Helpful Hepatic Hydrothorax Highlights: A Case Taken from the World of Twitter

Parita Patel

Case

75-year-old male presents with diuretic refractory hepatic hydrothorax. No overt hepatic encephalopathy but family has noted some episodes of intermittent confusion. He is independent in his activities of daily living. MELD is less than 10.  No history of congestive heart failure, chronic kidney disease or hyponatremia.

What do you recommend?

Correct Answer:

All of the above

Hepatic hydrothorax is a complication of end stage liver disease that can affect 5-11% of patients. TIPS, repeated thoracentesis, transplant referral and even placement of a indwelling pleural catheter could all be reasonable treatment options. The appropriate choice is dependent on the patient’s goals of care as well as an individualized discussion on risks and benefits. Keep reading to learn how to best identify the appropriate treatment for each patient.

Basic Management of Hepatic Hydrothorax 

Referral for a liver transplant evaluation should be made while initiating treatment. Initial therapy should consist of sodium restriction (< 2 g/day) and diuretics. If the patient responds, great! If not, then we need to consider alternative invasive options including TIPS, repeated thoracentesis, pleurodesis or insertion of a chronic indwelling pleural catheter for drainage (see Figure 1).

Figure 1: Proposed Algorithm for Management of Hepatic Hydrothorax

*IPC=indwelling pleural catheter
Taken from: Banini, B.A., et al., Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology, 2020

Options in REFRACTORY Hepatic Hydrothorax

20-30% of patients have persistent pleural effusions despite sodium restriction and diuretics. Treatment options include thoracentesis as needed, transjugular intrahepatic portosystemic shunt (TIPS), chronic pleural catheter drainage (i.e. PleurX), and/or liver transplant. Pleurodesis (ablation of space between parietal and visceral pleura) is rarely used and typically reserved when no other options exist.

Repeated thoracentesis: 

  • Can be helpful for fluid analysis and allow for rapid improvement of symptoms
  • Complications and risks of thoracentesis include pneumothorax, hemothorax, air embolism, empyema, etc.
    • Chances of these complications are higher in patients that will require repeated therapeutic thoracentesis.

Transjugular intrahepatic portosystemic shunt (TIPS): 

Back to Twitter case

Dr. Dave Johnson
Options are also available once TIPS is placed, particularly if hepatic encephalopathy develops. A constrained stent can be placed through the initial stent to raise the portosystemic gradient.

  • A study of 73 patients undergoing TIPS for hepatic hydrothorax found the following factors associated with higher mortality after TIPS placement:
    • Pre-TIPS MELD >15
    • Elevated pre-TIPS creatinine 
    • Lack of response in hydrothorax after TIPS placement
  • Absolute and relative contraindications to TIPS are summarized in Table 1

    Therefore, patient selection is key!


    Table 1: Relative and absolute contraindications to TIPS

Taken from: Saab, Sammy MD, MPH; Kim, Nathan G. MD, MS; Lee, Edward Wolfgang MD, PhD. Practical Tips on TIPS. The American Journal of Gastroenterology: June 2020 - Volume 115 - Issue 6 - p 797-800 

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Dr. John Rice and Dr. Elliot Tapper:
Do you view functional status as a pro or con for TIPS?
Does living independently mean that a patient is more likely to survive and benefit from TIPS despite an advanced age?
OR
Is the risk of losing independence and development of HE worth undergoing TIPS?

Transplant

  • Transplant is the definitive treatment for hepatic hydrothorax and those without contraindications should be referred for evaluation

Indwelling pleural catheter

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Dr. Arpan Patel and Dr. Binu John:
Important to remember that these discussions should be patient centered and in the context of goals of care. PleurX may be reasonable if comfort is more important than life expectancy

Obliteration of pleural space and repair of diaphragmatic defects

  • Pleurodesis invol­ves ablation of space between parietal and visceral pleura
    • Can be achieved by chemical means (i.e. use of a sclerosing agent) or mechanical means
  • In a meta-analysis of 180 patients, a pooled complete response rate of 72% and complication rate of 82% occurred in those undergoing different methods of pleurodesis
  • Surgical closure of diaphragmatic defect is an option but has significant limitations:
    • Invasive; one study showed a 3-month mortality of 25%
    • Diaphragm defects may be difficult to visualize
    • Complications include septic shock, acute renal insufficiency, bowel ischemia and gastrointestinal bleeding

Table 2: Advantages and Disadvantages of Treatment Options in Refractory Hepatic Hydrothorax

Adapted from: Banini, B.A., et al., Multidisciplinary Management of Hepatic Hydrothorax in 2020: An Evidence-Based Review and Guidance. Hepatology, 2020

Take Home Points:

  • Treatment options for hepatic hydrothorax include TIPS, thoracentesis as needed, chronic indwelling pleural catheter, and/or transplant referral. Decisions should be made on a case by case basis.
  • Goals of care discussions are essential when making treatment decisions. A treatment that benefits one patient may cause more harm to another patient.

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