COMMENTARY

Pulmonary Complications of Cirrhosis

Rowen K. Zetterman, MD

Disclosures

January 16, 2013

In This Article

Hepatic Hydrothorax (Pleural Effusion)

Pleural effusions complicate end-stage liver disease in 5% of patients.[5,6] Effusions (defined as 500 mL or more of fluid within the pleural space) are typically right-sided.[7,8] No cardiopulmonary cause for the pleural effusion is found. Coexisting ascites can be present with hepatic hydrothorax, although right-sided pleural effusion can develop in patients with cirrhosis, even in the absence of significant ascites, because the superior portion of the hepatic surface is in direct contact with the right diaphragm. Pleural effusions occur on the left side in 10%-15% of patients with liver disease,[9] and bilateral pleural effusions develop in approximately 2% of patients.[8] Patients with effusion can present with shortness of breath or a nonproductive cough. Typical findings include dullness to percussion and diminished breath sounds at the lung bases.

The mechanism of hydrothorax formation is thought to originate with diaphragmatic defects that allow the transfer of ascites developing from the hepatic surface to pass directly into the pleural space.[10] The negative intrathoracic pressure of the thorax draws ascitic fluid into the pleural space. Fluid analysis will show similar characteristics to abdominal ascites. Although it is important to perform a thoracentesis to exclude other causes of pleural effusion in the patient with advanced liver disease, development of a pneumothorax requiring a chest tube can be life-threatening if uncontrolled fluid removal occurs during lung expansion. Spontaneous bacterial infection of the pleural effusion occurs in 10%-15% of patients.[11] When analyzed, the fluid is similar to that of spontaneous bacterial peritonitis, with positive bacterial cultures and a polymorphonuclear leukocyte count > 250 cells/mm3. Low effusion protein levels and a high Child-Pugh score are associated with an increased risk for pleural infection.[12] Chest tube drainage of infected patients is not required and should not be performed because of the risk for volume loss and renal failure.

The patient with cirrhosis and an isolated pleural effusion raises the question of how much evaluation is required. Some experts recommend that routine CT scans of the chest should be obtained to ensure the absence of an isolated lung or mediastinal lesion. This recommendation is most helpful in the patient with liver disease and isolated pleural effusion.

The treatment of hepatic hydrothorax is similar to the treatment of ascites. A low-sodium diet and diuresis should be initiated. In patients with massive ascites, large-volume paracentesis may be helpful. Repetitive thoracentesis can be performed, but this always carries the risk for pneumothorax. In some patients, pleurodesis can be attempted through a previously placed chest tube or with video-assisted thoracoscopy (VATS) using tetracycline or talc. However, this technique may be of limited effectiveness in the presence of rapid pleural fluid accumulation.[13] Surgical closure of diaphragmatic defects has been proposed, but the increased morbidity and mortality of these procedures in patients with cirrhosis requires careful consideration before being undertaken. Transvenous intrahepatic portosystemic shunts (TIPS) can be helpful in the patient with persistent hepatic hydrothorax who is unresponsive to diuretics; TIPS can serve as a bridge to liver transplantation. The patient with persistent hepatic hydrothorax should be considered for liver transplantation, just as patients with intractable ascites would be.

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