Richard Goodgame, MD

Disclosures

June 24, 2002

Management Questions

What treatment modalities are effective in patients with hepatic hydrothorax?

  1. The first step in treatment should be to create a negative sodium balance by restricting sodium intake (< 90 mEq/day) and administering diuretics (spironolactone and furosemide). This strategy is simple and inexpensive. However, in many patients this goal may not be achieved without causing an increase in the serum creatinine level. Moreover, increasing the doses of diuretics may precipitate encephalopathy. Therefore, when diuretic therapy is not helpful, orthotopic liver transplantation should be considered. As in our patient, most patients with hepatic hydrothorax have end-stage liver disease. Thoracentesis or chest tube drainage is unsatisfactory for long-term management. Numerous complications may be associated with placement of a chest tube.[6,7] Other options, such as pleurodesis, repair of defects in the diaphragm, a peritoneovenous shunt, and methods aimed at decreasing portal hypertension, including a transjugular intrahepatic portosystemic shunt (TIPS),[8,9,10,11] should be considered as a bridge to liver transplantation.

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What are the relative merits of pleurodesis, surgical repair, and TIPS?

  1. Pleurodesis: Ablation of the space between the parietal and visceral pleura with a sclerosing agent injected by tube thoracostomy has been used to treat hepatic hydrothorax. Numerous complications of chest tube placement in these patients have made pleurodesis an unattractive option. Often, incomplete adhesions form between the parietal and visceral pleura, resulting in the formation of loculated pleural effusions. A retrospective study conducted by Milanez de Campos and colleagues[6] attempted to determine the indications, limitations, morbidity, and mortality of surgical thoracoscopy for management of hepatic hydrothorax. The study involved 10 men and 8 women, with a mean age of 58 years, who underwent 21 therapeutic thoracoscopies to achieve pleurodesis by application of talc. The procedure was effective in 10 of 21 cases (48%). Four recurrences (19%) were retreated, only 1 of which was successful. High morbidity (57%) and mortality (39%) were detected during the 3-month follow-up period. Diaphragmatic defects were localized and closed 5 times (24%). Hospital length of stay was approximately 15 days. The procedure has a low success rate, likely because fluid is formed too rapidly to allow the visceral and parietal pleural surfaces to approximate and adhere.Surgical repair: There are a few reports of successful primary repair of diaphragmatic defects.[6,7] Recently, videothoracoscopy was used to identify diaphragmatic defects in patients with recurrent hepatic hydrothorax, and biologic glue or sutures were used to close the defects.[3,11] However, pleurodesis was carried out by applying talc to the pleural cavity after the defects were closed, making it difficult to separate the individual effects of localized pleurodesis and the biologic glue or sutures. Nevertheless, this method is less invasive than thoracotomy and deserves further study.TIPS: In a study conducted by Gordon and colleagues,[8] a TIPS was placed in 24 consecutive cirrhotic patients with symptomatic refractory hepatic hydrothorax. Five (21%) of these patients were Child-Pugh class B, and 19 (79%) were class C. All patients had undergone multiple thoracenteses and were hypoalbumenic. Fourteen of the 24 patients with symptomatic hepatic hydrothorax had complete relief of symptoms and required no additional thoracentesis following shunt placement, and 5 additional patients required less-frequent thoracentesis. Of 12 patients with more than 2 months of follow-up, serum albumin level increased in 8 (mean, 1.2 g/dL), and Child-Pugh score improved in 7. However, hepatic encephalopathy developed in 9 patients and liver function deteriorated in 5 who died within 6 weeks of shunt placement. In another study, Chalasani and colleagues[11] found that TIPS controlled pleural effusions in more than 90% of 26 patients, resulting in less frequent therapeutic thoracenteses and lower doses of diuretic. However, 8 patients had subsequent hepatic encephalopathy and 6 had shunt dysfunction. The overall prognosis in this study was also poor; 50% of patients died or underwent orthotopic liver transplantation within 7 months. TIPS should be restricted to alleviating symptoms of refractory hepatic hydrothorax. Because a considerable percentage of patients developed liver failure and died within a short period of time after shunt placement, the procedure is ideally performed in a center where liver transplantation is possible.

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