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.