Hepatic Hydrothorax: Complete Opacification of a …eradiology.bidmc.harvard.edu/LearningLab/gastro/block.pdf · Hepatic Hydrothorax: Complete Opacification of a Hemithorax ... •

Hepatic Hydrothorax: Complete Opacification of a Hemithorax

Brian Block HMS IIIGillian Lieberman, MD

Core Radiology ClerkshipFebruary 22nd 2011

Brian Block, 2011Gillian Lieberman, MD

February 2011

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Agenda

1. Patient presentation2. Menu of available tests3. Differential diagnosis for white out of a

hemithorax4. Review the pathogenesis and

evaluation of hepatic hydrothorax5. Intervention6. Summary

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Index Patient Presentation

• Woman in her mid 50’s called 911 complaining of two days of progressive dyspnea and increasing abdominal girth

• When EMS arrived, O2 saturation was in the 80’s. She was placed on a Non-rebreather (NRB) at 15L/minute and brought to the ER

• On arrival in the ER, she was unable to speak in complete sentences.

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Index Patient: Initial Plain Film

• What is your wet read?• What are you

concerned about?• What is your preliminary

differential diagnosis?• What types of

information would be helpful in organizing your differential?

Frontal Chest X Ray-- PACS BIDMC

Continue to see a labeled image with findings highlighted

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Index Patient: Basic Interpretation of initial Plain Film

There is complete opacification of the left hemithorax

**More findings will be discussed in subsequent interpretations of this image

*

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Index patient: Further History

More History:- HCV Cirrhosis (MELD score of 13 on admission)

- Says she ran out of some of her medications several days ago- Hypothyroidism- Depression- MSSA spinal osteomyelitis s/p C2-3 laminectomy

Review Of Systems:(+) Chills, abdominal pain, cough with post-tussive emesis(-) Fevers, chest pain, hemoptysis, diarrhea, rashes,

urticaria, sick contacts

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Index Patient: Medications

• Furosemide 40mg daily• Lactulose 20g/30ml TID• Spironolactone 150mg Daily• Tramadol 50mg daily prn pain• Omeprazole 20mg BID• MVI daily

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Index Patient: Physical Exam

Vital Signs: T98.2 HR 82 BP 132/61 RR 22 O2Sat 100% 15L NRB 87% RA

General: AOx3, speaking in full sentences, mild respiratory distressHEENT: + Scleral icterusLungs: No air movement L hemithorax, dull to percussion ¾ the way up. Basilar crackles on right.CV: RRR, normal S1 S2, no murmursAbd: +BS, soft, tender to percussion over epigastrum, + splenomegalyExtrem: 1+ edema in lower extremitiesSkin: No rashes or jaundice

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Agenda

1. Case Presentation2. Menu of available tests3. Differential diagnosis for white out of a



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Menu of Tests: Initial Evaluation of Respiratory IllnessThe American College of Radiologists’ Expert Panel on Thoracic imaging has released guidelines for imaging in a patient older than 40 presenting with acute respiratory illness, which they define as as one of the following

– Cough– Sputum production– Chest pain– Dyspnea

Recommended Tests:– CXR (score of 8, usually appropriate)– CT (score of 4, maybe appropriate)

ACR Expert Panel on Thoracic Imaging 2008

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Index Patient: Official Read of Initial Plain Film

Official Read:Complete opacification of left hemithorax with slight shift of midline structures to the right


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Agenda




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Differential Diagnosis: White-out of a Hemithorax

(based on imaging alone)

Common:• Atelectasis• Consolidation• Pleural Effusion• Post-pneumonectomy

fibrothorax

Reeder and Felson 1993

Uncommon:• Adenomatoid malformation of

lung• Agenesis of a lung• Cardiomegaly• Diaphragmatic Hernia• Eventration of diaphragm• Fibrosisof lung or pleura• Hematoma of chest wall• Mediastinal or Pulmonary Mass• Pleural mesothelioma

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How to Pare Down this Differential

Look at the mediastinal structures and ask yourself whether they have been pulled towards the abnormal lung, or pushed away from it

Pulled: Pushed:For example For example

– Lung collapse – Diaphragmatic Hernia– Pneumonectomy – Pleural Effusion

Adapted from Davies 2009

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Companion Patient 1: An example of “pull” on plain films

Lateral Chest X Ray-- PACS BIDMCFrontal Chest X Ray-- PACS BIDMC

Continue to see annotated images…

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Companion Patient 1: An example of “pull” on frontal plain film

• Trachea deviated towards the affected hemithorax

• Left ventricle and left mediastinal border pulled towards affected lung

• Left diaphragm visible with normal costophrenic angle


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Companion Patient 1: An example of “pull” on lateral plain film

• Normal Vertebrae with negative spine sign

• Anterior and posterior heart borders well visualized

• Left hemidiaphragm clearly seen with normal costophrenic angle. No right hemidiaphragm seen.

Lateral Chest X Ray-- PACS BIDMC

***

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Companion Patient 1: An example of “pull” on Axial CT

Axial CT Chest with IV contrast-- PACS, BIDMC

Notice the following:• Rightward

displacement of heart

• Obliteration of right lung field

• Abdominal contents in right hemithorax

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Notice the following:• Rightward

displacement of heart

• Obliteration of right lung field

• Abdominal contents in right hemithorax

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Notice the following:• Liver in right

hemithorax at level of mid left lung field

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Companion Patient 1: View on coronal reconfiguration of CT

Coronal reconfiguration of CT Torso--PACS BIDMC

• Patient after right total pneumonectomy

• No residual lung, fibrosis of right hemithorax

• Invasion of right hemithorax by abdominal contents

Normal L Lung

Spleen

Kidneys

Fibrotic R hemithorax

Liver

PsoasMuscles

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Companion Patient 2: An example of “push” on plain film

Frontal and lateral plain films-- both PACS BIDMCContinue to see annotated images…

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Companion Patient 2: Demonstration of “push” on plain film

• Trachea deviated away from affected hemithorax

• Right atrium and right mediastinal border pushed away from affected hemithorax

• Right diaphragm visible with normal costophrenic angle

Frontal plain film-- PACS BIDMC

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Companion Patient 2: An example of “push” on plain film

• Air-fluid level

• Right diaphragm– No left diaphragm

visible

Lateral plain films-- PACS BIDMC

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Companion Patient 2: Worsening of “push” one year later

Continue to see annotated images…Frontal and lateral plain films-- both PACS BIDMC

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Frontal plain film-- PACS BIDMC

• Trachea deviated further away from affected hemithorax

• Right atrium and right mediastinal border pushed further away from affected hemithorax

• Right diaphragm visible with normal costophrenic angle

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No more air fluid level as lung completely opacified.

• Right Diaphragm clearly visualized, no left diaphragm seen

Lateral plain films-- PACS BIDMC

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Our Index Patient: Applying the Push-Pull Framework

You have now seen an organizational model for thinking about the differential of opacification of one hemithorax—breaking things into “push” versus “pull” categories based on the position of the mediastinum relative to the affected hemithorax.

Let’s return to our index patient, apply this framework, and see what category she belongs in.

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Our Index Patient: Plain Film Labeled to show “Push”

Frontal Chest X Ray-- PACS, BIDMC

• Trachea deviatedaway from affectedlung

• Right atrium and rightmediastinal borderpushed away fromaffected lung

• Right diaphragmvisualized with normalcostophrenic angle

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Index Patient: Diagnosis

Our index patient demonstrates a “push” type opacification, consistent with an infiltration of the left hemithorax by a space-occupying process.

The patient was ultimately diagnosed with hepatic hydrothorax. Let’s now review the pathogenesis, workup, and management of hepatic hydrothorax

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Agenda




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Hepatic Hydrothorax: Definition and Epidemiology

• Pleural effusion >500ml occurring in the setting of liver disease and in the absence of other potential causes of pleural effusion

• Occurs in 5-12% of patients with cirrhosis1

– BEWARE: 18%-30%2 of pleural effusions in cirrhotics are NOT due to hepatic hydrothorax

• 85% Right sided, 13% Left, 2% bilateral– Due to location of diaphragmatic defects1

1 Roussos et al. 20072 xiol et al. 2001

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Hepatic Hydrothorax: Pathogenesis of Ascites

Portal HTN

Liver Disease:–Decreased SVR–Splanchnic vasodilation–Sodium and water retention due to decreased circulating blood volume

**Ascites**

Diaphragms

Roussos et al. 2007

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Hepatic Hydrothorax: Pathogenesis of Pleural Effusion

Effusion!

Roussos et al. 2007

Portal HTN

Liver Disease:–Decreased SVR–Splanchnic vasodilation–Sodium and water retention due to decreased circulating blood volume

**Ascites**

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Hepatic Hydrothorax: Radiographic Evidence for

Transdiaphragmatic Leak of Ascites

• 99T-colloid injected into peritoneal cavity

• Passage into pleural space confirms transdiaphragmatic leak– 6 showed 99T in left

pleura only– 1 in right pleura only– 1 bilateral

Bhattacharya et al. 2001

T=3hrs: 99T in R pleural space

T=4hrs: 99T in R pleural space

T=20mins: 99T under diaphragm

T=5mins: 99T in abdomen only

Diaphragms in green

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Hepatic Hydrothorax: Spontaneous Bacterial Empyema

(SBEM) as a Potential Complication• Complicates ~13% of pleural effusions

associated with cirrhosis– This is similar to the rate of Spontaneous

Bacterial Peritonitis (SBP)• Signs/Symptoms

– Fever– Pleuritic pain– Encephalopathy Roussos et al. 2007

Xiol et al. 1996

Albillos et al. 1990

Fortunately our patient exhibited none of these signs or symptoms

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SBEM: Further Information

• Pathogenesis unclear– 45% occur in absence of bacterial peritonitis– May be that a transient bacteremia leads to

pleural infection• Causal Organisms

– E. Coli, Streptococcus Sp., Enterococcus, Klebsiella

• Risk factors– Low pleural total protein– High Child-Pugh Score– Low levels of C3 in pleural fluid

Roussos et al. 2007

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Agenda


hemithorax4. Review the pathophysiology and


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Hepatic Hydrothorax: Pathophysiologic Approach to

Understanding Treatment OptionsAs above, the pleural effusion in hepatic hydrothorax occurs as a result of liver disease, leading to accumulation of fluid in the splanchnic circulation, which leads to ascites, which can then cross the diaphragm to reach the pleura.

Treatment approaches can thus be thought to target the following:1) Liver function2) Accumulation of fluid and resultant portal hypertension 3) Transmigration of fluid across the diaphragm

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Hepatic Hydrothorax: Options for Treatment

1. Improving Liver Function- Transplant

2. Reducing fluid accumulation- Reduce volume

- Sodium Restriction- Diuretics

- Reduce portal HTN—relieve pressure build up- Transjugular Intrahepatic Portosystemic Shunt (TIPS)

3. Preventing fluid migration across the diaphragm- Repair of defects in tendinous portion of diaphragm- Pleurodesis

Roussos et al. 2007

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Hepatic Hydrothorax: Role for Therapeutic Thoracentesis

Thoracentesis is mandatory in patients with suspected hepatic hydrothroax for two reasons:

1. To diagnose or exclude infection2. To rule-out alternative etiologies of effusion

Additionally, one can compare thoracentesis fluid to paracentesis fluid to strengthen the argument for peritoneal origin of fluid

Roussos et al. 2007

Alberts et al. 1991

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Companion Patient 3: Ultrasound Guided Thoracentesis of a

Pleural Effusion

Heffner, 2003

The dotted line illustrates a potential path that could be taken by a needle when performing a thoracentesis to drain a right sided pleural effusion. Findings and anatomical landmarks are labeled in the image.

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Our index patient: Pleural Fluid Analysis

1L of serosanguinous fluid was drained. It proved to be benign—there were no laboratory signs of SBEM, which was consistent with her clincal presentation.

Component ResultWBC 115/ulTotal Protein 0.7g/dlGlucose 110mg/dlLDH 60 IU/LpH 7.56

Gram Stain No MicroorganismsFluid Culture No GrowthAnaerobic Culture No GrowthFungal Culture No Growth

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Our Index Patient: Plain Films after Thoracentesis

Continue to see annotated images…Frontal and lateral plain films-- both PACS BIDMC

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Our Index Patient: Frontal Plain Film after Thoracentesis

• Trachea now midline

• Heart borders now clearly visible

• Right and left hemidiaphragms now clearly visible

PACS BIDMC

46PACS BIDMC

Our Index Patient: Lateral Plain Film after Thoracentesis

• Trachea and both mainstem bronchi clearly visible

• Anterior and posterior heart borders well- defined

• Both hemidiaphragms are now visible without blunting of costophrenic angles

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Hepatic Hydrothorax: Refractory pleural effusions

You have learned that pleural effusions in the setting of hepatic hydrothorax should be drained by thoracentesis, for both diagnostic and therapeutic reasons.

In some cases, effusions rapidly re-accumulate after thoracentesis. In such cases, one may be tempted to place a chest tube to allow continuous drainage of the effusion. However, chest tube placement is ill-advised, as you will see.

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Refractory Pleural Effusions: Why not place a Chest Tube?

Chest tube placement can lead to protein loss,electrolyte abnormalities, and excess mortality

Retrospective cohort study of all patients with hepatichydrothorax who had a chest tube placed:

– 17 patients, Mean MELD score of 14• 16 had at least one complication • 12 had more than one complication• Two deaths in hospital, four more within 3 months of discharge

– Most frequent complications were• Acute kidney injury (11/17)• Pneumothorax (9/17)• Empyema (5/17) Orman et al. 2009

Runyon et al. 1986

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Presentation Summary: Radiology Teaching Points

• You have learned that a plain film of the chest is the best initial radiologic study for workup of respiratory illness in adults, and that CT of the chest can also be appropriate in some situations

• You have learned that CT and ultrasound can be helpful for estimating the size of a pleural effusion, and for guiding thoracenteses

• You have reviewed a long differential diagnosis for complete white out of one hemithorax, and learned to group and organize these conditions based on whether they “push” or “pull” on the mediastinum

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Presentation Summary: Hepatic Hydrothorax Teaching Points• You have learned the pathogenesis of hepatic

hydrothorax, and seen the radiologic evidence for transdiaphragmatic migration of peritoneal fluid.

• You heard about Spontaneous Bacterial Empyema, an important potential complication of a pleural effusion in hepatic hydrothorax

• You have reviewed the options for medical, radiologic, and surgical management of hepatic hydrothorax

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References1. Alberts WM et al. Hepatic hydrothorax, cause and management. Arch Intern

Med 1991: 151:2383-88.

2. Albillos A et al. Ascitic fluid polymorphonuclear cell count and serum to ascites albumin gradient in the diagnosis of bacterial peritonitis. Gastroenterology 1990; 98: 134-40

3. Bhattacharya A et al. Radioisotope scintigraphy in the diagnosis of hepatic hydrothorax. J Gastroenterol Hepatol 2001; 16: 317-21

4. Desai S and Padley S, in Chapman and Nakielny’s Aids to Radiological Differential Diagnosis. Fifth edition. Saunders Elsivier Philadelphia, PA. 2009 pp 66.

5. Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria: Acute Respiratory Illness. American College of Radiology, 2008. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteri a/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessDoc1.aspx (Accessed 2/21/11)

6. Heffner JE. The Dropped Lung. Agency for Healthcare Research and Quality Web M&M, May 2003. Available at http://www.webmm.ahrq.gov/case.aspx?caseID=11 (Accessed 2/21/11)

7. Kim YK, Kim Y, Shim SS. Thoracic complications of liver cirrhosis: Radiologic Findings. Radiographics 2009;29825-37

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessDoc1.aspx

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessDoc1.aspx

http://www.webmm.ahrq.gov/case.aspx?caseID=11

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References (2)8. Kochar R and Fallon M. Pulmonary diseases and the liver. Clin Liver Dis

15(2011)21-37.

9. Orman ES, Lok AS. Outcomes of patients with chest tube insertion for hepatic hydrothorax. Hepatol Int 2009; 3:582

10. Reeder and Felson. Gamuts in Radiology: Comprehensive Lists of Differential Diagnosis. 3rd Edition. Springer-Verlag, New York, NY. 1993 pp 427.

11. Roussos A et al. Hepatic Hydrothorax: Pathophysiology diagnosis and management. J Gastro and Hepatol 22(2007) 1388-93.

12. Runyon BA et al. Hepatic Hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol 1986; 81:566

13. Xiol X et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology 1996; 23:719-23

14. Xiol X, Cortes R, Castellote J. Utility and complications of thoracocentesis in cirrhotic patients. Am. J. Med. 2001; 111:67-9

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Acknowledgements

Index Patient Identification:- Dr. Peter Clardy

Identification of Companion Patients:- Dr. Erica Gupta

Support:-Emily Hanson

Brian Block, 2011Gillian Lieberman MD

Documents

Hepatic Hydrothorax: Complete Opacification of a …eradiology.bidmc.harvard.edu/LearningLab/gastro/block.pdf · Hepatic Hydrothorax: Complete Opacification of a Hemithorax ... •