Hepatic Hydrothorax

Epidemiology

Pleural effusion usually occurs in presence of ascites (although ascites may detectable only by U/S)
Incidence of effusion in presence of ascites: 6% of cases

Etiology

Percutaneous Transhepatic Procedures

Increased hepatic hydrothorax may occur in rare cases after transhepatic procedures: probably occurs due to inadvertent iatrogenic defect created in diaphragm -> leakage of ascitic fluid across diaphragm
Implicated Procedures
- Post-Percutaneous Transhepatic Coronary Vein Occlusion: used to control bleeding esophageal varices/transdiaphragmatic, transhepatic injection of gelfoam into coronary vein (material lodges in esophageal veins)
- Percutanous Transhepatic Cholangiogram: in addition to inducing hepatic hydrothorax, this procedure can also inadvertently result in cholethorax (see Pleural Effusion-Cholethorax)

Physiology

Characteristics of Pleural Fluid in the Setting of Uncomplicated Hepatic Hydrothorax (see Hepatic Hydrothorax)

Pleural Fluid in the Setting of Portal Hypertension is Transudative (in 94% of Cases) (Chest, 2011) [MEDLINE]
- Low Protein Content (<2.5 g/dL) (Aliment Pharmacol Ther, 2004) [MEDLINE]
  - Similar to Ascitic Fluid
- Serum-to-Pleural Albumin Gradient >1.1 (Medicine-Baltimore, 2014) [MEDLINE]
However, Because the Mechanisms of Fluid Absorption from the Pleural Space are Different from that from the Peritoneal Cavity, the Total Protein and Albumin May Be Slightly Higher in Pleural Fluid, as Compared to the Ascitic Fluid (J Clin Gastroenterol, 1988) [MEDLINE] (Semin Liver Dis, 1997) [MEDLINE] (Curr Opin Pulm Med, 1998) [MEDLINE] (Aliment Pharmacol Ther, 2004) [MEDLINE]
Transudation of ascitic fluid from peritoneal space across diaphragmatic defects into pleural space
India ink injection into ascitic fluid -> appears in pleural fluid
IV injection of radiolabelled albumin: appears in ascites first, only subsequently in the pleural fluid (injection of air in peritoneal space had same results, with PTX observed, due to observable defects in diaphragm at thoracoscopy)
Pleural pressure in cirrhosis-associated effusions are higher than in other transudates (due to fluid flowing down pressure gradient into pleural space from ascites)
Decreased plasma oncotic pressure only a secondary etiologic factor in cirrhotic effusions

Diagnosis

Pleural Fluid (see Thoracentesis)

Transudate (Usually)
- In 94% of Cases (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
  - Only a Single Patient Had a Protein Discordant Exudate Despite 83% of Patients Receiving Diuretics (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Pleural Fluid Total Protein
- Median Pleural Fluid Protein: 1.5 g/dL (Range: 0.58-2.34 g/dL) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
  - 48% of Cases Had Pleural Fluid Protein <1.5 g/dL
Pleural Fluid Total Protein/Serum Total Protein Ratio
- Median Pleural Fluid Total Protein/Serum Total Protein Ratio was 0.25 (Range: 0.10-0.43) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Serum-to-Pleural Albumin Gradient (SPAG)
- Serum-to-Pleural Albumin Gradient >1.1 (Medicine-Baltimore, 2014) [MEDLINE]
Pleural Fluid Lactate Dehydrogenase (LDH)
- Median Pleural Fluid Lactate Dehydrogenase (LDH) was 65 IU/L (Range: 36-138 IU/L) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Pleural Fluid Lactate Dehydrogenase (LDH)/Serum Lactate Dehydrogenase (LDH) Ratio
- Median Pleural Fluid LDH/Upper Limit of Serum Lactate Dehydrogenase (LDH) Ratio was 0.27 (Range: 0.14-0.57) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Pleural Fluid pH
- Median Pleural Fluid pH was 7.49 (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Pleural Fluid Neutrophil Count
- In Uncomplicated Hepatic Hydrothorax, the Neutrophil Count is Low (<250 Cells/mm3) (Hepatology, 1996) [MEDLINE] (Aliment Pharmacol Ther, 2004) [MEDLINE]
  - However, in the Setting of Spontaneous Bacterial Pleuritis (Spontaneous Bacterial Empyema) the Neutrophil Count is Increased
- Median Absolute Neutrophil Count (ANC) was 26 Cells/μL (1-230 Cells/μL ) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Pleural Fluid Cultures
- 76% of Cases Had Negative Pleural Fluid Cultures (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
Differentiation of Uncomplicated Hepatic Hydrothorax from Spontaneous Bacterial Pleuritis (Spontaneous Bacterial Empyema) (see Spontaneous Bacterial Pleuritis)
- When Comparing Uncomplicated Solitary Hepatic Hydrothorax with Spontaneous Bacterial Pleuritis (Spontaneous Bacterial Empyema), There was No Statistically Significant Difference in the Pleural Fluid Total Protein (P = 0.99), Pleural Fluid LDH (P = 0.33), and Serum Albumin (P = 0.47) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
- As Compared to Uncomplicated Solitary Hepatic Hydrothorax, Absolute Neutrophil Count was Higher in Patients with Spontaneous Bacterial Pleuritis (Spontaneous Bacterial Empyema) (P < 0.0001) (Data from a Retrospective Series, n = 41) (Chest, 2011) [MEDLINE]
- Appearance: usually straw-colored but may be bloody in rare cases
- pH:
- LDH ratio:
- Total protein ratio: pleural fluid protein is usually higher than ascitic fluid protein (but is still usually <3 g/dL)
- Cell count/ diff ( may be PMN or lymphocyte-predominant): PMN count >500/mm3 strongly suggests spontaneous bacterial empyema from associated SBP
- Gram stain/ culture:
- Cholesterol:
- Amylase: normal

Chest X-Ray (CXR)/Chest Computed Tomography (CT) (see Chest X-Ray and Chest Computed Tomography)

Laterality
- Approximately 67% of Cases are Bilateral (33% of Cases are Solitary) (Chest, 2011) [MEDLINE]: n = 41
- Most (Approximately 67%) Cases are Right-Sided

Thoracic Ultrasound (see Thoracic Ultrasound)

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Clinical Manifestations

General Comments

Symptoms/Signs of Cirrhosis Usually Dominate the Clinical Picture

Cardiovascular Manifestations

Diastolic Dysfunction (see xxxx)

Epidemiology
- Diastolic Dysfunction is Present in 52% of Cases (Chest, 2011) [MEDLINE]

Positive Bubble Study (Consistent with Intrapulmonary Shunt)

Epidemiology
- Intrapulmonary Shunt (by Echocardiography with Agitated Saline Bubble Study) is Present in 78% of Cases (Chest, 2011) [MEDLINE]

Gastrointestinal/Hepatic Manifestations

Ascites (see Ascites)

Epidemiology
- Coexistent Ascites is Present in 97% of Cases (Chest, 2011) [MEDLINE]

Pulmonary Manifestations

Hypoxemia (see Hypoxemia)

Epidemiology
- Variable

Symptoms/Signs Related to Pleural Effusion (see Pleural Effusion-General)

Physiology
- XXXXXXXX
Clinical
- Dyspnea (see Dyspnea)
- Decreased Breath Sounds Over Area
- Dullness to Percussion Over Area

Treatment

Thoracentesis (see Thoracentesis)

Indications for Diagnostic Thoracentesis in the Setting of Hepatic Hydrothorax

Determination of Fluid Characteristics
Exclusion of Infection (Empyema)

Indications for Therapeutic Thoracentesis in Setting of Hepatic Hydrothorax

Large Hepatic Hydrothorax with Respiratory Compromise
- Reasons to Avoid Repeated Thoracenteses in the Setting of Hepatic Hydrothorax
  - Hepatic Hydrothorax Usually Rapidly Reaccumulates After Fluid Removal
  - Repeated Thoracenteses Carry a Risk of Pneumothorax and Hemothorax
  - Protein Depletion Occurs with Repeated Thoracenteses: due to high protein content of hepatic hydrothorax pleural fluid

Pleurodesis

May be required in some cases with persistent symptomatic effusion despite aggressive therapy of ascites
- Monitor closely after chest tube placement, since amount of ascites can rapidly decrease (causing precipitous hypovolemia): inject Doxycycline as soon as lung is rexpanded (do not need to wait until drainage decreases)
- May be done with thoracoscopic talc insufflation (or thoracoscopic placement of biological glue over diaphragmatic defect + talc insufflation)

Chest Tube Placement (see Chest Tube)

Chest Tube Placement is Generally Contraindicated
- Due to large volume/electrolyte/protein losses that occur via chest tubes in the setting of hepatic Hydrothorax

Treat Ascites (see Ascites)

Since effusion is simply an extension of the ascites)
- Low sodium diet/ Lasix (start at 40 mg per day) + Aldactone (start at 100 mg per day)/ etc.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) (see Transjugular Intrahepatic Portosystemic Shunt)

May Be Required
Contraindications
- Hepatic Encephalopathy (see Hepatic Encephalopathy): TIPS may worsen hepatic encephalopathy
- Congestive Heart Failure (CHF) (see Congestive Heart Failure): TIPS increases right-sided heart return and may precipitate CHF
- Hepatopulmonary Syndrome (see Hepatopulmonary Syndrome): TIPS may worsen hepatopulmonary syndrome
- Portal Vein Thrombosis (see Portal Vein Thrombosis)
Complications
- Worsened Hepatic Encephalopathy (see Hepatic Encephalopathy)
- Congestive Heart Failure (CHF) (see Congestive Heart Failure)

Peritoneojugular Shunt

May control ascites but will not control effusion (since the fluid will preferentially move to the lower pressure pleural space over the central veins)

Thoracotomy

With repair of diaphragm and pleural abrasion (to effect a pleurodesis)
- Not usually necessary
- Post-op chest tube drainage may be excessive

Liver Transplantation (see Liver Transplant)

Definitive Treatment
- Refractory Hepatic Hydrothorax with Hypoxemia Represents a MELD Exception

References

General

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Physiology

Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol. 1988;10(6):663 [MEDLINE]
Hepatic hydrothorax: cause and management. Arch Intern Med 1991; 151:2383–2388 [MEDLINE]
Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719 [MEDLINE]
Hepatic hydrothorax. Semin Liver Dis. 1997;17(3):227 [MEDLINE]
Hepatic hydrothorax. Curr Opin Pulm Med. 1998;4(4):239 [MEDLINE]
Hepatic hydrothorax. Curr Opin Pulm Med. 2003 Jul;9(4):261-5 [MEDLINE]
Review article: hepatic hydrothorax. Aliment Pharmacol Ther. 2004;20(3):271 [MEDLINE]
Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature. Medicine (Baltimore). 2014;93(3):135 [MEDLINE]

Diagnosis

Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719 [MEDLINE]
Spontaneous bacterial empyema. Curr Opin Pulm Med 2012, 18:355–358 [MEDLINE]
Early thoracentesis correlated with survival benefit in patients with spontaneous bacterial empyema. Dig Liver Dis. 2022;54(8):1015 [MEDLINE]

Clinical

Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719 [MEDLINE]
Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest. 2011 Aug;140(2):448-53 [MEDLINE]
Spontaneous bacterial empyema. Curr Opin Pulm Med 2012, 18:355–358 [MEDLINE]

Treatment

Hepatic hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol 1986; 81:566–577 [MEDLINE]
Outcomes of patients with chest tube insertion for hepatic hydrothorax. Hepatol Int 2009; 3:582 – 586 [MEDLINE]