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2014 ; 93
(3
): 135-142
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Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients
and review of the literature
#MMPMID24797168
Badillo R
; Rockey DC
Medicine (Baltimore)
2014[May]; 93
(3
): 135-142
PMID24797168
show ga
Hepatic hydrothorax is an important and difficult-to-manage complication of
cirrhosis and portal hypertension. Here, we aimed to study its clinical features
and natural history. Complete clinical data, including outcomes, were abstracted
from hospital records of patients with cirrhosis and ascites admitted to
University of Texas Southwestern University teaching hospitals from January 2001
to July 2012. Hepatic hydrothorax was diagnosed based on currently accepted
clinical characteristics of the disease, including a known diagnosis of
cirrhosis, the presence of portal hypertension, pleural fluid analysis, and the
absence of primary cardiopulmonary disease.Seventy-seven of 495 (16%)
hospitalized cirrhotic patients with pleural effusion (28 female; mean age, 52
yr) met the criteria for diagnosis of hepatic hydrothorax. Resting dyspnea and
cough were the most prominent presenting symptoms, occurring in 34% and 22% of
patients, respectively. Pleural effusions were most often right-sided (56/77;
73%), followed by left-sided only (13/77; 17%) and bilateral effusions (8/77;
10%); 7 (9%) patients did not have detectable ascites. The mean Model for
End-Stage Liver Disease (MELD) score at presentation was 16. The serum to pleural
fluid albumin gradient (SPAG) was ?1.1 in all 48 patients in whom it was
measured. Most patients (64/77; 83%) were managed with diuretics and/or
thoracentesis, while 8 (10%) underwent transjugular intrahepatic portosystemic
shunt (TIPS) and 5 (7%) underwent liver transplant. A total of 44 of 77 (57%)
patients died during a mean follow-up of 12 months. The average time from
presentation to death for all patients was 368 days, while for those after TIPS
it was 845 days. No deaths were reported in the liver transplant group. The data
indicate that a substantial number of patients with hepatic hydrothorax had what
may be considered atypical presentations, including left-sided only effusions, or
pleural effusion without ascites. Here, we propose that the term "serum to
pleural fluid albumin gradient (SPAG)" be used to describe the gradient between
serum and pleural fluid albumin levels and suggest that not only is it consistent
with the portal hypertensive pathophysiology of hepatic hydrothorax, but also it
is a useful criterion for diagnosis of hepatic hydrothorax. Finally, the overall
outcome of hepatic hydrothorax was extremely poor, except in those undergoing
TIPS or liver transplantation.
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