy BF, Saberi B, Ditah C, Kamath PS. Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis. World J Hepatol 2015; 7: 1797-1806 [PMID: 26167253 DOI: 10.4254/wjh.v7.i13.1797] DISCLOSURES: No relevant relationships by Bharat Bhandari, source=Web Response No relevant relationships by Saadia Faiz, source=Web Response No relevant relationships by Carlos Jimenez, source=Web Response