Management Of Hepatic Hydrothorax Research Articles

Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax.

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.

An Unusual Case of Resistant Hepatic Hydrothorax Treated with Octreotide Infusion

Hepatic hydrothorax is an uncommon clinical problem observed inpatients with end stage liver disease and portal hypertension. The pathogenesis of pleural effusion in this condition is thought to involve the movement of ascitic fuid across diaphragmatic defects into pleural cavity facilitated by a negative pleural pressure. Therefore, tube thoracostomy is not considered to be a defnitive treatment option in the management of hepatic hydrothorax. We present a case of massive pleural effusion secondary to hepatic hydrothorax not responding to conventional treatment successfully treated with intravenous infusion of octreotide.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

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. 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. Of the 37443 patients included from the Nationwide Inpatient Sample, 26889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15191). 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 30days. 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. 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.

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature

Introduction: 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 as well. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. Methods: A literature search was conducted using the electronic database engines MEDLINE through PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trialsand Cochrane Database of Systematic Reviews)from inception to April, 2018 to identify published articles and reports addressing outcomes in patients treated with an IPC for the treatment of HH [figure 1]. Risk of bias was rated for each study by using the Cochrane criteria. Results: The search strategy retrieved 370 papers out of which 4 observational studies were selected with a total of 111 patients.After insertion of IPCs for HH spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients and mean duration to achieve spontaneous pleurodesis was 73-222 days. As far as secondary outcomes are concerned, 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 2 (2.9%) out of 68 patients, pleural fluid infection 5 (4.5%) out of 111 patients and catheter site cellulitis 1 (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study in which 12 (20%) out of 60 patients developed recurrence of pleural effusion. Primary and secondary end points are summarized in figure 2. Conclusion: We conclude that IPC is an acceptable therapeutic option for the management of refractory pleural effusion in patients with hepatic hydrothorax. Although TIPS and liver transplantation are gold standards for management of pleural effusion in these patients, cost and availability are major concerns with these treatment modalities. Tunneled pleural catheter is safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.969_A Figure 1. Prisma diagram showing method of study selection969_B Figure 2. showing primary and secondary end points

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature.

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.

To Assess Outcome of Slow Low-Dose Continuous Albumin, Furosemide ± Terlipressin Sifa (±T) Infusion in Patients of Cirrhosis With Hepatic Hydrothorax

Background and Aim: Management of hepatic hydrothorax is challenging in view of limited treatment options specially medical management. The study was done to assess efficacy and safety of SIFA (±T) as a response-guided protocol in patients of cirrhosis with hydrothorax. Methods: 27 consecutive patients of cirrhosis with hepatic hydrothorax [(Arm I (n = 15); Arm II (n = 12)] were included. Baseline standard workup including, (hemogram, biochemistry, urine analysis and ascitic fluid examination) along with 24 h urinary sodium (UNa+)/potassium (UK)/creatinine (Ucre), CXR and ECG were done. Arm I patients received furosemide infusion at 2 mg/h, albumin 2 g/h (20–40 g/d). As per clinical response and lab parameters, graded increase of furosemide was done by 1 mg/12 h if UNa+ < 80 meq/d. After 48 h, if UNa+ was <80 meq/d, terlipressin infusion was added @4 mg/24 h after correction of anemia (≥8 g/dl) and obtaining baseline ECG (repeated 12 hourly) and response-guided increase (1 mg/12 hourly) was done (maximum up to 8 mg/24 h). Arm II patients received SMT. Results: A total 27 patients (Arm I n = 15; Arm II n = 12) of ACLF with hepatic hydrothorax were included. Baseline parameters were comparable among both Arm. All patients in Arm I responded over a median period of 8.6 ± 2.7 days whereas only 41% (5/12) patients responded to SMT in Arm II. Baseline parameters of Arm I patients were: age 44.2 ± 11.4, serum creatinine 1.19 ± 0.53, serum sodium 125.6 ± 8.4, UNa+ 26.02 ± 13.4, CTP-score 10.68 ± 1.42, MELD-score 28.5 ± 4.7. At the end of treatment serum creatinine 0.88 ± 0.48, serum Na 133.47 ± 5.25, maximum (max) UNa+ 192.50 ± 94.35. Baseline urine output (UO) was 475 ± 215 ml, whereas maximum UO was 3280 ± 780 ml while on treatment. 3 patients in terlipressin group had nonspecific mild pain abdomen. 2 patient developed t-wave inversion on terlipressin. All these resolved spontaneously. No other significant adverse events were noted in any group. Conclusions: Response-guided use of furosemide, albumin ± terlipressin is relatively safe and effective treatment options for hepatic hydrothorax. The authors have none to declare.

Paradigms in the management of hepatic hydrothorax: past, present, and future.

Hepatic hydrothorax (HH) is an infrequent but a well-known complication of portal hypertension in patients with end-stage liver disease. The estimated prevalence of HH is around 4-6% in cirrhotics. Thoracentesis and pleural fluid analysis is a must for establishing the diagnosis of this transudative effusion in the absence of primary cardiopulmonary disease. Management strategies include sodium restriction, diuretics, thoracentesis, transjugular intrahepatic portosystemic shunt, pleurodesis, and video assisted thoracic surgery in selected patients. Liver transplantation remains the ultimate definitive management paradigm. Refractory HH thus warrants prompt consideration of liver transplantation.

Transjugular Intrahepatic Portalsystemic Shunt is an Effective Bridge to Liver Transplant in the Management of Hepatic Hydrothorax

Transjugular Intrahepatic Portalsystemic Shunt is an Effective Bridge to Liver Transplant in the Management of Hepatic Hydrothorax

Der hepatische Hydrothorax

Hepatic hydrothorax describes a pleural effusion (> 500 ml) in patients suffering from advanced liver cirrhosis and portal hypertension without an underlying disease of heart, lung or pleura. Hepatic hydrothorax can be observed in 5-10% of the patients with ascites secondary to advanced liver cirrhosis. The underlying pathophysiological mechanism seems to be a direct movement of fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. In rare cases complete translocation of fluid into the pleural space and absence of clinically relevant ascites can be observed. The management of hepatic hydrothorax is difficult. Recurrent thoracentesis is the most important therapeutic measurement in all cases, in which sodium restriction and diuretics fail and liver transplantation is not an option. Placement of chest tubes should be strictly avoided, because otherwise massive protein and electrolyte depletion can result. Further options for patients with continuous reaccumulation of fluid include more invasive therapeutic measurements as transjugular intrahepatic portosystemic shunt (TIPS) placement, pleurodesis and surgical repair of defects of the diaphragm.

The impact of preoperative hepatic hydrothorax on the outcome of adult liver transplantation

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. 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. 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. 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.

Thoracoscopic Diaphragmatic Repair for Refractory Hepatic Hydrothorax: Application of Pleural Flap and Mesh Onlay Reinforcement

Management of hepatic hydrothorax is difficult, and no radical treatment has been established. Based on accumulating evidence that diaphragmatic defects contribute to hepatic hydrothorax, we developed a diaphragmatic repair method for the management of this complex condition. From October 2003 to March 2005, 10 patients (age, 32 - 83 years; 6 men and 4 women) with refractory hepatic hydrothorax (Child-Pugh class B-C) underwent thoracoscopic pleura (n = 7) or mesh (n = 3) onlay reinforcement to repair the diaphragmatic defects on which this study focuses, and all patients have since been under follow-up in a prospective observation study. After a mean of 7.7 months of follow-up examinations, no local recurrence occurred in all patients. Two patients died of hemorrhage from esophageal varices two months postoperatively. All patients had a better postoperative pulmonary function. The use of pleura and mesh onlay reinforcement of the diaphragm is an encouraging treatment for refractory hepatic hydrothorax.

Hepatic Hydrothorax

Hepatic hydrothorax (HH) is an uncommon manifestation of cirrhosis with ascites. Pleural effusions form when ascitic fluid moves through diaphragmatic defects that have been opened by increased peritoneal pressure. The diagnosis is established clinically by finding a serous transudate and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces. In end-stage liver disease, the management of hepatic hydrothorax is problematic and often does not respond to medical therapy. Therapeutic options for a refractory hepatic hydrothorax include therapeutic thoracentesis, talc slurry through a chest tube, peritoneovenous and pleurovenous shunting, thoracoscopic talc poudrage, transjugular intrahepatic portosystemic shunt (TIPS), thoracosopic diaphragmatic defect repair followed by talc poudrage, and lastly, liver transplant. TIPS can be used as a bridge for transplantation but is often complicated by encephalopathy. Video assisted thoracic surgery (VATS) with patching the defect and talc poudrage may provide symptomatic relief; however, the morbidity and mortality in these extremely ill patients is high. The only definitive treatment for refractory hepatic hydrothorax associated with end-stage cirrhosis is liver transplantation.