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A 73-year-old man was admitted because of abdominal fullness and systemic oedema. He had been followed up as alcoholic cirrhosis for 3 years. He had been drinking about 70–80 g of ethanol every day. The model for end-stage liver disease (MELD) score and MELD-serum sodium (Na) (MN) score are used

Pleural effusions (PEs) are frequently encountered in routine clinical practice, affecting more than 3000 people per million population every year. Heart and liver failures are two of the most common causes of transudative PE. Because these effusions have nonmalignant etiologies, they are commonly referred to as benign effusions despite of the poor prognosis they foretell in their refractory stages. Like malignant effusions, symptom management is important and plays a significant role in palliation when these effusions become refractory to medical therapy.

Hepatic hydrothorax is the formation of transudative pleural effusion as a consequence of portal hypertension. Only a minority of cases resolve after sodium restriction and diuretics. Despite the relatively low incidence of 5-15% among patients with cirrhotic portal hypertension, the high morbidity and serious clinical implications associated with hepatic hydrothorax necessitate a well-defined treatment strategy to guide patient care. Management is typically multidisciplinary, involving hepatologists, interventional pulmonologists, interventional radiologists, surgeons, and other specialties. In this manuscript, we assemble a multidisciplinary team to critically review the available literature and provide an evidence-based guidance for management of hepatic hydrothorax.

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.

Hepatic hydrothorax is a rare complication of portal hypertension. The optimal treatment for this condition is liver transplantation. Liver transplantation is significantly more manageable in children who weigh more than 8 kg. Here, an implantable pleural access device was used in a 5-month-old infant for painless iterative punctures to relieve respiratory symptoms, while waiting for liver transplantation and the patient's growth. The patient underwent successful transplantation 3 months later with a more optimal weight.

Objectives: To determine the frequency of spontaneous bacterial empyema in cirrhotic patients with hepatic hydrothorax. Study Design: Descriptive cross sectional study. Setting: Conducted in gastroenterology unit at Isra University Hospital, Hyderabad. Periods: One year from April 2016 to March 2017. Material & Methods: Sample of 174 patients of Hepatic Hydrothorax was taken. Patients were of both gender and age ≥ 18 years, having diagnosed cirrhosis since last 5 years and currently having child class B & C severity were included. Hepatic hydrothorax was confirmed on ultrasound chest. After aseptic measures 50ml of pleural fluid was aspirated and sent to Isra University Hospital laboratory following the ultrasound guidelines. Spontaneous bacterial empyema was assessed as “polymorph nuclear cell count” more than 500 cells/mm3 or +ve culture with PMN cell count more than 250 cells/mm3 without parapneumonic effusion. All the data was recorded in the proforma. Results: The mean ± SD age of patients was 53.52 ± 5.52 years. Males were 60.92% while 39.08% were females. The frequency of spontaneous bacterial empyema was about 14.9%. Frequency of spontaneous bacterial empyema was little more in male gender than females (p value = 0.391), while it was significantly increased with increasing age as most common in age group of 61-65 years (p-value = 0.017). Conclusion: It was concluded that spontaneous bacterial empyema in cirrhosis patients was 14.9%.

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.

Background and Objective: Hepatic hydrothorax is a type of pleural effusion that occurs in 5-10% of patients with poor liver function. This causes patients to experience shortness of breath and chest discomfort with the potential for respiratory or cardiovascular collapse. When medical management fails, thoracentesis to directly drain fluid is a second-line therapy but frequent treatment is not recommended. For patients requiring serial thoracentesis, a transjugular intrahepatic portosystemic shunt (TIPS) may relieve hepatic hydrothorax by creating a connection between the portal vein and hepatic vein, thus reducing portal hypertension and decreasing fluid accumulation. Our objective was to assess the safety and efficacy of TIPS for hepatic hydrothorax. Methods: An IRB approved, HIPAA compliant institutional database of 320 patients who underwent TIPS creation between 2011-2016 was retrospectively reviewed for patients whose primary indication for TIPS creation was hepatic hydrothorax. This yielded a total of 24 individual patients. Records were reviewed and evaluated for overall survival (OS), response (as measured by persistent need for thoracentesis), and frequency of new and/or worsening hepatic encephalopathy (HE). Results: Survival was 92%, 62% and 38% for 30 days, 1 year, and 3 year survival, respectively. Response to TIPS was graded as complete (52%), partial (19%), or unresponsive (29%) for an overall response rate of 71%. 29% of patients required TIPS revision. 24% of patients experienced new or worsened hepatic encephalopathy that was successfully managed with medication in all but 1 case. Analysis of relationships between response grades, 1 year survival, and age older vs younger than 60 years did not have statistically significant relationships between MELD scores, Child-Pugh scores, post-TIPS pressure gradients, and serological data. Conclusion: This study reaffirms the safety and efficacy of TIPS for hepatic hydrothorax but further work must be done to identify ideal candidates and prognostic factors for this procedure.

We read with interest the article by Banini et al.1 They have succinctly described the pathophysiology and management of hepatic hydrothorax. We would like to share a few thoughts on the management of hepatic hydrothorax.

We agree with Kulkarni et al on the potential role of splanchnic and peripheral vasoconstrictors in the treatment of HH. In our review (1), we summarize the sparse data on octreotide and terlipressin in HH management. However, there are currently no large studies or randomized trials on the use of these medications in HH, and evidence for their use is limited to case reports and case series. Most of the studies cited by Kulkarni et al examine these pharmacologic agents in the control of ascites, not HH per se.

Pleural effusions account for significant symptoms and morbidity. Recent studies demonstrate a high mortality in patients with “benign” pleural effusions, now better characterized as nonmalignant pleural effusions (NMPEs) based on their prognosis. The most common nonmalignant clinical conditions with recurrent pleural effusions are congestive heart failure and hepatic hydrothorax, although many other diseases exist in isolation or as comorbid conditions. When conventional therapy fails, thoracentesis is often performed for relief of dyspnea. Many times, however, the effusions recur despite maximal medical therapy. Placement of tunneled or indwelling pleural catheters provides an effective therapeutic strategy for recurrent NMPEs when other medical therapy fails.

Hepatic hydrothorax is a nonmalignant pleural effusion associated with portal hypertension that may cause increased morbidity or mortality in cirrhotic patients. For patients who are refractory to salt restriction and diuretics, thoracentesis and catheter drainage are necessary for symptomatic relief. This review aimed to identify the best drainage method in patients with hepatic hydrothorax.Chest tube placement is discouraged in cases of hepatic hydrothorax due to high complication and mortality rates. Although the complication rate associated with smaller caliber catheter drainage appears lower than with chest tube drainage, patients treated with catheter drainage still had a higher 30-day mortality compared with patients treated by thoracentesis. Catheter drainage was an independent risk factor for 30-day mortality in cirrhotic patients with pleural effusion after adjusting for age, hepatic dysfunction, and other comorbidities. Treating the underlying disorder with liver transplantation can dramatically improve survival in these patients.The recent evidence supports series thoracentesis as the first-line drainage method in cases of hepatic hydrothorax compared with catheter drainage. Further prospective, randomized, controlled trials are necessary to further evaluate the mortality and complication rates of catheter drainage compared with thoracentesis in cirrhotic patients.

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. info:eu-repo/semantics/publishedVersion

No abstract available. Article truncated after 150 words. A 54-year-old woman with decompensated alcoholic liver cirrhosis presented to the emergency department with exertional dyspnea. She was afebrile, tachycardic (110), with oxygen saturation of 74% on 5 liters/minute (L/min), in moderate respiratory distress and was subsequently placed on a non-rebreather. On examination, she had absent breath sounds throughout her right lung with chest radiograph revealing large right-sided pleural effusion (Figure 1). A pigtail catheter was placed, draining approximately 4 liters of fluid (Figure 2), resulting in improved oxygenation to 93% on 3 L/min. On admission to internal medicine, the chest tube was clamped immediately. In the next 24 hours, patient developed increased oxygen requirements, with worsening tachypnea and tachycardia, requiring bilevel positive airway pressure and admission to the medical intensive care unit for reexpansion pulmonary edema (Figure 3). Hepatic hydrothorax is a complication of cirrhosis and portal hypertension, defined as pleural effusion without any underlying pulmonary or cardiac etiologies. …

We thank Aithal et al 1 for their recent guidelines on the management of ascites in cirrhosis. We lead a pleural service in the North East of England and frequently deal with hepatic hydrothoraces (HH). We believe that the guidelines will be significantly enhanced by mentioning some figures around HH and the management so that clinicians and patients are better informed. HH is predominantly right-sided due to diaphragmatic defects, but up to 17.5% of effusions are left and 3% bilateral. Of patients 21%–26% develop refractory HH.2 As a first-line intervention, thoracocentesis has a low complication rate (pneumothorax 0.6%–6% and haemothorax 0%–2%). Shojaee et al 3 performed a case–control study of 82 patients with HH undergoing 274 thoracenteses and 100 control patients undergoing 188 thoracenteses. The complication rate was higher with repeat thoracocentesis in patients with HH (8% vs 0%, p=0.016, 95% CI …

Pleural effusions occur in 1.5 million patients yearly and are a common cause of dyspnea. For nonmalignant effusions, initial treatment is directed at the underlying cause, but when effusions become refractory to medical therapy, palliative options are limited. Tunneled pleural catheters (TPCs) are commonly used for palliation of malignant effusions, but many clinicians are reluctant to recommend these devices for palliation of nonmalignant effusions, citing concerns of infection, renal failure, electrolyte disturbances and protein-loss malnutrition. Based on the published experience to date, TPCs relieve dyspnea and can result in spontaneous pleurodesis in patients with nonmalignant effusions. The infection rate compares favorably to that for malignant effusions with possible increased risk in patients with hepatic hydrothorax and posttransplant patients. Renal failure, electrolyte disturbance and protein-loss malnutrition have not been observed. TPCs are a reasonable option in select patients to palliate nonmalignant effusions refractory to maximal medical therapy.

We present a young patient with chronic liver disease who presented with severe breathlessness and discuss possible causes and lines of management.

There are only a few studies with a small sample size of patients that have compared the risks of using chest tubes versus thoracentesis in hepatic hydrothorax. It has been shown that many complications may arise secondary to chest tube placement and is associated with increased morbidity and mortality. In this retrospective study, patients with cirrhosis were identified from the 2009 National Inpatient Sample by using ICD-9 codes; we evaluated the risk of chest tube versus thoracentesis in a largest population with hepatic hydrothorax to date to measure the mortality and the length of stay. A total of 140,573 patients with liver cirrhosis were identified. Of this, 1981 patients had a hepatic hydrothorax and ended up with either thoracentesis (1776) or chest tube (205). The mortality in those who received a chest tube was two times higher than that in thoracentesis group with a P value of ≤0.001 (CI 1.43–312). In addition, the length of hospital stay of the chest tube group was longer than that of the thoracentesis subset (7.2 days versus 3.8 days, resp.). We concluded that chest tube placement has two times higher mortality rate and longer hospital length of stay when compared to patients who underwent thoracentesis.

Hepatic hydrothorax is a complication of cirrhosis in which hydrostatic imbalances result in fluid accumulation within the pleural space. Although uncommon, this may cause significant morbidity, resulting in dyspnea requiring repeated pleural drainage procedures. Liver transplantation is curative, but it is rarely immediately available to qualified patients, presenting the clinical challenge of managing recurrent pleural effusions. Indwelling tunneled pleural catheters (ITPCs) have been used successfully to palliate dyspnea associated with recurrent malignant pleural effusions.This study was performed to evaluate the feasibility of using ITPCs for the management of hepatic hydrothorax.A single-center prospective feasibility study was performed to evaluate the use of ITPCs for the management of recurrent hepatic hydrothorax in patients who were eligible for liver transplant evaluation.Twenty-five ITPCs were placed in 24 patients. The mean number of pleural drainage procedures before ITPC placement was 1.9, with no further pleural drainages required in any patient after ITPC placement. Spontaneous pleurodesis occurred in 8 of 24 patients (33%). All eight catheters were successfully removed without pleural fluid reaccumulation. Mean time to pleurodesis was 131.8 days. Pleural fluid infection occurred in 4 of 24 patients (16.7%), requiring catheter removal in 3 of the 4 patients.ITPCs may be successfully and safely used to control symptoms associated with hepatic hydrothorax. The rate of spontaneous pleurodesis that occurs is similar to that observed with ITPCs placed for malignant pleural effusion, although the infection rate may be higher. Clinical trial registered with www.clinicaltrials.gov (NCT02595567).

Hepatic hydrothorax (HH) is an infrequent but a well-known complication of portal hypertension. Medical management of this condition often fails, and there are no large randomized-controlled trials establishing the best treatment strategies. HH thus represents a formidable entity in the management of end-stage liver disease, and the only definitive treatment is liver transplantation. Despite documented ominous outcome, tube thoracostomy (TT) is still a widely practiced approach to HH mostly by the unaware primary care physician. This communication reports the occurrence of pleurosubcutaneous fistula as a presenting complication of TT in a patient with HH. TT should thus be avoided at all costs in this subset of patients because it is fraught with multiple complications. This report reinforces the importance of clinical education and awareness of these complications and outcomes of TT in a cirrhotic patient with HH.

Introduction : In patients with advanced liver disease, dysregulation of extracellular fluid volume results in abnormal accumulation of fluid such as ascites, pleural effusion and edema .Hepatic hydrothorax occurs with accumulation of fluid (≥500ml) in patients with cirrhosis of liver in the absence of cardiopulmonary disease.The effusion which is transudate most commonly occurs in the right hemithorax .Treatment includes pharmacological–diuretics administration ,therapeutic thoracocentesis, operative interventions like TIPSS would be required in relapsed and refractory cases . We present a rare case of a male patient ,who presented to emergency with progressively worsening dyspnoea, having massive pleural effusion ,was later diagnosed to have hepatic hydrothorax with cirrhosis of liver with portal hypertension , was stabilized and treated in the emergency department .

Pulmonary conditions, such as chronic obstructive pulmonary disease, interstitial lung disease, hepatic hydrothorax, hepatopulmonary syndrome (HPS), and portopulmonary hypertension (POPH), commonly affect liver transplant (LT) candidates. A systematic preoperative pulmonary evaluation and a basic understanding of these conditions are necessary in order to recognize and manage these comorbid diseases. Pulmonary vascular complications of liver disease, such as HPS and POPH, can affect mortality as well as LT eligibility and prioritization. This chapter will provide an overview of the pulmonary evaluation of LT candidates with an emphasis on the perioperative evaluation and management of the pulmonary vascular complications of liver disease, i.e., HPS and POPH.

Background and Study Aim : Hepatic hydrothorax is the presence of more than 500 ml of pleural effusion in a patient with liver disorder. The work aimed to study the frequency of Hepatic hydrothorax in patients with decompensated cirrhosis admitted to the Tropical Medicine department, Faculty of Medicine, Zagazig University (inpatients, outpatient and intensive care unit) trying to determine the frequency of this disorder. Patients and Methods: This study was performed on 208 decompensated cirrhotic patients (112 males and 96 females), their ages ranged from 27 to73 years old (53.8 ±7.09) between April 2013 to April 2014. Which were randomly divided into Group I included 182 decompensated cirrhotic patients without pleural effusion and Group II included 26 cirrhotic patients with pleural effusion. Clinical assessment, laboratory evaluation, plain chest x-ray and diagnostic paracentesis and pleurocentesis for cytological, biochemical analysis and bacteriological, biochemical and bacteriological analysis were carried out. Results: In this study; the frequency of pleural effusion in decompensated cirrhotic patients was