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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