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8/10/2019 SIR RFS Case Series: Recurrent Hepatic Hydrothorax
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RECURRENT HEPATICHYDROTHORAX
Originally Posted:
Resident(s): Osama Abdul-RahimAttending(s): Paul Brady
Program/Dept(s): Einstein Healthcare Network, Philadelphia, PA
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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
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DIAGNOSTIC WORKUP
Physical Exam Distended abdomen with tenderness to palpation
Hepatic encephalopathy, unclear what constitutes his bmental 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
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DIAGNOSTIC WORKUP - IMAGING
Initial CT abdand pelvis shdiffuse infectcolitis, sequeportal HTN, right pleuraleffusion
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DIAGNOSTIC WORKUP - IMAGING
1 week later right pleuraleffusion hadworsened depercutaneou
catheter drai
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DIAGNOSIS
Refractory hepatic hydrothorax
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INTERVENTION
In the setting of a MELD 18-22 and questionable baselineencephalopathy, 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
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INTERVENTION DENVER SHUNT
One end of shunt placed in pleural space Venipuncture access s
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INTERVENTION DENVER SHUNT
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CLINICAL FOLLOW UP
Improving eafter sh
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SUMMARY & TEACHING POINTS
54 y/o male with refractory hepatic hydrothorax 2oHCV c
Poor TIPS candidate (MELD 18-22)
Poor PleurX catheter candidate (non-compliance)
Pleurovenous (Denver) shunt placed resulting in a signific
improvement of his hydrothorax Shunt works by compressing the pump against chest w
several times per day to manually move fluid from the pspace to the systemic venous system
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QUESTION SLIDE 1
1) What a laboratory values are needed for calculating the Model fStage 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
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THE CORRECT ANSWER IS B.
1) What a laboratory values are needed for calculating the Model fStage 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
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QUESTION SLIDE 2
2) Above what MELD score is TIPS relatively contraindicated due toincreased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25
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THE CORRECT ANSWER IS A.
2) Above what MELD score is TIPS relatively contraindicated due toincreased risk of 30 day mortality?
A: 18
B: 8
C: 13
D: 25
Continue with the Case
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REFERENCES & FURTHER READING
Ferral H, et al. Survival after elective transjugular intrahepatic portosystemcreation: prediction with model for end-stage liver disease score. RadiologyApr;231(1):231-6.
Martin LG. Percutaneous placement and management of the Denver shunthypertensive ascites.Am J Roentgenol. 2012 Oct;199(4):W449-53.
Harris K, Chalhoub M. The use of a PleurX catheter in the management of
benign pleural effusion: a concise review. Heart Lung Circ. 2012 Nov;21(1
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