Originally Posted: March 01, 2015

RECURRENT HEPATIC
HYDROTHORAX
Resident(s): Osama Abdul-Rahim
Attending(s): Paul Brady
Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA

CHIEF COMPLAINT & HPI

Chief Complaint and/or reason for consultation
Abdominal pain

History of Present Illness

54 y/o male w/ HCV cirrhosis and portal hypertension presents with
abdominal pain

RELEVANT HISTORY
Past Medical History

HIV, non-compliant w/ HAART

HCV cirrhosis w/ portal HTN
HTN
Anemia/Thrombocytopenia
GSW to back

Past Surgical History

Exploratory laparotomy

Family & Social History

Past tobacco and alcohol use

Allergies
NKDA

DIAGNOSTIC WORKUP
Physical Exam
Distended abdomen with tenderness to palpation
Hepatic encephalopathy, unclear what constitutes his baseline
mental status
No asterixis
Decreased breath sounds at the right lung base
Laboratory Data
INR 1.5, Cr 2.8, T. bili 1.2
MELD 18-22 during admission

DIAGNOSTIC WORKUP - IMAGING

Initial CT abdomen
and pelvis shows
diffuse infectious
colitis, sequelae of
portal HTN, and a
right pleural
effusion

DIAGNOSTIC WORKUP - IMAGING

1 week later his
right pleural
effusion had
worsened despite
percutaneous
catheter drainage

DIAGNOSIS
Refractory hepatic hydrothorax

INTERVENTION
In the setting of a MELD 18-22 and questionable baseline
encephalopathy, the options for treatment included:
TIPS
30 Day mortality rate after TIPS
MELD 11-17: 7.3%
MELD 18-24: 17.9%

Tunneled PleurX Catheter

The primary physician was concerned about non-compliance issues

Pleurovenous (Denver) Shunt

INTERVENTION DENVER SHUNT

Carefusion

One end of shunt placed in pleural space

Venipuncture access secured

INTERVENTION DENVER SHUNT

CLINICAL FOLLOW UP

Improving effusion
after shunt

SUMMARY & TEACHING POINTS

54 y/o male with refractory hepatic hydrothorax 2o HCV cirrhosis
Poor TIPS candidate (MELD 18-22)
Poor PleurX catheter candidate (non-compliance)
Pleurovenous (Denver) shunt placed resulting in a significant
improvement of his hydrothorax
Shunt works by compressing the pump against chest wall
several times per day to manually move fluid from the pleural
space to the systemic venous system

QUESTION SLIDE 1
1) What a laboratory values are needed for calculating the Model for EndStage Liver Disease (MELD) score?
A: Creatinine, Total Bilirubin, Alkaline Phosphatase
B: Creatinine, Total Bilirubin, INR
C: INR, Total Bilirubin, Alkaline Phosphatase
D: INR, Direct Bilirubin, Alkaline Phosphatase

THE CORRECT ANSWER IS B.

1) What a laboratory values are needed for calculating the Model for EndStage Liver Disease (MELD) score?
A: Creatinine, Total Bilirubin, Alkaline Phosphatase
B: Creatinine, Total Bilirubin, INR
C: INR, Total Bilirubin, Alkaline Phosphatase
D: INR, Direct Bilirubin, Alkaline Phosphatase

Continue with the Case

QUESTION SLIDE 2
2) Above what MELD score is TIPS relatively contraindicated due to
increased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25

THE CORRECT ANSWER IS A.

2) Above what MELD score is TIPS relatively contraindicated due to
increased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25

Continue with the Case

REFERENCES & FURTHER READING

Ferral H, et al. Survival after elective transjugular intrahepatic portosystemic shunt
creation: prediction with model for end-stage liver disease score. Radiology. 2004
Apr;231(1):231-6.
Martin LG. Percutaneous placement and management of the Denver shunt for portal
hypertensive ascites. Am J Roentgenol. 2012 Oct;199(4):W449-53.
Harris K, Chalhoub M. The use of a PleurX catheter in the management of recurrent
benign pleural effusion: a concise review. Heart Lung Circ. 2012 Nov;21(11):661-5.