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leural effusions occur in 5 to 10 of patients w ith
cirrhosis of the liver (1 ). In these patients, ascites is
usually evident but a pleural effusion m ay develop in a
cirrh otic p atien t in the ab sen ce o fd etectab le ascites (2 ).
The e ffu sio ns a re u su ally rig ht-s id ed , b ut ma y b e b ila t
eral or left-sided. The precise mechanism of fluid ac
cum ulation is not clear.
We describe a case w here a periton eopleural com
m unication has been dem onstrated by radioisotopic
meth od . T he p ossib le mec han ism s in vo lv ed in th e fo r
mation of pleural effusion in liver cirrhosis are dis
cussed.
CAS E RE POR T
A 5 4-y r-o ld w hite fem ale w as admitte d for p ro gressiv e
d ys pn ea o f re ce nt o nse t a nd sig ns o f u pp er re sp ira to ry in fe c
tion. H er past history included a background of considerable
a lc oh ol in ge stio n, a nd a d ia gn os is o f L ae nn ec c irrh osis h ad
b ee n p re vio us ly made by l iv er b io ps y.
On a dm iss io n, th e p atie nt lo ok ed c hro nic ally ill. S he was
afe brile w ith reg ular pu lse rate o f 1 20 /mm an d a b lo od p res
su re o f 1 80 /1 00 . T here w ere c lin ical sign s o f cirrh osis and
fra nk ja un dic e. C he st e xamin atio n re ve ale d e vid en ce fo r a
m as siv e rig ht p le ura l e ffu sio n. O th er p hy sic al fin din gs in
Rece ivedDec . 13 , 1985; revis ion accepted Apr . 23 , 1986.
For r ep rin ts c on ta ct: J ea n Ve rr ea ul t, MD, Dept. o f Nucle ar
Medicine,Centre Hospital ier Universitaire,Sherbrooke, Qué bec,
Canada, J 1H-5N4.
c lu de d e nla rg ed liv er a nd e vid en ce o f fre e liq uid in th e p en
tonea l cavity.
The ches t x -r ay demonst ra ted a l ar ge r igh t p leu ra l e ff us ion .
Othe r l abo ra to ry t es ts we re compa ti bl e wi th l ive r c i rr hosi s and
t ox ic e ff ec ts o fa lcoho l. Tho racen te si s r eveal ed a f lu id t ha t had
t he char ac te ri st ic s o fa t ransuda te a s d id a s amp le o f pent oneal
f lu id . Fo rt y- ei gh t hour s a ft er t he t ho racen te si s o f 1 ,800cc , t he
r igh t p leu ra l space was compl et el y r ef il led (Fi g. 1 ).
T o p ro ve th at rig ht p le ura l e ffu sio n was re la te d to a sc ite s,
5 mCi of technetium -99m (@mT c) s ulfur colloid w as injected
with a se ptic te chni qu e i nt o t he ri gh t l owe r a bdom in al c av ity .
A se ria l im ag in g stu dy was d on e in a nte rio r v iew a t in te rv als
of 5 mm for 30 mm and at 2 and 24 hr postinjection (F ig. 2).
Image s we re obta in ed on a l ar ge f ie ld -o f-v iew c ame ra w ith a n
a ll-p urp ose , p ara lle l c ollim ato r. A t 2 h r th e ra dio co llo id a p
peared in the right hemithorax and at 24 hr activity w as
fu rth er in cre as ed . It c on firm ed th e p re se nc e o f a p erito ne o
p le ur al c ommunic ati on . Th e p atie nt r es pond ed we ll to medi
ca l the rapy and pleura l e ffus ion reso lvedcomple te ly in 10
days.
DISCUSSION
The a ssoc ia ti on o fhyd ro thor ax with hepat ic c ir rhos is
h as b een reco gn iz ed fo r man y y ears b ut th ere h as b een
much spe cu la ti on a s to its o rig in .
In 1947, H ig gins and his colleagues suggested that
p le ura l e ffu sio n was r ela te d to th e fa ll in th e c on ce nt ra
tio n of plasm a pro teins (3). In 1958, M orrow , K antor
and A rm en suggested that the fluid m ight com e from
the blood stream as a result of hypoalbum inem ia or
17 6 Verreault epageBissontal
The J ou rn al o f Nuc le ar M ed ic in e
Case Reports
Ascites and Right
Pleural Effusion: Demonstration
of a Pentoneo P leural Communica tion
Jean V erreault, Serge L epage, G uy B isso n, and A nd re Plante
D ep artm en ts o fN uc ea r M ed icin e a nd In terna l M ed icin e C entre H osp ita lier U niversita ire
Unive r si ty o fShe rbrooke She rbrook e Québe c Canada
A 54-yr -o ldfemale wi th known l ive rci rrhos is presen ted wi th a r igh t t r ansuda tive pleura l
e ffus ion and asc ites . To f ind the source of p leura l f luid, [@“TcJsuIfurolloidwas injected
int ra pe ri tone al lyand a ser ia l imag ings tudy r evea led i ts pas sage to the r igh tp l eu ra l spac e on
2-hr and 24-hr images. M echanisms proposed in the formation of pleural effusion in liver
c irrh osis a re (a ) lymp ha tic d ra in ag e a nd (b ) d ia ph ra gm atic d efe ct. R ad io iso to pe m ig ra tio n
speed m ay be a clue for differentiating these tw o m echanism s, being m ore rapid in the
presence of a d iaphragmatic de fect .
J NucIMed 27:17 6—17 9986
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bum in from the peritoneal to pleural spaces in a patient
with rig ht h ep atic h yd ro th ora x. The a uto ps y s howed no
g ross def ec t i n the r ight d ia ph ragm.
S in ce lymphatic s a re mo re a bund an t in th e rig ht th an
 £ in the left diaphragm 10 , this m echanism m ight ex
p la in tha t hepat ic hyd ro thor ax a re more f re quen tl y r ight
sided. In addition to this, Leak (1 1) used electron
m icroscopy to show that pores of 4—1 @ zn diam eter
exi st between meso thel ia l c el ls a nd d iaph ragma ti c lym
phatics. They provide a system of open channels
th ro ugh whic h flu id s a nd c ells may ra pid ly b e remove d
from th e sero us cav ities . What remain s u nclear is h ow
and why the fluid leaves the lym phatic system and
en ters th e pleu ral sp ace instead o fbe in g exp elled to ward
the larg er collecting vessels. It m ay result from lym
pha ti c sys tem ove rload (12 ).
There is strong evidence to support the tw o m ech
anism s. W e think that each of these can explain the
form atio n of hyd rothorax from ascites depending on
the c ase. Lymphat ic d ra inage i sp r obably the f ir st mech
an ism to o ccu r in rea ctio n to th e p resen ce o f asc ites. It
can be th e w ay by w hich hydrothorax w ill be fo rm ed if
there is an overload of the lym phatic system . If it is
insufficient, the abdom inal pressure increases and m ay
c au se s ub se qu en t ru pt ure o fth e d ia ph ra gm . One obje c
tion to this assum ption m ay be that pleu ral effusion s
c an be p re sent i n l iver c ir rhos is w ithou t a sc it es . I n the se
cases, th e altern ativ e ex plan atio n is th at th ere is co n
genital diaphragm atic w eakness caused by an insuffi
dent deposition of muscle and tendon bundles. W e
p ropo se d th at th e c lu e to d is tin gu is h b etwee n th es e two
mechanisms may be the use of radioisotope injected
i nt ra pe ri tone al ly a s we d id .
Indeed, w hen w e assum e that the radiocolloid in
jected intrapentoneally is m ixed w ith ascites fluid and
consider that its m igration from peritoneal to pleural
space w as right sided as w as the pleural effusion, w e
c an p re sume th at th ere i s a re la tio ns hip b etwee n a sc ite s
fluid and pleural effusion. Furtherm ore, our proposal
extends to the tim e required to show accum ulation of
the agent in the pleural space. If it happens within a
few minutes, as it was reported by Faiyaz and Goyal
13 , a diaphragmatic defect isprobably present partic
u la rl y when the a ccumu la ti on i s a s int en se a s per it onea l
activity. If it takes a longer period of time as was seen
fo r o ur p atie nt, th e p erito ne op le ura l c ommunic atio n
may b e a ttrib ute d to d ia ph ra gmatic l ympha tic s p artic
u la rly w hen th at accumu latio n is less in ten se th an p er
itoneal activity.
Such a study can b e done either by the use of[@mTc1
sulfu r c oll oid o r [9 9mTc]ma cro aW@ted a lb um in . The
ra dio ph arm ac eu tic al c an b e in je cte d in tra pe rito ne ally
at the end of th e usual diagno stic or therap eutic p eri
toneal puncture. It can show the source of pleural
effusions in liver cirrhosis and also in patients w ith
peritoneal dialysis (14). W e postulate that the speed at
I
hypertension in the azygous and hem iazygous system s
or be second ary to ascites either by direct p assage of
fluid through a diaphragm atic defect or by its transport
t hr ough the d iaph ragma ti c lymphat ic s ( 4) .
H ypoproteinem ia as a sole cause can be elim inated
for there are many patients, cirrhotic or not, w ho have
lo w serum pro tein lev els b ut n ev er d eve lop h yd ro th orax
5 . I fazygous hypertension ispresent due to col laterals
b etw een th is sy stem an d th e p ortal sy stem , tran su datio n
of fluid into the chest m ight appear. However, this
can no t ex plain h yd ro th orax o ccu rrin g in Meig s sy n
drom e w here there is no portal hypertension. The m ost
probable explanation is that hydrothorax is derived
d irectly from the perito neal flu id eith er th ro ug h a d efect
in the diaphragm or through the lymphatic channels
th at p en etra te it.
A t l ea st t hr ee s tudi es ( 6—8)have p rovided evidenc e
that hydrothorax com plicating cirrhosis is generated
from a sc ite s t hro ugh a d ia ph ra gmatic d efe ct a cqui re d
a s a re su lt o f in cre as ed in tra -a bdom in al p re ss ure . This
has been dem onstrated eith er by rap id passage of d ye
from th e ascites in to th e p leu ral effu sio n, in du ctio n o f
a hyd ropn eumothora x by th e in tra -a bdom in al in sti lla
tion of oxygen, thoracoscopy, or by necropsy findings.
The other m echanism proposed in literature is that
p erit on ea l flu id p as se s to th e p le ura l s pa ce th ro ugh th e
diaphragm atic lym phatics. Johnston and Rodolfo (9)
support it by the dem onstration of unidirectional trans
port of carbon particles and radioiodinated serum al
FIGURE 1
Chest x-ray showing large r igh tp leura le f fus ion
Volume27 •umber11 •ovember1986
1707
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8/19/2019 J Nucl Med 1986 Verreault 1706 9
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,) s
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FIGURE 2
Serial anteriorimaging study of abdomen and thorax. A:5 mm, B: 30 mm, C: 2 hr. D:24 hrafter intraperitonealinjection
of [@‘TcJsuffuro lloid.Migrationof radio iso tope is seen on 2 hr(C)and 24 hr(D)images
w hic h the radio iso to pe m ig rate s from pe rito ne al to
pl eural space may be a c lue for di ff erenti ati on be tween
the two pathophy sio lo gic al mechani sms propo sed in
the l iterature . Such a di ff erenti ati on may inf luence the
patient's tre atment. If trans it time i s rapid, a macro
sco pic diaphrag matic defect co uld be so ug ht. If transit
is slow, o nly medic al tre atm ent has to be c ontemplate d.
FOOTNOTE
Picker In ternational H igh land Heights O H
170 8 Ve rre a u ft,e pa ge ,B is s one ta l
A C K N O W L E D G M E N T
The authors thank Mrs. LiseCôtéorherexcellentsecre
tanal assistance.
REFERENCES
1 . B ro dy iS : D iseases o f the pleura, mediastinum, dia
phragm and chestw all. In Cecil TextbookofMedicine,
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ders 1982 p 423
2 . S ing er JA , Kaplan M M, Katz RL: Cirrhotic pleural
effusion in the absence of ascites. Gastroenterology
73:575—577977
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315 1983
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l abe lled macroaggregated a lbumin in demonstrat ion
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Vo lume 27 •umber 11 â €¢ov ember1986
7 9
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1986;27:1706-1709.J Nucl Med.
Jean Verreault, Serge Lepage, Guy Bisson and Andre Plante CommunicationAscites and Right Pleural Effusion: Demonstration of a Peritoneo-Pleural
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