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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

We herein report a case with intractable pleural effusion attributed to superior vena cava (SVC) and upper extremity deep vein thrombosis in a patient with lung cancer. A 62-year-old woman presented to our hospital with shortness of breath and bilateral upper extremity edema. One year ago, she was diagnosed with stage IVB lung adenocarcinoma with bilateral malignant pleural effusions. A genetic analysis of the cells from pleural effusion revealed an epidermal growth factor receptor (EGFR) point mutation at exon 21 (L858R); since then, she was treated with gefitinib. Although her lung cancer and metastatic lesions had markedly reduced and the tumor cells in the pleural effusion had disappeared, pleural effusion remained. Contrast-enhanced whole-body computed tomography (CT) revealed intravenous thrombosis extending from the SVC to the left brachiocephalic and subclavian veins, and her pleural effusion was attributed to this thrombosis. Anticoagulant therapy with intravenous heparin and oral warfarin was started, nevertheless, the thrombus remained and pleural effusion did not decrease. After the placement of a pleuroperitoneal shunt, her pleural effusion resolved and her symptoms improved. This case highlights the importance of awareness of SVC or upper extremity deep vein thrombosis as a differential diagnosis of intractable pleural effusion in lung cancer patients.

Hydrothorax is a rare complication of peritoneal dialysis occurring in about 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. These effusions occur soon after the onset of dialysis and are usually right-sided. We describe an unusual case of late-onset, left-sided, and recurrent effusions in the setting of CAPD. A 67-year-old patient with end-stage renal disease on CAPD for the last three years was admitted to our hospital with acute hypoxic respiratory failure secondary to a left-sided effusion. Although previously asymptomatic, he had three admissions for bilateral (left predominant) effusions in the last year, all of which were found to be transudative on analysis. Therapeutic thoracentesis once again revealed a transudative effusion with an elevated pleural fluid-serum glucose gradient. On this occasion, pleuro-peritoneal scintigraphy with technetium-99m was performed, uncovering a communication between the peritoneal cavity and the left pleural cavity. The peritoneal dialysis was substituted with hemodialysis, and the patient showed an eventual resolution of left-sided effusions within 18 months. Hydrothorax in peritoneal dialysis is due to the transudation of fluid across congenital or acquired pleuro-peritoneal communications. Pleural fluid with protein content less than 3 g/dl, high glucose, and low lactate dehydrogenase (LDH) relative to blood, and the presence of both D and L isomers of lactic acid suggest a transdiaphragmatic leak. Early diagnosis via peritoneal scintigraphy and appropriate management can prevent significant morbidity and mortality.

Refractory pleural effusion can be a life-threatening complication in patients receiving maintenance hemodialysis. We report successful treatment of refractory pleural effusion using a Denver® pleuroperitoneal shunt in one such patient. A 54-year-old Japanese man, who had previously undergone left nephrectomy, was admitted urgently to our department because of a high C-reactive protein (CRP) level, right pleural effusion, and right renal abscess. Because antibiotics proved ineffective and his general state was deteriorating, he underwent emergency insertion of a thoracic drainage tube and nephrectomy, and hemodialysis was started. Although his general state improved slowly thereafter, the pleural effusion, which was unilateral and transudative, remained refractory and therefore he needed to be on oxygenation. To control the massive pleural effusion, a pleuroperitoneal shunt was inserted. Thereafter, his respiratory condition became stable without oxygenation and he was discharged. His general condition has since been well. Although pleural effusion is a common complication of maintenance hemodialysis, few reports have documented the use of pleuroperitoneal shunt to control refractory pleural effusion. Pleuroperitoneal shunt has been advocated as an effective and low-morbidity treatment for refractory pleural effusion, and its use for some patients with recurrent pleural effusion has also been reported, without any severe complications. In the present case, pleuroperitoneal shunt improved the patient’s quality of life sufficiently to allow him to be discharged home without oxygenation. Pleuroperitoneal shunt should be considered a useful treatment option for hemodialysis patients with refractory pleural effusion.

OBJECTIVE Nuclear imaging can confirm pleuroperitoneal shunt as the cause of pleural effusion. No society guidelines exist for scintigraphic pleuroperitoneal shunt detection. Our institutional protocol was evaluated to determine optimal imaging time points for shunt detection. METHODS Pleuroperitoneal shunt studies over 4 years were blindly reviewed by 2 nuclear radiologists. Data from blinded review included presence or absence of pleuroperitoneal shunt, laterality of shunt and time points for shunt detection. RESULTS Chart review yielded 30 studies. Three cases were excluded because of improper injection. Imaging was positive for pleuroperitoneal shunt in 81% (22/27) of cases. In positive cases, activity was identified in the right hemithorax in 82% (18/22), left hemithorax in 9% (2/22), and bilaterally in 9% (2/22). One-hour imaging demonstrated 91% (20/22) of positive cases. The remaining 2 positive cases were negative at 1 hour but positive after 4 hours. No study was negative at 1 and 4 hours and positive at 24 hours. All negative cases (5/27) were confirmed on 24-hour imaging. CONCLUSIONS The majority of positive pleuroperitoneal shunt examinations will demonstrate activity in the right hemithorax on 1-hour imaging. Although no case was negative at 1 and 4 hours and positive at 24 hours, imaging at 24 hours may still be necessary to confirm absence of shunt. Therefore, optimal imaging time points consist of early 1-hour and delayed 24-hour images if the 1-hour time point was negative. The 4-hour time point may be considered optional, thereby potentially optimizing patient safety and resource utilization.

Ascites can cause pleural effusions when the peritoneal fluid crosses the diaphragm through a pleuroperitoneal shunt in the setting of hepatic cirrhosis (hepatic hydrothorax) or malignant ascites. Scintigraphic imaging for pleuroperitoneal shunt requires intraperitoneal injection of Tc-SC or Tc-macroaggregated albumin followed by planar imaging of the chest and abdomen. Pleuroperitoneal shunt is confirmed by identifying radiotracer crossing the diaphragm from the peritoneal to pleural space. An atlas of pleuroperitoneal shunt imaging pitfalls is presented to facilitate optimal performance and interpretation of nuclear pleuroperitoneal shunt examinations. Examples include cases of nondiagnostic radiotracer injections, processing errors, and nontarget uptake.

Metabolic and mechanic complications can be seen due to peritoneal dialysis. Pleuroperitoneal leakage is rare but can be a life-threatening mechanic complication of peritoneal dialysis. Some techniques have been used to diagnose this entity. Radionuclide imaging can be used as a reliable technique in order to show the pleuroperitoneal passage and can be used to show the recovery. Herein we present the first case report in the literature about a patient with pleuroperitoneal shunt that was demonstrated scintigraphically during the leakage and after the resolution.

Central vein thrombosis as a cause of chylothorax is uncommon, and in a few cases in the literature was related to thrombotic complications of central venous access devices (CVAD). Superior vena cava (SVC) occlusion-induced chylothorax has been described in adult sickle cell disease (SCD) in a setting of chronic indwelling CVAD. There are limited reports on chylothorax induced by central venous thrombosis secondary to chronic CVAD in children with SCD. We describe an 8-year-old male patient, with a history of SCD, maintained on long term erythrocytapheresis for primary prevention of stroke, and whose clinical course was complicated by chylothorax which was successfully treated with a pleuroperitoneal shunt.

がん性胸水に対して一般的には胸水穿刺, 胸腔ドレナージや胸膜癒着療法などを行うが, 成功率, 処置操作やカテーテル留置に伴う苦痛の程度や入院期間などにおいて必ずしも満足される結果が得られているとはいえない. 今回われわれは高齢者肺がん患者に生じたがん性胸水症例に対して皮下埋め込み型の胸腔―腹腔シャント造設を行い, 患者の希望する在宅移行に有効であった症例を経験した. 本法はがん性胸水に対する緩和医療, 特に在宅緩和医療の有効な手段の1つとなりうる可能性がある. Palliat Care Res 2008; 3(2): 326-330

Malignant pleural effusion (MPE) is a common clinical problem in patients with neoplastic disease. The optimal palliative management for patients with symptomatic MPE is not well understood. There is a variety of possible treatments: thoracentesis or repeat thoracentesis; instillation of irritating agents into the pleural cavity by the thoracostomy tube or under thoracoscopic vision; alternatives to the pleurodesis such as chronic indwelling pleural catheter and pleuroperitoneal shunt for those cases with trapped lung. The treatment choice depends on the clinician’s specialty and expertise, the patient’s performance status and the hospitalization status. This chapter presents a comprehensive review of the current methods for diagnosing and managing patients with MPE.

A non-valved silastic pleuroperitoneal shunt and omentoplasty were used to treat persistent chylothorax and chylopericardium in a 2-year-old boy who had undergone a Fontan operation.

A 59-year-old woman underwent chest tube placement, repeated pleurodesis, and pleuroperitoneal shunt implantation for unsuccessful treatment of a large refractory hepatic hydrothorax. Two days after placement of a transjugular intrahepatic portosystemic shunt for treatment of variceal hemorrhage, her pleural effusion resolved. At 10 months' follow-up, only minimal fluid remains.

A 3-year-old spayed female Whippet was examined for cough and respiratory distress. Lung lobe torsion with pleural effusion was diagnosed, and lung lobectomy was performed. Pleural effusion recurred during the following 27 months; conventional bacteriologic cultures of pleural effusion did not result in bacterial growth. A second lung lobectomy, pleuroperitoneal shunt placement. and pericardectomy were subsequently performed. Mycobacterium kansasii was eventually isolated from pleural fluid and identified by polymerase chain reaction amplification and DNA sequencing. The dog was euthanatized before therapeutic response could be evaluated. To our knowledge, this is the first report of M. kansasii infection in a dog. Additionally, this is the first report of mycobacterial isolation from pleural fluid, and one of few reports of antemortem mycobacterial isolation from a body fluid, as opposed to identification in specimens during histologic examination. Routine bacteriologic culture methods are insufficient to isolate mycobacterial agents, and special methods are indicated in dogs with persistent pleural effusion.

Objective—To describe complications and outcome associated with chronic nonseptic pleural effusion treated with pleuroperitoneal shunts in dogs. Design—Retrospective study. Animals—14 dogs. Procedure—Medical records at 4 veterinary schools were examined to identify dogs with chronic nonseptic pleural effusion that were treated by use of a pleuroperitoneal shunt between 1985 and 1999. Signalment, history, physical examination and laboratory findings, cause and type of pleural effusion, medical and surgical treatments, complications, and outcome were reviewed. Results—10 of 14 dogs had idiopathic chylothorax, and 4 had an identified disease. All but 1 dog with idiopathic chylothorax and 1 dog with chylothorax from a heart base tumor had unsuccessful thoracic duct ligation prior to pump placement. No intraoperative complications developed during shunt placement. Short-term complications developed in 7 of 13 dogs, necessitating shunt removal in 2 dogs and euthanasia in 1. Eight of 11 dogs with long-term follow- up developed complications; the overall mean survival time and the interval in which dogs remained free of clinical signs of pleural effusion were 27 months (range, 1 to 108 months) and 20 months (range, 0.5 to 108 months), respectively. Conclusions and Clinical Relevance—Pleuroperitoneal shunts can effectively palliate clinical signs associated with intractable pleural effusion in dogs. Numerous short- and long-term complications related to the shunt should be expected. Most complications can be successfully managed, but even when shunts are functional some treatments fail because of severe abdominal distension or massive pleural fluid production that overwhelms the functional capacity of the shunt. (J Am Vet Med Assoc 2001;219:1590–1597)

We report 3 patients with chylothorax who were successfully managed as outpatients using external pleuroperitoneal shunts. This external shunt has the advantage over subcutaneously placed shunts of pumping large volumes of fluid with each compression of the pumping chamber, of not causing the discomfort associated with pumping a subcutaneous chamber, of not becoming difficult to find in the subcutaneous space, and of being constructed of larger components which do not kink or become easily clogged with fibrinous debris.

Four years after successful implantation of a pleuroperitoneal shunt in a dog with persistent pleural effusion, signs of lethargy and dyspnea reappeared. Although the shunt was still functional, compartmentalization of the right pleural space eventually isolated a pocket of fluid, causing dyspnea. Symptomatic relief was achieved for at least 11 months by contralateral implantation of a second shunt.

Persistent effusions of chylous fluid may prolong the hospitalization period of many patients who have had a Fontan procedure. Herein we report the case histories of two patients in whom use of a pleuroperitoneal shunt to control the effusion shortened the hospital stay by several weeks.

Malignant pleural effusions are often debilitating conditions for the patient with advanced cancer. Traditionally, treatment has been repeated thoracentesis or tube thoracostomy with installation of sclerosing agents. This, however, required the patient to be hospitalized and subjected to the pain and inconveniences of the chest tubes. The drainage also had to be low enough for sclerotherapy to be effective. In 1982, the pleurovenous shunt was modified and the pleuroperitoneal shunt became a feasible alternative to sclerotherapy. We started using the Denver pleuroperitoneal shunt in July 1991. Seventeen shunts were inserted into 13 patients over a 1-year period ending June 30, 1992. All patients were relieved of their dyspnea. The average length of patency was 2.5 months, and fewer than 25% of the shunts clotted. Our favorable experience with the shunt has lead us to recommend the Denver pleuroperitoneal shunt for the treatment of recurrent malignant effusions.

A 57 year old woman developed a chylothorax as a result of having had filariasis as a child. This failed to respond to conservative measures but was successfully managed by means of a Denver pleuroperitoneal shunt.

Pleuroperitoneal shunts have been placed in five ventilator-dependent newborns with persistent chylothorax. The etiology of the chylothorax appeared to be secondary to superior vena caval obstruction in three patients and was idiopathic in the remaining two. Despite traditional therapies these infants were on a progressively deteriorating clinical course. Hakim-Cordis low-pressure ventricular-peritoneal shunt catheter systems were used in each infant. Ultrasonography was used to follow the regression of pleural effusions and to determine the need for shunt compression. Shunt patency was confirmed with radionuclide studies. Four of five infants had a complete resolution of their chylothorax and pulmonary insufficiency. Three of these infants were extubated within 28 days following the placement of the shunt. Nutritional and metabolic stability was rapidly achieved. The shunts were removed several weeks later without recurrence of the chylothorax. A fifth infant failed to improve after the placement of the pleuroperitoneal shunt and died of progressive pulmonary insufficiency. The placement of pleuroperitoneal shunts in infants with refractory chylothroax is safe, technically easy to perform, and is associated with few complications.

Delayed mediastinal shift toward the remaining lung is an unusual cause of postpneumonectomy dyspnea. We report a patient who developed severe dyspnea when a malignant effusion occurred in the pneumonectomy cavity and caused a contralateral mediastinal shift. Repeated thoracentesis was needed until insertion of a pleuroperitoneal shunt effected palliation.