Application of Contrast-Enhanced Ultrasound to Detect Hepatic Hydrothorax in Patients with Liver Cirrhosis

Abstract

Purpose Hepatic hydrothorax (HH) is defined as transudate in the pleural cavity in patients with decompensated liver cirrhosis (DC) without concomitant cardiopulmonary or pleural disease. It is associated with high short-term mortality. HH can evolve via translocation through diaphragmatic gaps. The aim of this study was to evaluate the feasibility and safety of injecting ultrasound contrast medium into the peritoneal cavity to detect HH.

Materials and Methods This study included patients with concomitant ascites and pleural effusion who were admitted to our hospital between March 2009 and February 2019. A peritoneal catheter was inserted and ultrasound contrast medium was injected into the peritoneal cavity. In parallel, the peritoneal and pleural cavities were monitored for up to 10 minutes.

Results Overall, 43 patients were included. The median age was 60 years and the majority of patients were male (n = 32, 74 %). Most patients presented with right-sided pleural effusion (n = 32, 74 %), 3 (7 %) patients with left-sided and 8 (19 %) patients had bilateral pleural effusion. In 12 (28 %) patients ascites puncture was not safe due to low volume ascites. Thus, the procedure could be performed in 31 (72 %) patients. No adverse events occurred. In 16 of 31 (52 %) patients we could visualize a trans-diaphragmic flow of microbubbles. The median time until transition was 120 seconds.

Conclusion Our clinical real-world experience supports the safety and feasibility of intraperitoneal ultrasound contrast medium application to detect HH in patients with DC, as a non-radioactive real-time visualization of HH. Our study comprises the largest cohort and longest experience using this method to date.

Zusammenfassung

Ziel Der hepatische Hydrothorax (HH) ist definiert als pleurales Transsudat in Patienten mit dekompensierter Leberzirrhose (DC) ohne begleitende kardiopulmonale oder pleurale Erkrankungen. Er geht mit einer hohen Sterblichkeitsrate einher. Der HH kann durch Flüssigkeitstranslokation durch diaphragmale Lücken entstehen. Ziel dieser Studie war es, die Durchführbarkeit und Sicherheit der intraperitonealen Ultraschallkontrastmittelinjektion zur Detektion eines HH zu evaluieren.

Material und Methoden Die Studie umfasste Patienten mit simultanem Aszites und Pleuraergüssen, die zwischen März 2009 und Februar 2019 in unserer Klinik stationär waren. Nach Anlage eines Peritonealkatheters erfolgte die Injektion von Ultraschallkontrastmittel in die Peritonealhöhle. Parallel wurden Peritoneal- und Pleurahöhlen für bis zu 10 Minuten gemonitort.

Ergebnisse Insgesamt wurden 43 Patienten eingeschlossen. Das Durchschnittsalter betrug 60 Jahre, wobei die Mehrheit der Patienten männlich war (n = 32, 74 %). Die meisten Patienten wiesen rechtsseitige Pleuraergüsse auf (n = 32, 74 %), 3 Patienten (7 %) linksseitige und 8 Patienten (19 %) hatten beidseitige Pleuraergüsse. In 12 Patienten (28 %) war eine Aszitespunktion aufgrund zu geringer Aszitesmengen nicht sicher. Die Prozedur wurde so in 31 Patienten (72 %) durchgeführt. Es ereigneten sich keinerlei unerwünschte Ereignisse. In 16 der 31 Patienten (52 %) konnte ein transdiaphragmaler Fluss von Mikrobubbles beobachtet werden. Die mediane Zeit bis zum Übertritt betrug 120 Sekunden.

Schlussfolgerungen Unsere Real-World-klinischen Erfahrungen unterstützen die Sicherheit und Durchführbarkeit der intraperitonealen Ultraschallkontrastmittelapplikation zur Detektion des HH in Patienten mit DC als nichtradioaktive Echtzeit-Untersuchung. Wir berichten über die bisher größte Kohorte und die längsten Erfahrungen in der Anwendung dieser Methodik.

Key words

hepatic hydrothorax - complications of cirrhosis - short-term mortality - contrast-enhanced ultrasound - SonoVue

Publication History

Received: 19 January 2020

Accepted: 19 May 2020

Article published online:
16 July 2020

• References

• 1 Porcel JM. Identifying transudates misclassified by Light’s criteria. Current opinion in pulmonary medicine 2013; 19: 362-367 DOI: 10.1097/MCP.0b013e32836022dc. PubMed PMID: 23508114
• 2 Dinu M, Georgescu AC, Ciurea RN. et al The role of cytology in the diagnosis of fluid collection syndromes associated with liver cirrhosis. Clinical, epidemiological, cytological and biochemical study of pleural effusion. Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie 2012; 53: 989-995 . PubMed PMID: 23303023
• 3 Abbasi A, Bhutto AR, Alam MT. et al Frequency of Hepatic Hydrothorax and its Association with Child Pugh Class in Liver Cirrhosis Patients. Journal of the College of Physicians and Surgeons – Pakistan: JCPSP 2016; 26: 566-569 . doi:2371. PubMed PMID: 27504545
• 4 Kim JS, Kim CW, Nam HS. et al Hepatic hydrothorax without ascites as the first sign of liver cirrhosis. Respirology case reports 2016; 4: 16-18 DOI: 10.1002/rcr2.140. PubMed PMID: 26839695; PubMed Central PMCID: PMC4722098
• 5 Garbuzenko DV, Arefyev NO. Hepatic hydrothorax: An update and review of the literature. World journal of hepatology 2017; 9 (31) 1197-1204 DOI: 10.4254/wjh.v9.i31.1197. PubMed PMID: 29152039; PubMed Central PMCID: PMC5680207
• 6 Lazaridis KN, Frank JW, Krowka MJ. et al Hepatic hydrothorax: pathogenesis, diagnosis, and management. The American journal of medicine 1999; 107: 262-267 DOI: 10.1016/s0002-9343(99)00217-x. PubMed PMID: 10492320
• 7 Huang PM, Chang YL, Yang CY. et al The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. The Journal of thoracic and cardiovascular surgery 2005; 130 (01) 141-145 DOI: 10.1016/j.jtcvs.2004.08.051. PubMed PMID: 15999054
• 8 Hewett LJ, Bradshaw ML, Gordon LL. et al Diagnosis of isolated hepatic hydrothorax using peritoneal scintigraphy. Hepatology 2016; 64: 1364-1366 DOI: 10.1002/hep.28634. PubMed PMID: 27178806
• 9 Zenda T, Miyamoto S, Murata S. et al Detection of diaphragmatic defect as the cause of severe hepatic hydrothorax with magnetic resonance imaging. The American journal of gastroenterology 1998; 93: 2288-2289 DOI: 10.1111/j.1572-0241.1998.00639.x. PubMed PMID: 9820418
• 10 Tamano M, Hashimoto T, Kojima K. et al Diagnosis of hepatic hydrothorax using contrast-enhanced ultrasonography with intraperitoneal injection of Sonazoid. Journal of gastroenterology and hepatology 2010; 25: 383-386 DOI: 10.1111/j.1440-1746.2009.06002.x. PubMed PMID: 19817961
• 11 Foschi FG, Piscaglia F, Pompili M. et al Real-time contrast-enhanced ultrasound--a new simple tool for detection of peritoneal-pleural communications in hepatic hydrothorax. Ultraschall in der Medizin 2008; 29: 538-542 DOI: 10.1055/s-2008-1027328. PubMed PMID: 19241513
• 12 Piscaglia F, Nolsoe C, Dietrich CF. et al The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall in der Medizin 2012; 33: 33-59 DOI: 10.1055/s-0031-1281676. PubMed PMID: 21874631
• 13 Badillo R, Rockey DC. Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature. Medicine 2014; 93: 135-142 DOI: 10.1097/MD.0000000000000025. PubMed PMID: 24797168; PubMed Central PMCID: PMC4632908
• 14 European Association for the Study of the L. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of hepatology 2010; 53: 397-417 DOI: 10.1016/j.jhep.2010.05.004. PubMed PMID: 20633946
• 15 Yoon JH, Kim HJ, Jun CH. et al Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?. Yonsei medical journal 2019; 60: 944-951 DOI: 10.3349/ymj.2019.60.10.944. PubMed PMID: 31538429; PubMed Central PMCID: PMC6753336
• 16 Dietrich CF, Averkiou M, Nielsen MB. et al How to perform Contrast-Enhanced Ultrasound (CEUS). Ultrasound international open 2018; 4: E2-E15 DOI: 10.1055/s-0043-123931. PubMed PMID: 29423461; PubMed Central PMCID: PMC5802984