8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

1/17

RECURRENT HEPATICHYDROTHORAX

Originally Posted:

Resident(s): Osama Abdul-RahimAttending(s): Paul Brady

Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

2/17

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

3/17

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

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

4/17

DIAGNOSTIC WORKUP

Physical Exam Distended abdomen with tenderness to palpation

Hepatic encephalopathy, unclear what constitutes his bmental 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

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

5/17

DIAGNOSTIC WORKUP - IMAGING

Initial CT abdand pelvis shdiffuse infectcolitis, sequeportal HTN, right pleuraleffusion

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

6/17

DIAGNOSTIC WORKUP - IMAGING

1 week later right pleuraleffusion hadworsened depercutaneou

catheter drai

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

7/17

DIAGNOSIS

Refractory hepatic hydrothorax

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

8/17

INTERVENTION

In the setting of a MELD 18-22 and questionable baselineencephalopathy, 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

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

9/17

INTERVENTION DENVER SHUNT

One end of shunt placed in pleural space Venipuncture access s

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

10/17

INTERVENTION DENVER SHUNT

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

11/17

CLINICAL FOLLOW UP

Improving eafter sh

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

12/17

SUMMARY & TEACHING POINTS

54 y/o male with refractory hepatic hydrothorax 2oHCV c

Poor TIPS candidate (MELD 18-22)

Poor PleurX catheter candidate (non-compliance)

Pleurovenous (Denver) shunt placed resulting in a signific

improvement of his hydrothorax Shunt works by compressing the pump against chest w

several times per day to manually move fluid from the pspace to the systemic venous system

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

13/17

QUESTION SLIDE 1

1) What a laboratory values are needed for calculating the Model fStage 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

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

14/17

THE CORRECT ANSWER IS B.

1) What a laboratory values are needed for calculating the Model fStage 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

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

15/17

QUESTION SLIDE 2

2) Above what MELD score is TIPS relatively contraindicated due toincreased risk of 30 day mortality?

A: 18

B: 8

C: 13

D: 25

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

16/17

THE CORRECT ANSWER IS A.

2) Above what MELD score is TIPS relatively contraindicated due toincreased risk of 30 day mortality?

A: 18

B: 8

C: 13

D: 25

Continue with the Case

8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax

17/17

REFERENCES & FURTHER READING

Ferral H, et al. Survival after elective transjugular intrahepatic portosystemcreation: prediction with model for end-stage liver disease score. RadiologyApr;231(1):231-6.

Martin LG. Percutaneous placement and management of the Denver shunthypertensive ascites.Am J Roentgenol. 2012 Oct;199(4):W449-53.

Harris K, Chalhoub M. The use of a PleurX catheter in the management of

benign pleural effusion: a concise review. Heart Lung Circ. 2012 Nov;21(1