Hepatic hydrothorax:An update and review of the literature

This review considers the modern concepts of pathogenesis,diagnostic methods,and treatment principles of hepatic hydrothorax(HH).HH is the excessive(>500 mL)accumulation of transudate in the pleural cavity in patients with decompensated liver cirrhosis but without cardiopulmonary and pleural diseases.It causes respiratory failure which aggravates the clinical course of liver cirrhosis,and the emergence of spontaneous bacterial pleural empyema may be the cause of death.The information was collected from the PubM ed database,the Google Scholar retrieval system,the Cochrane reviews,and the reference lists from relevant publications for 1994-2016 using the keywords:"liver cirrhosis","portal hypertension","hepatic hydrothorax","pathogenesis","diagnostics",and"treatment".To limit the scope of this review,only articles dealing with uncomplicated hydrothorax in patients with liver cirrhosis were included.The analysis of the data showed that despite the progress of modern hepatology,the presence of HH is associated with poor prognosis and high mortality.Most patients suffering from it are candidates for orthotopic liver transplantation.In routine clinical practice,stratification of the risk for an adverse outcome and the subsequent determination of individual therapeutic strategies may be the keys to the successful management of the patient’s condition.The development of pathogenetic pharmacotherapy and optimization of minimally invasive treatment will improve the quality of life and increase the survival rate among patients with HH.

Natural history and outcomes of patients with liver cirrhosis complicated by hepatic hydrothorax

BACKGROUNDHepatic hydrothorax (HH) is an uncommon and difficult-to-manage complicationof cirrhosis with limited treatment options.AIMTo define the clinical outcomes of patients presenting with HH managed withcurrent standards-of-care and to identify factors associated with mortality.METHODSCirrhotic patients with HH presenting to 3 tertiary centres from 2010 to 2018 wereretrospectively identified. HH was defined as pleural effusion in the absence ofcardiopulmonary disease. The primary outcomes were overall and transplant-freesurvival at 12-mo after the index admission. Cox proportional hazards analysiswas used to determine factors associated with the primary outcomes.RESULTSOverall, 84 patients were included (mean age, 58 years) with a mean model forend-stage liver disease score of 29. Management with diuretics alone achievedlong-term resolution of HH in only 12% patients. At least one thoracocentesis wasperformed in 73.8% patients, transjugular intrahepatic portosystemic shuntinsertion in 11.9% patients and 33% patients received liver transplantation within12-mo of index admission. Overall patient survival and transplant-free survival at12 mo were 68% and 41% respectively. At multivariable analysis, current smoking [hazard ratio (HR) = 8.65, 95% confidence interval (CI): 3.43-21.9, P < 0.001) and acute kidneyinjury (AKI) (HR = 2.91, 95%CI: 1.21-6.97, P = 0.017) were associated with a significantly increasedrisk of mortality.CONCLUSIONCirrhotic patients with HH are a challenging population with a poor 12-mo survival despitecurrent treatments. Current smoking and episodes of AKI are potential modifiable factors affectingsurvival. HH is often refractory of diuretic therapy and transplant assessment should beconsidered in all cases.

Bi-directional hepatic hydrothorax

A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia,and 4 mo of exertional dyspnea.He was noted to be tachypneic and hypoxic.He had a massive right sided pleural effusion with leftward mediastinal shift and gross ascites,with a tense,fluid-filled,umbilical hernia.Emergent paracentesis with drain placement and a large volume thoracentesis were performed.Despite improvement in dyspnea and drainage of 15 L of ascitic fluid,the massive transudative pleural effusion remained largely unchanged.He underwent a repeat large volume thoracentesis on hospital day 4.The patient subsequently developed a tension pneumothorax,which resulted in a dramatic reduction in the effusion.A chest tube was placed and serial radiographs demonstrated resolution of the pneumothorax but recurrence of the effusion.The radiographs illustrate the movement of fluid between the peritoneal and pleural cavities.In this case,the mechanism of pleural effusion was confirmed to be a hepatic hydrothorax via an unintended tension pneumothorax.Methods to elucidate a hepatic hydrothorax include Tc99m or indocyanine green injection into the ascitic fluid followed by its demonstration above the diaphragm.The unintended tension pneumothorax in this case additionally demonstrates bi-directional flow across the diaphragm.

Thoracoscopy for diagnosis and management of refractory hepatic hydrothorax

The prevalence of pleural effusion caused by hepatocirrhosis ranges from 0.4% to 30%. Some patients with hepatic hydrothorax （HH） fail to respond to aggressive medical management such as albumin application, diuretics, and thoracentesis, and remain refractory massive pleural fluid. The repeated suctions to relieve the symptoms such as respiratory distress are associated with significant hyponatremia and hypoalbuminemia caused by the large volumes of fluid loss. Review of the literature has revealed that, to date, no therapy is ideal. This report describes our experiments in treating HH of patients with cirrhosis and ascites by thoracoscopy and talc poudrage, to offer our efforts to approach the pathogenesis of HH and to explore the new therapeutic strategy.

Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax:report of twelve cases

Background： Hepatic hydrothorax is defined as a significant pleural effusion in patients with liver cirrhosis and without underlying cardiopulmonary diseases. Treatment of hepatic hydrothorax remains a challenge at present. Methods： Herein we share our experiences in the treatment of 12 patients with hepatic hydrothorax by video-assisted thoracoscopic surgery （VATS） Repair of the diaphragmatic defects, or pleurodesis by focal pleurectomy, talc spray, mechanical abrasion, electro-cauterization or injection was administered intraoperatively, and tetracycline intrapleural injection was used postoperatively for patients with prolonged （〉7 d） high-output （〉300 ml/d） pleural effusion. Results： Out of the 12 patients, 8 （67%） had uneventful postoperative course and did not require tube for drainage more than 3 months after discharge. In 4 （33%） patients the pleural effusion still recurred after discharge due to end-stage cirrhosis with massive ascites. Conclusion： We conclude that the repair of the diaphragmatic defect and pleurodesis through VATS could be an alternative of transjugular intrahepatic portal systemic shunt （T1PS） or a bridge to liver transplantation for patients with refractory hepatic hydrothorax. Pleurodesis with electrocauterization can be an alternative therapy if talc is unavailable.

Pulmonary complications of hepatic diseases

Severe chronic liver disease(CLD) may result from portal hypertension, hepatocellular failure or the combination of both. Some of these patients may develop pulmonary complications independent from any pulmonary pathology that they may have. Among them the hepatopulmonary syndrome(HPS), portopulmonary hypertension(PPH) and hepatic hydrothorax(HH) are described in detail in this literature review. HPS is encountered in approximately 15% to 30% of the patients and its presence is associated with increase in mortality and also requires liver transplantation in many cases. PPH has been reported among 4%-8% of the patient with CLD who have undergone liver transplantation. The HH is another entity, which has the prevalence rate of 5% to 6% and is associated in the absence of cardiopulmonary disease. These clinical syndromes occur in similar pathophysiologic environments. Most treatment modalities work as temporizing measures. The ultimate treatment of choice is liver transplant. This clinical review provides basic concepts; pathophysiology and clinical presentation that will allow the clinician to better understand these potentially life-threatening complications. This article will review up-to-date information on the pathophysiology, clinical features and the treatment of the pulmonary complications among liver disease patients.

Pulmonary complications of portal hypertension:The overlooked decompensation

The systemic nature of cirrhosis and portal hypertension has long been recognized,and the amount of data characterizing the interplay between each system is becoming ever so complex.Lung involvement was among the first described associated entities in cirrhosis,with reports dating back to the late nineteenth century.However,it appears that throughout the years,interest in the pulmonary complications of portal hypertension has generally faded,especially in contrast to other decompensating events,as expertise in this field has primarily been concentrated in highly experienced tertiary care facilities and liver transplantation centers.Despite affecting up to 10%-15%of patients with advanced liver disease and having a proven prognostic impact,hepato-pulmonary syndrome,porto-pulmonary hypertension,and hepatic hydrothorax are frequently misdiagnosed,mistreated,or misinterpreted.This lack of precision might adversely impact patient care,referral to expert centers,and,ultimately,liver disease-related mortality and successful transplantation odds.The present minireview aims to increase awareness of the pulmonary complications of chronic liver disease by providing a brief overview of each of the three entities.The paper focuses on the essential theoretical aspects,addressing the most critical knowledge gaps on the one hand and,on the other hand,critically discussing one key issue for each complication.

Spontaneous bacterial empyema in cirrhosis:A systematic review and meta-analysis

BACKGROUND Spontaneous bacterial empyema(SBE)occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis(SBP).It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis.Current understanding is limited by small cohorts,while studies reporting its association with ascites/SBP are conflicting.AIM To explore the incidence of SBE,to determine its association with ascites,and to summarize what is known regarding treatment and outcomes for patients with SBE.METHODS Major databases were searched until June 2021.Outcomes include the incidence of SBE in pleural effusions,SBP in peritoneal fluid,and SBE in patients without ascites within our cohort of patients with cirrhosis.We performed a meta-analysis using a randomeffects model with pooled proportions and 95%confidence intervals(CI).We assessed heterogeneity using I^(2)and classic fail-safe to determine bias.RESULTS Eight studies with 8899 cirrhosis patients were included.The median age ranged between 41.2 to 69.7 years.The majority of the patients were Child-Pugh B and C.Mean MELD score was 18.6±8.09.A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6%(CI 12.6-19;I^(2)50).Amongst patients diagnosed with SBE,the most common locations included right(202),left(64),and bilateral(8).Amongst our cohort,a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2%(CI 9.9-42.7;I^(2)97.8).The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5%(CI 3.6-22.8;I^(2)82.5).CONCLUSION SBE frequently occurs with concurrent ascites/SBP;our results suggest high incidence rates of SBE even in the absence of ascites.The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion.Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection.The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.