Subscribe to RSS
DOI: 10.1055/s-2007-980143
Der hepatische Hydrothorax - seltene Differenzialdiagnose des Pleuraergusses mit schwierigem Management
Hepatic Hydrothorax - A Rare Cause of Pleural Effusion that is Difficult to ManagePublication History
eingereicht 26.8.2007
akzeptiert 24.9.2007
Publication Date:
20 November 2007 (online)
![](https://www.thieme-connect.de/media/pneumologie/200801/lookinside/thumbnails/10.1055-s-2007-980143-1.jpg)
Zusammenfassung
Der hepatische Hydrothorax stellt eine seltene, aber wichtige Differenzialdiagnose eines meist einseitigen Pleuraergusses dar. Zu beobachten ist er als Komplikation der portalen Hypertension bei < 10 % der Patienten mit Aszites im Rahmen einer fortgeschrittenen Leberzirrhose. Pathogenetisch zugrunde liegt eine peritoneo-pleurale Flüssigkeits-Translokation, am ehesten durch Zwerchfelldefekte. In seltenen Fällen kann es zu einem kompletten Flüssigkeitsübertritt in den Pleuraraum kommen. Wir beschreiben den Fall eines 67-jährigen Leberzirrhose-Patienten mit einem massiven isoliert rechtsseitigen Pleuraerguss und ohne relevanten Aszitesnachweis. Basierend auf dieser Kasuistik wird die Pathophysiologie und das - insbesondere bei kontinuierlichem Anfall größerer pleuraler Flüssigkeitsmengen - sehr schwierige diagnostische und therapeutische Management des hepatischen Hydrothorax im Spiegel der aktuellen Literatur kritisch diskutiert. Im vorliegenden Fall sicherte erst eine intraperitoneale Farbstoffapplikation mit dem Nachweis von raschem Farbstoffübertritt in den Pleuraraum die Diagnose.
Abstract
Hepatic hydrothorax is a rare but important cause of - usually unilateral - pleural effusion. Hepatic hydrothorax can be observed as a complication of portal hypertension in < 10 % of the patients with ascites secondary to advanced liver cirrhosis. The underlying pathophysiological mechanism seems to be a direct movement of fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. In rare cases complete translocation of fluid into the pleural space can be observed. We describe a 67-year-old cirrhotic patient suffering from a massive pleural effusion on the right side in the absence of any relevant ascites. Based on this case report and a review of the literature, we discuss the pathogenesis and - especially in cases characterised by a continuous accumulation of large amounts of pleural effusion - the notoriously difficult diagnostic and therapeutic management of hepatic hydrothorax. In the case described here, the intraperitoneal application of dye helped to prove that the fluid in the pleural space originated from the peritoneal cavity.
Literatur
- 1 Morrow C S, Kantor M, Armen R N. Hepatic hydrothorax. Ann Intern Med. 1958; 49 193-203
- 2 Cardenas A, Kelleher T, Chopra S. Hepatic hydrothorax. Aliment Pharmacol Ther. 2004; 20 271-279
- 3 Alberts W M, Salem A J, Solomon D A. et al . Hepatic hydrothorax. Cause and management. Arch Intern Med. 1991; 151 2353-2358
- 4 Kinasewitz G T, Keddissi J I. Hepatic hydrothorax. Curr Opin Pulm Med. 2003; 9 261-265
- 5 Lieberman F L, Hidemura R, Peters R L. et al . Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med. 1966; 6 341-351
- 6 Emerson P A, Davies J H. Hydrothorax complicating ascites. Lancet. 1955; 268 487-488
- 7 Chen A, Ho Y S, Tu Y C. et al . Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol. 1988; 10 663-666
- 8 Kakizaki S, Katakai K, Yoshinaga T. et al . Hepatic hydrothorax in the absence of ascites. Liver. 1998; 18 216-220
- 9 Kirsch C M, Chui D W, Yenokida G G. et al . Hepatic hydrothorax without ascites. Am J Med Sci. 1991; 302 103-106
- 10 Truninger K, Frey L D. Hepatischer Hydrothorax ohne Aszites. Schweiz Med Wochenschr. 2000; 130 1706
- 11 Umino J, Tanaka E, Ichijoh T. et al . Hepatic hydrothorax in the absence of ascites diagnosed by intraperitoneal spraying of indiocyanine green. Internal Med. 2004; 43 283-288
- 12 Bozkurt S, Stein J, Teuber G. Hepatic hydrothorax. Z Gastroenterol. 2005; 43 1319-1328
- 13 Leuallen E C, Carr D T. Pleural effusion: a statistical study of 436 patients. N Engl J Med. 1955; 252 79-83
- 14 Lazaridis K N, Frank J W, Krowka M J. et al . Hepatic hydrothorax: pathogenesis, diagnosis, and management. Am J Med. 1999; 107 262-267
- 15 Zenda T, Miyamoto S, Murata S. et al . Detection of diaphragmatic defect as the cause of severe hepatic hydrothorax with magnet resonance imaging. Am J Gastroenterol. 1998; 93 2288-2289
- 16 Huang P M, Chang Y L, Yang C Y. et al . The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg. 2005; 130 141-145
- 17 Benet A, Vidal F, Toda R. et al . Diagnosis of hepatic hydrothorax in the absence of clinical ascites by intraperitoneal injection of 99 m-Tc-Fluor colloid. Postgrad Med J. 1992; 68 153
- 18 Albin R J, Johnston G S. External accumulation of radionuclide in hepatic hydrothorax. Clin Nucl Med. 1989; 14 341-343
- 19 Pfammatter R, Quattropani C, Reichen J. et al . Treatment of hepatic hydrothorax and reduction of chest tube output with octreotide. Eur J Gastroenterol. 2001; 13 977-980
- 20 Runyon B A, Greenblatt M, Ming R H. Hepatic hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol. 1986; 81 566-567
- 21 Gordon F D, Anastopoulus H T, Crenshaw W. et al . The successful treatment of symptomatic, refractory hepatic hydrothorax with TIPS. Hepatology. 1997; 25 1366-1369
- 22 Siegerstetter V, Deibert P, Ochs A. et al . Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol. 2001; 13 529-534
- 23 Boyer T. Transjugular intrahepatic portosystemic shunt: current status. Gastroenterology. 2003; 124 1700-1710
- 24 Garrido Serrano A, Pascasio Acevedo J M, Marquez Galan J L. Treatment of hepatic hydrothorax with octreotide. Rev Esp Enferm Dig. 2006; 98 627-629
- 25 Chalasani N, Clark W S, Martin L G. et al . Determinants of mortality in patients with advanced liver cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology. 2000; 118 138-144
- 26 Malinchoc M, Kamath P S, Gordon F D. et al . A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000; 31 864-870
Privatdozent Dr. med. Axel F. G. von Bierbrauer
Chefarzt Abteilung Innere Medizin, Städtisches Klinikum Neunkirchen gGmbH, Akademisches Lehrkrankenhaus der Universität des Saarlandes
Brunnenstraße 20
66538 Neunkirchen/Saar
Email: a.vonbier@krh-nk.de