effusion in ESLD

 Q: 58 years old male with a history of cirrhosis is admitted to ICU with severe shortness of breath. Chest x-ray showed massive right sided effusion. Your next line of action is to insert right-sided chest tube?

A) Yes

B) No

Answer: B

The most common cause of portal hypertension is cirrhosis. Portal hypertension leads to many life-threatening complications including ascites, encephalopathy, variceal bleed, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy.

Hepatic hydrothorax is more of a mechanical pathology in comparison to pleural effusions due to cardiopulmonary disease. It is basically the movement of ascitic fluid into the pleural space through defects in the diaphragm, mostly visible on the right side of the chest x-ray. This is fundamentally important to understand as placement of a chest tube can be fatal in such a scenario, though repeated thoracenteses can be done to relieve the symptoms. The treatment is to target the underlying pathology of ascites with diuretics and sodium restriction. Transjugular intrahepatic portosystemic shunt (TIPS) can also be performed. The ultimate cure is usually liver transplantation.

#hepatology

References: 

1. Runyon BA, Greenblatt M, Ming RH. Hepatic hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol 1986; 81:566. 

2. Liu LU, Haddadin HA, Bodian CA, et al. Outcome analysis of cirrhotic patients undergoing chest tube placement. Chest 2004; 126:142. 

3. Orman ES, Lok AS. Outcomes of patients with chest tube insertion for hepatic hydrothorax. Hepatol Int 2009; 3:582. 

4. Ridha A, Al-Abboodi Y, Fasullo M. The Outcome of Thoracentesis versus Chest Tube Placement for Hepatic Hydrothorax in Patients with Cirrhosis: A Nationwide Analysis of the National Inpatient Sample. Gastroenterol Res Pract 2017; 2017:5872068.