Hepatic hydrothorax

INTRODUCTION

Patients with advanced cirrhosis and portal hypertension have abnormal extracellular fluid volume regulation that in most cases results in accumulation of fluid, typically in the abdominal cavity (ascites) or lower extremities (edema). In approximately 5 to 10 percent of cirrhotic patients, fluid accumulates in the pleural space [1-3]. Hepatic hydrothorax is defined as a pleural effusion, usually greater than 500 mL, in patients with cirrhosis and without primary cardiac, pulmonary, or pleural disease [1,4].

While patients with ascites can often tolerate up to 5 to 10 L of fluid with only mild symptoms, those with a pleural effusion can have severe symptoms (such as shortness of breath, cough, and hypoxemia) with as little as 1 to 2 L of fluid. This topic review will summarize issues related to hepatic hydrothorax while other complications of cirrhosis are presented separately.

PATHOGENESIS

The underlying mechanisms leading to fluid retention in patients with hepatic hydrothorax are similar to those leading to other forms of fluid accumulation in patients with cirrhosis. (See "Pathogenesis of ascites in patients with cirrhosis".)

Although the exact mechanisms involved in the development of hepatic hydrothorax are incompletely understood, it probably results from the passage of ascites from the peritoneal to the pleural cavity through small diaphragmatic defects. These are typically less than 1 cm (and may be microscopic) and are generally located in the tendinous portion of the diaphragm [5-10].

The negative intrathoracic pressure generated during inspiration favors the passage of fluid from the intra-abdominal to the pleural space. Thus, many patients have only mild or no clinically detectable ascites [2,11-13]. Hepatic hydrothorax develops when the absorptive capacity of the pleural space is exceeded. This theory is supported by studies using 99mTc-human albumin or 99mTc-sulphur colloid, which demonstrate unidirectional passage of these markers from the abdominal to the pleural cavity [14-19].

            

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Literature review current through: Mar 2014. | This topic last updated: Aug 22, 2012.
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References
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  1. Cardenas A, Kelleher T, Chopra S. Review article: hepatic hydrothorax. Aliment Pharmacol Ther 2004; 20:271.
  2. Strauss RM, Boyer TD. Hepatic hydrothorax. Semin Liver Dis 1997; 17:227.
  3. Xiol X, Guardiola J. Hepatic hydrothorax. Curr Opin Pulm Med 1998; 4:239.
  4. Kinasewitz GT, Keddissi JI. Hepatic hydrothorax. Curr Opin Pulm Med 2003; 9:261.
  5. Huang PM, Chang YL, Yang CY, Lee YC. The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg 2005; 130:141.
  6. Lieberman FL, Hidemura R, Peters RL, Reynolds TB. Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med 1966; 64:341.
  7. EMERSON PA, DAVIES JH. Hydrothorax complicating ascites. Lancet 1955; 268:487.
  8. Mouroux J, Perrin C, Venissac N, et al. Management of pleural effusion of cirrhotic origin. Chest 1996; 109:1093.
  9. Chen A, Ho YS, Tu YC, et al. Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol 1988; 10:663.
  10. Zenda T, Miyamoto S, Murata S, Mabuchi H. Detection of diaphragmatic defect as the cause of severe hepatic hydrothorax with magnetic resonance imaging. Am J Gastroenterol 1998; 93:2288.
  11. Cárdenas A, Arroyo V. Mechanisms of water and sodium retention in cirrhosis and the pathogenesis of ascites. Best Pract Res Clin Endocrinol Metab 2003; 17:607.
  12. Lazaridis KN, Frank JW, Krowka MJ, Kamath PS. Hepatic hydrothorax: pathogenesis, diagnosis, and management. Am J Med 1999; 107:262.
  13. Serrat J, Roza JJ, Planella T. Hepatic hydrothorax in the absence of ascites: respiratory failure in a cirrhotic patient. Anesth Analg 2004; 99:1803.
  14. Rubinstein D, McInnes IE, Dudley FJ. Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management. Gastroenterology 1985; 88:188.
  15. Benet A, Vidal F, Toda R, et al. Diagnosis of hepatic hydrothorax in the absence of ascites by intraperitoneal injection of 99m-Tc-Fluor colloid. Postgrad Med J 1992; 68:153.
  16. Serena A, Aliaga L, Richter JA, et al. Scintigraphic demonstration of a diaphragmatic defect as the cause of massive hydrothorax in cirrhosis. Eur J Nucl Med 1985; 11:46.
  17. Kakizaki S, Katakai K, Yoshinaga T, et al. Hepatic hydrothorax in the absence of ascites. Liver 1998; 18:216.
  18. Menteş BB, Kayhan B, Görgül A, Unal S. Hepatic hydrothorax in the absence of ascites: report of two cases and review of the mechanism. Dig Dis Sci 1997; 42:781.
  19. Giacobbe A, Facciorusso D, Tonti P, et al. Hydrothorax complicating cirrhosis in the absence of ascites. J Clin Gastroenterol 1993; 17:271.
  20. Castellote J, Gornals J, Lopez C, Xiol X. Acute tension hydrothorax: a life-threatening complication of cirrhosis. J Clin Gastroenterol 2002; 34:588.
  21. Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology 1996; 23:719.
  22. Chen CH, Shih CM, Chou JW, et al. Outcome predictors of cirrhotic patients with spontaneous bacterial empyema. Liver Int 2011; 31:417.
  23. Sese E, Xiol X, Castellote J, et al. Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema. J Clin Gastroenterol 2003; 36:75.
  24. Garcia N Jr, Mihas AA. Hepatic hydrothorax: pathophysiology, diagnosis, and management. J Clin Gastroenterol 2004; 38:52.
  25. Falchuk KR, Jacoby I, Colucci WS, Rybak ME. Tetracycline-induced pleural symphysis for recurrent hydrothorax complicating cirrhosis. A new approach to treatment. Gastroenterology 1977; 72:319.
  26. Alagiakrishnan K, Patel PJ. Left-sided hepatic hydrothorax with ascites. Int J Clin Pract 1999; 53:225.
  27. Xiol X, Castellote J, Cortes-Beut R, et al. Usefulness and complications of thoracentesis in cirrhotic patients. Am J Med 2001; 111:67.
  28. Xiol X, Tremosa G, Castellote J, et al. Liver transplantation in patients with hepatic hydrothorax. Transpl Int 2005; 18:672.
  29. Borchardt J, Smirnov A, Metchnik L, Malnick S. Treating hepatic hydrothorax. BMJ 2003; 326:751.
  30. Runyon BA, Greenblatt M, Ming RH. Hepatic hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol 1986; 81:566.
  31. Liu LU, Haddadin HA, Bodian CA, et al. Outcome analysis of cirrhotic patients undergoing chest tube placement. Chest 2004; 126:142.
  32. Orman ES, Lok AS. Outcomes of patients with chest tube insertion for hepatic hydrothorax. Hepatol Int 2009; 3:582.
  33. Sherman SC. Reexpansion pulmonary edema: a case report and review of the current literature. J Emerg Med 2003; 24:23.
  34. Collins TR, Sahn SA. Thoracocentesis. Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817.
  35. McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991; 31:164.
  36. Gordon FD, Anastopoulos HT, Crenshaw W, et al. The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt. Hepatology 1997; 25:1366.
  37. Strauss RM, Martin LG, Kaufman SL, Boyer TD. Transjugular intrahepatic portal systemic shunt for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol 1994; 89:1520.
  38. Siegerstetter V, Deibert P, Ochs A, et al. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001; 13:529.
  39. Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002; 13:385.
  40. Conklin LD, Estrera AL, Weiner MA, et al. Transjugular intrahepatic portosystemic shunt for recurrent hepatic hydrothorax. Ann Thorac Surg 2000; 69:609.
  41. Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut 2010; 59:988.
  42. Dhanasekaran R, West JK, Gonzales PC, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010; 105:635.
  43. Wilputte JY, Goffette P, Zech F, et al. The outcome after transjugular intrahepatic portosystemic shunt (TIPS) for hepatic hydrothorax is closely related to liver dysfunction: a long-term study in 28 patients. Acta Gastroenterol Belg 2007; 70:6.
  44. Milanez de Campos JR, Filho LO, de Campos Werebe E, et al. Thoracoscopy and talc poudrage in the management of hepatic hydrothorax. Chest 2000; 118:13.
  45. Ferrante D, Arguedas MR, Cerfolio RJ, et al. Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax. Am J Gastroenterol 2002; 97:3172.
  46. Northup PG, Harmon RC, Pruett TL, et al. Mechanical pleurodesis aided by peritoneal drainage: procedure for hepatic hydrothorax. Ann Thorac Surg 2009; 87:245.
  47. Huang PM, Kuo SW, Lee JM. Thoracoscopic diaphragmatic repair for refractory hepatic hydrothorax: application of pleural flap and mesh onlay reinforcement. Thorac Cardiovasc Surg 2006; 54:47.
  48. Barreales M, Sáenz-López S, Igarzabal A, et al. Refractory hepatic hydrothorax: successful treatment with octreotide. Rev Esp Enferm Dig 2005; 97:830.
  49. Ibrisim D, Cakaloglu Y, Akyuz F, et al. Treatment of hepatic hydrothorax with terlipressin in a cirrhotic patient. Scand J Gastroenterol 2006; 41:862.