Download Hepatic Hydrothorax: Complete Opacification of a Hemithorax

Brian Block, 2011
Gillian Lieberman, MD
February 2011
Hepatic Hydrothorax: Complete
Opacification of a Hemithorax
Brian Block HMS III
Gillian Lieberman, MD
Core Radiology Clerkship
February 22nd 2011
Agenda
1. Patient presentation
2. Menu of available tests
3. Differential diagnosis for white out of a
hemithorax
4. Review the pathogenesis and
evaluation of hepatic hydrothorax
5. Intervention
6. Summary
2
Index Patient Presentation
• Woman in her mid 50’s called 911
complaining of two days of progressive
dyspnea and increasing abdominal girth
• When EMS arrived, O2 saturation was in the
80’s. She was placed on a Non-rebreather
(NRB) at 15L/minute and brought to the ER
• On arrival in the ER, she was unable to speak
in complete sentences.
3
Index Patient:
Initial Plain Film
• What is your wet read?
• What are you
concerned about?
• What is your preliminary
differential diagnosis?
• What types of
information would be
helpful in organizing
your differential?
Frontal Chest X Ray-- PACS BIDMC
Continue to see a labeled image
with findings highlighted
4
Index Patient:
Basic Interpretation of initial Plain Film
There is complete
opacification of the left
hemithorax
*
**More findings will be discussed in
subsequent interpretations of this
image
5
Index patient:
Further History
More History:
- HCV Cirrhosis (MELD score of 13 on admission)
- Says she ran out of some of her medications several days ago
- Hypothyroidism
- Depression
- MSSA spinal osteomyelitis s/p C2-3 laminectomy
Review Of Systems:
(+) Chills, abdominal pain, cough with post-tussive emesis
(-) Fevers, chest pain, hemoptysis, diarrhea, rashes,
urticaria, sick contacts
6
Index Patient:
Medications
•
•
•
•
•
•
Furosemide 40mg daily
Lactulose 20g/30ml TID
Spironolactone 150mg Daily
Tramadol 50mg daily prn pain
Omeprazole 20mg BID
MVI daily
7
Index Patient:
Physical Exam
Vital Signs: T98.2 HR 82 BP 132/61 RR 22 O2Sat 100% 15L NRB
87% RA
General: AOx3, speaking in full sentences, mild respiratory distress
HEENT: + Scleral icterus
Lungs: No air movement L hemithorax, dull to percussion ¾ the
way up. Basilar crackles on right.
CV: RRR, normal S1 S2, no murmurs
Abd: +BS, soft, tender to percussion over epigastrum, +
splenomegaly
Extrem: 1+ edema in lower extremities
Skin: No rashes or jaundice
8
Agenda
1. Case Presentation
2. Menu of available tests
3. Differential diagnosis for white out of a
hemithorax
4. Review the pathogenesis and
evaluation of hepatic hydrothorax
5. Intervention
6. Summary
9
Menu of Tests:
Initial Evaluation of Respiratory Illness
The American College of Radiologists’ Expert Panel on
Thoracic imaging has released guidelines for imaging in
a patient older than 40 presenting with acute respiratory
illness, which they define as as one of the following
–
–
–
–
Cough
Sputum production
Chest pain
Dyspnea
Recommended Tests:
–
–
CXR (score of 8, usually appropriate)
CT (score of 4, maybe appropriate)
ACR Expert Panel on Thoracic Imaging 2008
10
Index Patient:
Official Read of Initial Plain Film
Official Read:
Complete opacification
of left hemithorax with
slight shift of midline
structures to the right
Frontal Chest X Ray-- PACS BIDMC
11
Agenda
1. Case Presentation
2. Menu of available tests
3. Differential diagnosis for white out of a
hemithorax
4. Review the pathogenesis and
evaluation of hepatic hydrothorax
5. Intervention
6. Summary
12
Differential Diagnosis:
White-out of a Hemithorax
(based on imaging alone)
Common:
Uncommon:
•
•
•
•
•
Atelectasis
Consolidation
Pleural Effusion
Post-pneumonectomy
fibrothorax
•
•
•
•
•
•
•
•
Adenomatoid malformation of
lung
Agenesis of a lung
Cardiomegaly
Diaphragmatic Hernia
Eventration of diaphragm
Fibrosisof lung or pleura
Hematoma of chest wall
Mediastinal or Pulmonary Mass
Pleural mesothelioma
Reeder and Felson 1993
13
How to Pare Down this
Differential
Look at the mediastinal structures and ask
yourself whether they have been pulled towards
the abnormal lung, or pushed away from it
Pulled:
For example
– Lung collapse
– Pneumonectomy
Pushed:
For example
– Diaphragmatic Hernia
– Pleural Effusion
Adapted from Davies 2009
14
Companion Patient 1:
An example of “pull” on plain films
Frontal Chest X Ray-- PACS BIDMC
Lateral Chest X Ray-- PACS BIDMC
Continue to see annotated images…
15
Companion Patient 1:
An example of “pull” on frontal plain film
• Trachea deviated
towards the affected
hemithorax
• Left ventricle and left
mediastinal border
pulled towards affected
lung
• Left diaphragm visible
with normal
costophrenic angle
Frontal Chest X Ray-- PACS BIDMC
16
Companion Patient 1:
An example of “pull” on lateral plain film
• Normal Vertebrae with
negative spine sign
• Anterior and posterior
heart borders well
visualized
• Left hemidiaphragm
clearly seen with normal
costophrenic angle. No
right hemidiaphragm
seen.
*
*
*
Lateral Chest X Ray-- PACS BIDMC
17
Companion Patient 1:
An example of “pull” on Axial CT
Notice the following:
• Rightward
displacement of
heart
• Obliteration of
right lung field
• Abdominal
contents in right
hemithorax
Axial CT Chest with IV contrast-- PACS, BIDMC
18
Companion Patient 1:
An example of “pull” on Axial CT
Notice the following:
• Rightward
displacement of
heart
• Obliteration of
right lung field
• Abdominal
contents in right
hemithorax
Axial CT Chest with IV contrast-- PACS, BIDMC
19
Companion Patient 1:
An example of “pull” on Axial CT
Notice the following:
• Liver in right
hemithorax at
level of mid left
lung field
Axial CT Chest with IV contrast-- PACS, BIDMC
20
Companion Patient 1:
View on coronal reconfiguration of CT
Fibrotic
R hemithorax
Liver
Psoas
Muscles
Normal L
Lung
Spleen
Kidneys
Coronal reconfiguration of CT Torso--PACS BIDMC
• Patient after right total
pneumonectomy
• No residual lung, fibrosis
of right hemithorax
• Invasion of right
hemithorax by abdominal
contents
21
Companion Patient 2:
An example of “push” on plain film
Frontal and lateral plain films-- both PACS BIDMC
Continue to see annotated images…
22
Companion Patient 2:
Demonstration of “push” on plain film
• Trachea deviated away
from affected
hemithorax
• Right atrium and right
mediastinal border
pushed away from
affected hemithorax
• Right diaphragm visible
with normal
costophrenic angle
Frontal plain film-- PACS BIDMC
23
Companion Patient 2:
An example of “push” on plain film
• Air-fluid level
• Right diaphragm
– No left diaphragm
visible
Lateral plain films-- PACS BIDMC
24
Companion Patient 2:
Worsening of “push” one year later
Frontal and lateral plain films-- both PACS BIDMC
Continue to see annotated images…
25
Companion Patient 2:
Worsening of “push” one year later
• Trachea deviated
further away from
affected hemithorax
• Right atrium and right
mediastinal border
pushed further away
from affected
hemithorax
• Right diaphragm visible
with normal
costophrenic angle
Frontal plain film-- PACS BIDMC
26
Companion Patient 2:
Worsening of “push” one year later
No more air fluid level
as lung completely
opacified.
• Right Diaphragm
clearly visualized, no
left diaphragm seen
Lateral plain films-- PACS BIDMC
27
Our Index Patient:
Applying the Push-Pull Framework
You have now seen an organizational model for
thinking about the differential of opacification of
one hemithorax—breaking things into “push”
versus “pull” categories based on the position of
the mediastinum relative to the affected
hemithorax.
Let’s return to our index patient, apply this
framework, and see what category she belongs
in.
28
Our Index Patient:
Plain Film Labeled to show “Push”
• Trachea deviated
away from affected
lung
• Right atrium and right
mediastinal border
pushed away from
affected lung
Frontal Chest X Ray-- PACS, BIDMC
• Right diaphragm
visualized with normal
costophrenic angle
29
Index Patient: Diagnosis
Our index patient demonstrates a “push” type
opacification, consistent with an infiltration of
the left hemithorax by a space-occupying
process.
The patient was ultimately diagnosed with
hepatic hydrothorax. Let’s now review the
pathogenesis, workup, and management of
hepatic hydrothorax
30
Agenda
1. Case Presentation
2. Menu of available tests
3. Differential diagnosis for white out of a
hemithorax
4. Review the pathogenesis and
evaluation of hepatic hydrothorax
5. Intervention
6. Summary
31
Hepatic Hydrothorax:
Definition and Epidemiology
• Pleural effusion >500ml occurring in the
setting of liver disease and in the absence of
other potential causes of pleural effusion
• Occurs in 5-12% of patients with cirrhosis1
– BEWARE: 18%-30%2 of pleural effusions in
cirrhotics are NOT due to hepatic hydrothorax
• 85% Right sided, 13% Left, 2% bilateral
– Due to location of diaphragmatic defects1
1 Roussos
2 xiol
et al. 2007
et al. 2001
32
Hepatic Hydrothorax:
Pathogenesis of Ascites
Portal HTN
Diaphragms
Liver Disease:
–Decreased SVR
–Splanchnic vasodilation
–Sodium and water retention
due to decreased circulating
blood volume
**Ascites**
Roussos et al. 2007
33
Hepatic Hydrothorax:
Pathogenesis of Pleural Effusion
Portal HTN
Effusion!
Liver Disease:
–Decreased SVR
–Splanchnic vasodilation
–Sodium and water retention
due to decreased circulating
blood volume
**Ascites**
Roussos et al. 2007
34
Hepatic Hydrothorax:
Radiographic Evidence for
Transdiaphragmatic Leak of Ascites
•
99T-colloid
injected into
peritoneal cavity
• Passage into pleural
space confirms
transdiaphragmatic leak
– 6 showed 99T in left
pleura only
– 1 in right pleura only
– 1 bilateral
T=5mins: 99T in
abdomen only
T=20mins: 99T
under diaphragm
Diaphragms in green
T=3hrs: 99T in
R pleural space
T=4hrs: 99T in
R pleural space
Bhattacharya et al. 2001
35
Hepatic Hydrothorax:
Spontaneous Bacterial Empyema
(SBEM) as a Potential Complication
• Complicates ~13% of pleural effusions
associated with cirrhosis
Xiol et al. 1996
– This is similar to the rate of Spontaneous
Albillos et al. 1990
Bacterial Peritonitis (SBP)
• Signs/Symptoms
– Fever
– Pleuritic pain
– Encephalopathy
Roussos et al. 2007
Fortunately our patient exhibited none of
these signs or symptoms
36
SBEM: Further Information
• Pathogenesis unclear
– 45% occur in absence of bacterial peritonitis
– May be that a transient bacteremia leads to
pleural infection
• Causal Organisms
– E. Coli, Streptococcus Sp., Enterococcus,
Klebsiella
• Risk factors
– Low pleural total protein
– High Child-Pugh Score
– Low levels of C3 in pleural fluid
Roussos et al. 2007
37
Agenda
1. Case Presentation
2. Menu of available tests
3. Differential diagnosis for white out of a
hemithorax
4. Review the pathophysiology and
evaluation of hepatic hydrothorax
5. Intervention
6. Summary
38
Hepatic Hydrothorax:
Pathophysiologic Approach to
Understanding Treatment Options
As above, the pleural effusion in hepatic hydrothorax
occurs as a result of liver disease, leading to
accumulation of fluid in the splanchnic circulation, which
leads to ascites, which can then cross the diaphragm to
reach the pleura.
Treatment approaches can thus be thought to target the
following:
1) Liver function
2) Accumulation of fluid and resultant portal hypertension
3) Transmigration of fluid across the diaphragm
39
Hepatic Hydrothorax:
Options for Treatment
1.
Improving Liver Function
-
2.
Transplant
Reducing fluid accumulation
-
Reduce volume
-
-
Reduce portal HTN—relieve pressure build up
-
3.
Sodium Restriction
Diuretics
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Preventing fluid migration across the diaphragm
-
Repair of defects in tendinous portion of diaphragm
Pleurodesis
Roussos et al. 2007
40
Hepatic Hydrothorax:
Role for Therapeutic Thoracentesis
Thoracentesis is mandatory in patients with
suspected hepatic hydrothroax for two reasons:
1. To diagnose or exclude infection
2. To rule-out alternative etiologies of effusion
Roussos et al. 2007
Additionally, one can compare thoracentesis
fluid to paracentesis fluid to strengthen the
argument for peritoneal origin of fluid
Alberts et al. 1991
41
Companion Patient 3:
Ultrasound Guided Thoracentesis of a
Pleural Effusion
Heffner, 2003
The dotted line
illustrates a potential
path that could be
taken by a needle
when performing a
thoracentesis to drain
a right sided pleural
effusion. Findings and
anatomical landmarks
are labeled in the
image.
42
Our index patient:
Pleural Fluid Analysis
1L of serosanguinous fluid was drained. It proved to be
benign—there were no laboratory signs of SBEM, which
was consistent with her clincal presentation.
Component
WBC
Total Protein
Glucose
LDH
pH
Result
115/ul
0.7g/dl
110mg/dl
60 IU/L
7.56
Gram Stain
Fluid Culture
Anaerobic Culture
Fungal Culture
No Microorganisms
No Growth
No Growth
No Growth
43
Our Index Patient:
Plain Films after Thoracentesis
Frontal and lateral plain films-- both PACS BIDMC
Continue to see annotated images…
44
Our Index Patient:
Frontal Plain Film after Thoracentesis
• Trachea now midline
• Heart borders now
clearly visible
• Right and left
hemidiaphragms now
clearly visible
PACS BIDMC
45
Our Index Patient:
Lateral Plain Film after Thoracentesis
• Trachea and both
mainstem bronchi
clearly visible
• Anterior and posterior
heart borders welldefined
• Both hemidiaphragms
are now visible without
blunting of costophrenic
angles
PACS BIDMC
46
Hepatic Hydrothorax:
Refractory pleural effusions
You have learned that pleural effusions in the
setting of hepatic hydrothorax should be
drained by thoracentesis, for both diagnostic
and therapeutic reasons.
In some cases, effusions rapidly re-accumulate
after thoracentesis. In such cases, one may be
tempted to place a chest tube to allow
continuous drainage of the effusion. However,
chest tube placement is ill-advised, as you will
see.
47
Refractory Pleural Effusions:
Why not place a Chest Tube?
Chest tube placement can lead to protein loss,
electrolyte abnormalities, and excess mortality
Runyon et al. 1986
Retrospective cohort study of all patients with hepatic
hydrothorax who had a chest tube placed:
– 17 patients, Mean MELD score of 14
• 16 had at least one complication
• 12 had more than one complication
• Two deaths in hospital, four more within 3 months of discharge
– Most frequent complications were
• Acute kidney injury (11/17)
• Pneumothorax (9/17)
• Empyema (5/17)
Orman et al. 2009
48
Presentation Summary:
Radiology Teaching Points
• You have learned that a plain film of the chest is the
best initial radiologic study for workup of respiratory
illness in adults, and that CT of the chest can also be
appropriate in some situations
• You have learned that CT and ultrasound can be
helpful for estimating the size of a pleural effusion,
and for guiding thoracenteses
• You have reviewed a long differential diagnosis for
complete white out of one hemithorax, and learned to
group and organize these conditions based on
whether they “push” or “pull” on the mediastinum
49
Presentation Summary:
Hepatic Hydrothorax Teaching Points
• You have learned the pathogenesis of hepatic
hydrothorax, and seen the radiologic evidence for
transdiaphragmatic migration of peritoneal fluid.
• You heard about Spontaneous Bacterial Empyema,
an important potential complication of a pleural
effusion in hepatic hydrothorax
• You have reviewed the options for medical,
radiologic, and surgical management of hepatic
hydrothorax
50
References
1.
Alberts WM et al. Hepatic hydrothorax, cause and management. Arch Intern
Med 1991: 151:2383-88.
2.
Albillos A et al. Ascitic fluid polymorphonuclear cell count and serum to
ascites albumin gradient in the diagnosis of bacterial peritonitis.
Gastroenterology 1990; 98: 134-40
3.
Bhattacharya A et al. Radioisotope scintigraphy in the diagnosis of hepatic
hydrothorax. J Gastroenterol Hepatol 2001; 16: 317-21
4.
Desai S and Padley S, in Chapman and Nakielny’s Aids to Radiological
Differential Diagnosis. Fifth edition. Saunders Elsivier Philadelphia, PA. 2009
pp 66.
5.
Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria: Acute
Respiratory Illness. American College of Radiology, 2008. Available at
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteri
a/pdf/ExpertPanelonThoracicImaging/AcuteRespiratoryIllnessDoc1.aspx
(Accessed 2/21/11)
6.
Heffner JE. The Dropped Lung. Agency for Healthcare Research and Quality
Web M&M, May 2003. Available at
http://www.webmm.ahrq.gov/case.aspx?caseID=11 (Accessed 2/21/11)
7.
Kim YK, Kim Y, Shim SS. Thoracic complications of liver cirrhosis: Radiologic
Findings. Radiographics 2009;29825-37
51
References (2)
8.
Kochar R and Fallon M. Pulmonary diseases and the liver. Clin Liver Dis
15(2011)21-37.
9.
Orman ES, Lok AS. Outcomes of patients with chest tube insertion for
hepatic hydrothorax. Hepatol Int 2009; 3:582
10.
Reeder and Felson. Gamuts in Radiology: Comprehensive Lists of
Differential Diagnosis. 3rd Edition. Springer-Verlag, New York, NY. 1993 pp
427.
11.
Roussos A et al. Hepatic Hydrothorax: Pathophysiology diagnosis and
management. J Gastro and Hepatol 22(2007) 1388-93.
12.
Runyon BA et al. Hepatic Hydrothorax is a relative contraindication to chest
tube insertion. Am J Gastroenterol 1986; 81:566
13.
Xiol X et al. Spontaneous bacterial empyema in cirrhotic patients: a
prospective study. Hepatology 1996; 23:719-23
14.
Xiol X, Cortes R, Castellote J. Utility and complications of thoracocentesis in
cirrhotic patients. Am. J. Med. 2001; 111:67-9
52
Brian Block, 2011
Gillian Lieberman MD
Acknowledgements
Index Patient Identification:
- Dr. Peter Clardy
Identification of Companion Patients:
- Dr. Erica Gupta
Support:
-Emily Hanson
53