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

Case contributed by Jayanth Keshavamurthy
Diagnosis certain

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
Gender: Female

Massive left pleural effusion. Mediastinal shift to right and complete left lung collapse.

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.

Impression:

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.

Case Discussion

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

This again tells the good teamwork 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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