The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt

Abstract

Management of hepatic hydrothorax is difficult and oftenHepatic hydrothorax is a rare complication of portal results in iatrogenic complications. Repeated thoracentesis, hypertension. Conservative therapy may be successful chest tube thoracostomy, pleurodesis, and peritoneovenous but refractory hepatic hydrothorax is not uncommon.shunt have been used with varying degrees of success. HowManagement of refractory hydrothorax is usually inefever, there have been many reports of failure and complicafective and can result in a worsened clinical status.tion with each of these procedures. [7][8][9] The only definitive Transjugular intrahepatic portosystemic shunts (TIPS) treatment is liver transplantation. lower portal pressure and have been used in the treatTransjugular intrahepatic portosystemic shunt (TIPS) rement of refractory ascites. The aim of this study was duces portal pressure and has been reported to improve the to determine the efficacy of TIPS in the treatment of control of refractory ascites in cirrhotic patients. [10][11][12] The goal symptomatic refractory hepatic hydrothorax. A TIPS was placed in 24 consecutive cirrhotic patients with of this study was to determine if the reduction in portal pressymptomatic refractory hepatic hydrothorax. Five pa-sure by TIPS improved the control of symptomatic hepatic tients (20.8%) were Child's/Pugh class B and 19 (79.2%) hydrothorax. Additionally, we evaluated the effect of TIPS in were class C. All had undergone multiple thoracenteses these patients on the Child's-Pugh class and the need for and were hypoalbuminemic. Mean follow-up was 7.2 orthotopic liver transplantation. The Child's-Pugh score improved in 7 (58.3%) of these 12candidates. All acceptable alcoholic liver transplantation candidates patients and two patients improved from class C to class were considered to have been abstinent for at least 6 months. A. These two patients no longer require liver transAll patients had clinical, laboratory, and radiologic evidence of plantation. This study shows that TIPS can be effective liver disease and portal hypertension. All patients had persistent in the management of symptomatic, refractory hepatic right-sided hydrothorax despite sodium and fluid restriction and the hydrothorax. Clinical and laboratory improvement may use of the maximum tolerable doses of diuretics. Diuretic use was be seen and liver transplantation may become unneces-limited by progressive azotemia, electrolyte imbalance, and hypotension. Infectious causes of hydrothorax were ruled out by fluid analysary. (HEPATOLOGY 1997;25:1366-1369.) sis and culture. Only patients with pulmonary symptoms, such as dyspnea and orthopnea, were enrolled in the study. All patients had Hepatic hydrothorax is the accumulation of ascitic fluid undergone multiple thoracenteses before transfer to our hospital. in the pleural space. It occurs in 0.4% to 12.2% of cirrhotic Five patients had chest tubes in place draining at least 4 L/d. Atpatients.1-3 The precise pathogenetic mechanisms remain un-tempts to remove or clamp ...

Outcomes of patients with chest tube insertion for hepatic hydrothorax

“…Jeffries et al [9] reported one response lasting greater than 2 years. In Table 3 Reports of chest tubes placed for hepatic hydrothorax N Successful removal TIPS Complications Mortality addition, short-term mortality in the series in which therapeutic TIPS was performed is \30% [23,24]. This study is limited by its design.…”

“…TIPS has been shown to be effective in preventing reaccumulation of pleural effusion in patients who are refractory to diuretics and in decreasing mortality. Clinical and radiographic improvement in hydrothorax has been documented in up to 68% of patients undergoing TIPS [8,[22][23][24]. Jeffries et al [9] reported one response lasting greater than 2 years.…”

Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax

“…10,22 Currently, information on the use of TIPS for refractory hepatic hydrothorax is limited to several small series. 14,15 In the earliest series, a clinical benefit was demonstrated in all 5 treated subjects.…”

“…[10][11][12][13] In addition, several reports of the beneficial effect of TIPS in treatment of patients with refractory hepatic hydrothorax have recently been published. 14,15 In one series, a beneficial response was observed in 79% of treated patients, but substantial early and late mortality was also encountered. 15 The aim of this longitudinal study was to report on the long-term efficacy and safety of TIPS for refractory hepatic hydrothorax in 12 consecutive subjects treated at a single center.…”

Early Diagnosis of Hepatic Hydrothorax with Associated Occlusion of a Peritoneo-Venous Shunt with Tc-99m MAA

“…Though not as effective as replacing shunt, urokinase has been reported to be able to restore shunt patency [8]. Other treatment options for recurrent hydrothorax besides thoracentesis are transjugular intrahepatic portosystemic shunt (TIPS), pleurodesis, and thoracoscopic surgery to repair the diaphragmatic defect [9,10]. In addition, portal venous thrombosis was also noted (b, solid white arrow)…”