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? (Find Twitter Case here)
A. Transjugular intrahepatic portosystemic shunt (TIPS)
B. Transplant referral
C. Thoracentesis prn
D. Indwelling pleural catheter
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.
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
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.
Transjugular intrahepatic portosystemic shunt (TIPS):
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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.
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?
Is the risk of losing independence and development of HE worth undergoing TIPS?
Indwelling pleural catheter
Obliteration of pleural space and repair of diaphragmatic defects
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
Transplant Hepatologist, Piedmont Health