Left hepatohydrothorax without ascites in a case of cirrhosis, portal hypertension and splenomegaly

Case contributed by Dr Jayanth Keshavamurthy

Presentation

60-year-old white female with elevated portal venous pressure and recent GI bleeding requiring endoscopic intervention. Patient presents today for TIPS procedure. History of alcoholism with negative serology for Hepatitis B and C.

Patient Data

Age: 60 years old
Gender: Female

Name some unique causes for left pleural effusion.

Modality: X-ray

Given patient's hepatosplenomegaly and cirrhosis this could be a rare left hepato hydrothorax. As opposed to pleural effusions of cardiac origin that are typically bilateral, 79.5% of pleural effusions in a patient with cirrhosis are right sided only, 17.5% are left sided only, and 3% are bilateral.

Up to 20% of patients with hepatic hydrothorax have no clinically significant ascites.

Also, radioactive isotope scans confirm communication between the peritoneal cavity and the pleural space, even in the absence of sonographic evidence of ascites.

If this is confirmed then possibly intervention radiology can be consulted for TIPS placement.
 

When is portal vein diameter abnormal and indicates portal hypertension?

Modality: Ultrasound

Impression:
1. Hepatosplenomegaly with hepatic cirrhosis and portal hypertension but no portal venous thrombosis or ascites.
2. Cholelithiasis without acute cholecystitis.

The cut off is 13 mm for portal vein measurement to call portal hypertension.

What is normal portal pressure?

Modality: DSA (angiography)

TECHNIQUE:

The risks, benefits and alternatives were discussed and informed consent was obtained. Prior to beginning the procedure, Universal Protocol was performed to confirm the patient's identity and the planned procedure. The fluoroscopy time has been recorded in the electronic medical record. Maximum sterile barriers including cap, mask, hand hygiene, sterile gloves, sterile gown, large sterile drape and 2% chlorhexidine for cutaneous antisepsis were used.

The skin over the right internal jugular access site was infiltrated with 2% plain lidocaine. The vein was accessed using real-time ultrasound guidance. A wire was advanced centrally followed byplacement of a 10 french vascular sheath.

Using fluoroscopic guidance, a MPA catheter was advanced into the  right hepatic vein. Over an Amplatz wire the catheter was exchanged for a balloon occlusion catheter. Wedged hepatic venography was done in two projections using carbon dioxide in order to identify the location of the main portal vein branches.

The catheter was exchanged for a Colapinto needle. Passes were made across the liver parenchyma until the right portal vein was entered. A guidewire followed by a catheter was advanced into the portal vein which was confirmed by contrast injection. A marking pigtail catheterwas then advanced into the portal vein. Simultaneous portal and hepatic venography was done to measure the length of the transhepatic tract. Pre-TIPS pressures were measured in the portal vein and right atrium.

The catheter was exchanged over an extra-stiff guidewire for an 8 mm balloon which was used to pre-dilate the parenchymal tract. The long sheath was advanced into the portal vein and through this a 7 x 5 x 2 cm fluency stent was advanced and deployed.

The stent graft was dilated using a 10 mm balloon. The pigtail catheter was re-advanced into the portal vein for post-TIPS venography and pressure measurements. The catheters were removed and hemostasis was achieved at the access site by manual compression

Pre-TIPS portosystemic gradient: 25 mmHg
Post-TIPS portosystemic gradient: 10 mmHg
 

Case Discussion

Patient so far is doing well after TIPS and a quick improvement in the left pleural effusion.

This again tells the good team work of GI and interventional radiology.

The left pleural effusion was a transudate -serum albumen is < 1g/dl and total protein is <2 g/dl.

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Case Information

rID: 44986
Case created: 11th May 2016
Last edited: 11th Mar 2017
Inclusion in quiz mode: Included

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