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RECURRENT HEPATIC HYDROTHORAX
Originally Posted: March 01, 2015
Resident(s): Osama Abdul-Rahim
Attending(s): Paul Brady
Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA
CHIEF COMPLAINT & HPI
Chief Complaint and/or reason for consultation Abdominal pain
History of Present Illness 54 y/o male w/ HCV cirrhosis and portal hypertension presents with
abdominal pain
RELEVANT HISTORY
Past Medical History HIV, non-compliant w/ HAART HCV cirrhosis w/ portal HTN HTN Anemia/Thrombocytopenia GSW to back
Past Surgical History Exploratory laparotomy
Family & Social History Past tobacco and alcohol use
Allergies NKDA
DIAGNOSTIC WORKUP
Physical Exam Distended abdomen with tenderness to palpation Hepatic encephalopathy, unclear what constitutes his baseline
mental status No asterixis Decreased breath sounds at the right lung base
Laboratory Data INR 1.5, Cr 2.8, T. bili 1.2 MELD 18-22 during admission
DIAGNOSTIC WORKUP - IMAGING
Initial CT abdomen and pelvis shows diffuse infectious colitis, sequelae of portal HTN, and a right pleural effusion
DIAGNOSTIC WORKUP - IMAGING
1 week later his right pleural effusion had worsened despite percutaneous catheter drainage
DIAGNOSIS
Refractory hepatic hydrothorax
INTERVENTION
In the setting of a MELD 18-22 and questionable baseline encephalopathy, the options for treatment included: TIPS 30 Day mortality rate after TIPS MELD 11-17: 7.3% MELD 18-24: 17.9%
Tunneled PleurX Catheter The primary physician was concerned about non-compliance issues
Pleurovenous (Denver) Shunt
INTERVENTION – DENVER SHUNT
One end of shunt placed in pleural space Venipuncture access secured
Carefusion ©
INTERVENTION – DENVER SHUNT
CLINICAL FOLLOW UP
Improving effusion after shunt
SUMMARY & TEACHING POINTS
54 y/o male with refractory hepatic hydrothorax 2o HCV cirrhosis
Poor TIPS candidate (MELD 18-22)
Poor PleurX catheter candidate (non-compliance)
Pleurovenous (Denver) shunt placed resulting in a significant improvement of his hydrothorax Shunt works by compressing the pump against chest wall
several times per day to manually move fluid from the pleural space to the systemic venous system
QUESTION SLIDE 1
1) What a laboratory values are needed for calculating the Model for End-Stage Liver Disease (MELD) score?
A: Creatinine, Total Bilirubin, Alkaline Phosphatase
B: Creatinine, Total Bilirubin, INR
C: INR, Total Bilirubin, Alkaline Phosphatase
D: INR, Direct Bilirubin, Alkaline Phosphatase
THE CORRECT ANSWER IS B.
1) What a laboratory values are needed for calculating the Model for End-Stage Liver Disease (MELD) score?
A: Creatinine, Total Bilirubin, Alkaline Phosphatase
B: Creatinine, Total Bilirubin, INR
C: INR, Total Bilirubin, Alkaline Phosphatase
D: INR, Direct Bilirubin, Alkaline Phosphatase
Continue with the Case
QUESTION SLIDE 2
2) Above what MELD score is TIPS relatively contraindicated due to increased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25
THE CORRECT ANSWER IS A.
2) Above what MELD score is TIPS relatively contraindicated due to increased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25
Continue with the Case
REFERENCES & FURTHER READING
Ferral H, et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology. 2004 Apr;231(1):231-6.
Martin LG. Percutaneous placement and management of the Denver shunt for portal hypertensive ascites. Am J Roentgenol. 2012 Oct;199(4):W449-53.
Harris K, Chalhoub M. The use of a PleurX catheter in the management of recurrent benign pleural effusion: a concise review. Heart Lung Circ. 2012 Nov;21(11):661-5.
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