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home - Liver - Hepatopulmonary Disorders - Hepatic hydrothorax Written by Dr Sebastian Zeki

Hepatic hydrothorax

Written by Dr Sebastian Zeki Hepatic hydrothorax Thoracentesis —Therapeutic thoracentesis is the most effective way of reducing large effusions (>1.5 liters). After thoracentesis, diuretics should be started to prevent reaccumu-lation of fluid.Transjugular intrahepatic portosystemic shunt (TIPS) — Response rates in the range of 70 to 80 %.Considerin Child-Pugh score < 10 and < 60yrs with no hepatic encephalopathy. Pleurodesis —Very difficult to treat with chemical pleurodesis as cant keep pleaural surfaces opposed for long enough Thoracoscopic repair —A diaphragmatic repair involving a pleural flap and surgical mesh reinforcement has been described but experience is limited.Liver transplantation — Management -The patient should be assessed for liver transplantation and relieve symptoms.-Treat largely as per ascites.-Chest tubes should not be placed as can result in massive protein and electrolyte depletion, infection, renal failure, and bleeding.-Once a chest drain has been inserted, it is impossible to remove the tube because of the continuous reaccumulation of fluid.Sodium restriction and diuretics is necessary.If a patient develops a refractory hydrothorax the options include repeated thoracentesis, TIPSS, pleurodesis, and surgical repair of defects in the diaphragm. DiagnosisIt is right sided in 85 % of patients.It is left sided in 13 % of patients.It is bilateral in 2 % of patients.Up to 20 % of patients will have evidence of infection or a cause of pleural effusion other than hepatic hydr-thorax.These are transudates (The SAAG >1.1 g/dL as in PHTN).In uncomplicated hepatic hydrothorax, the cell count is low (<500 cells).In cases where the diagnosis is uncertain, an intraperitoneal injection of 99mTc-sulphur colloid or 99mTc-human serum albumin can be helpful.The optimal time to do an isotope study is shortly after therapeutic thoracentesis, when the fluid is reaccum-lating in the pleural cavity. Clinical ManifestationsIt presents as a pleural effusion.13% develop "spontaneous bacterial empyema" (SBEM) (polymorphonuclear cell count >500 cells/mm3 or positive culture with exclusion of a parapneumonic effusion).Mortality of SBEM is as high as 20 %, even with anti-microbial therapy.50% are associated with SBP.The aetiologic agents are the same as SBP. PathogenesisIt is due to ascites passing from the peritoneal to the pleural cavity through small diaphragmatic defects (<1cm) in tendinous part.The negative intrathoracic pressure generated during inspiration favors the passage of fluid from the intra-abdominal to the pleural space.Many patients have only mild or no clinically detectable ascites.

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