Showing papers on "Hydrothorax published in 2014"

Bronchopulmonary sequestration with massive pleural effusion: pleuroamniotic shunting vs intrafetal vascular laser ablation.

Abstract: Objective To assess the incidence of complications among a relatively large cohort of fetuses with bronchopulmonary sequestration (BPS) and the success of two different intrauterine treatment modalities. Methods All cases with a prenatal diagnosis of BPS detected in a 10-year period (2002–2011) in two tertiary referral centers were reviewed retrospectively for intrauterine course and outcome. Up to May 2010 severe pleural effusions were treated with pleuroamniotic shunting. Thereafter, they were treated with ultrasound-guided laser coagulation of the feeding artery. Results A total of 41 fetuses with BPS were included in the study. In 29 (70.7%) there was no pleural effusion or hydrops and they were treated conservatively. In 19/29 (65.5%) there was partial or complete regression of the lesion during the course of pregnancy. All were born alive (median age at delivery, 38.3 (interquartile range (IQR), 34.0–39.6) weeks) and 16 (55.2%) required sequestrectomy. Intrauterine intervention was performed in all 12 (29.3%) fetuses with pleural effusion. Seven fetuses were treated with pleuroamniotic shunting. One fetus with severe hydrops died in utero. There was no complete regression in any case of BPS in this group. Six infants were born alive (median age, 37.2 (IQR, 30.3–37.4) weeks), of which five (83.3%) required sequestrectomy. Five fetuses were treated with laser ablation of the feeding vessel. In all cases of BPS there was regression after laser ablation. All infants were delivered at term (median age, 39.1 (IQR, 38.0–40.0) weeks). One (20.0%) neonate required sequestrectomy after birth. Following intrauterine shunt placement complete regression of the lesion was significantly less frequent (0/7 (0%) with shunt placement vs 4/5 (80%) with intrafetal laser treatment) and gestational age at birth was significantly lower, compared to treatment with intrafetal laser. Complete regression of the lesion was also significantly more frequent in the laser group compared to cases without intervention. Conclusion In the absence of pleural effusion, the likelihood of spontaneous regression of BPS is high and the prognosis is therefore favorable. In cases with massive pleural effusion, treatment by laser ablation of the feeding vessel seems to be more effective than is pleuroamniotic shunting, with fewer complications. It might also reduce the need for postnatal surgery. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Management of refractory hepatic hydrothorax.

Abstract: Purpose of reviewTreatment of hepatic hydrothorax is challenging because of its rapid symptomatic recurrence. This review will focus on potential therapeutic approaches to hepatic hydrothorax.Recent findingsHepatic hydrothorax is refractory to salt restriction and diuretics in approximately 25% of c

Hydrops fetalis in a preterm newborn heterozygous for the c.4A>G SHOC2 mutation

Abstract: Fetal hydrops is a condition resulting from interstitial fluid accumulation in fetal compartments secondary to increased capillary permeability and characterized by high rates of perinatal mortality and morbidity. Clinical features include skin edema, hydrothorax, pericardial effusion, ascites with or without polyhydramnios, and placental edema. While it may occur as associated feature in multiple disorders, it has been documented to recur in Noonan syndrome, the most common disorder among RASopathies, but also in cardiofaciocutaneous and Costello syndromes. Here, we report on the occurrence of severe hydrops in a newborn heterozygous for the invariant c.4A>G missense change in SHOC2 which underlies Noonan-like syndrome with loose anagen hair, documenting that it represents a clinically relevant complication in this condition, shared by RASopathies.

Diagnosis by Peritoneal scintigraphy of Peritoneal Dialysis–Associated Hydrothorax in an Infant:

Abstract: 1. LaMont JT. Clostridium difficile infection in adults: clinical manifestations and diagnosis [Web page]. Waltham, MA: UpToDate; n.d. [Available at: http://www. uptodate.com/contents/clostridium-difficile-in-adultsclinical-manifestations-and-diagnosis?source=search_ result&search=Clinical+manifestations+and+diagnosis+ of+Clostridium+difficile+infection+in+adults&selected Title=1~139; accessed 25 June 2013] 2. Seppälä K, Hjelt L, Sipponen P. Colonoscopy in the diagnosis of antibiotic-associated colitis. A prospective study. Scand j Gastroenterol 1981; 16:465–8. 3. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, et al. Peritoneal dialysis–related infections recommendations: 2005 update. Perit Dial Int 2005; 25:107–31. 4. Genta VM, Gilligan PH, McCarthy LR. Clostridium difficile peritonitis in a neonate. A case report. arch Pathol Lab Med 1984; 108:82–3. 5. de Leeuw P, de Mot H, Dugernier T, Wautelet J, Bohy E, Delmée M. Primary infection of ascitic fluid with Clostridium difficile. j Infect 1990; 21:77–80. 6. Laroche MC, Alfa MJ, Harding GK. Isolation of toxigenic Clostridium difficile from dialysate fluid in a fatal case of chronic ambulatory peritoneal dialysis–related peritonitis. Clin Infect Dis 1997; 25:1248. 7. Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010; 31:431–55. doi:10.3747/pdi.2012.00177

Impact of preoperative uncontrollable hepatic hydrothorax and massive ascites in adult liver transplantation

Abstract: Uncontrollable hepatic hydrothorax and massive ascites (HM 3 years: 58.9 vs. 77.7 %; P = 0.003) in group HA than in group C. The multivariate proportional regression analyses revealed that uncontrollable H&MA and the Child–Pugh score were independent risk factors for the postoperative prognosis. Postoperative infection control may be an important means of improving the outcome for patients with uncontrollable H&MA undergoing LT, and clinicians should strive to perform surgery before H&MA becomes uncontrollable.

Thoracoscopic removal of retained thoracoamniotic shunt catheters in newborns.

Abstract: Fetal hydrothorax is associated with significant mortality. However, the development of fetal thoracoamniotic shunting has reduced the mortality rate. Fetal thoracoamniotic shunting can be characterized by significant complications, such as intrathoracic dislodgement of the catheter. The ideal management of dislodged catheters postnatally is not known. We report two newborns with a prenatal diagnosis of fetal hydrothorax who underwent thoracoamniotic shunting complicated by intrathoracic dislodgement of the catheters requiring thoracoscopic removal of the shunts in the neonatal period.

Pleuroperitoneal leak: an unusual cause of acute shortness of breath in a peritoneal dialysis patient.

Abstract: Introduction. Pleuroperitoneal leak is an uncommon complication of continuous ambulatory peritoneal dialysis (CAPD), with an estimated incidence of 1.6%. It should be suspected in these patients when they present with recurrent unilateral pleural effusions and/or acute shortness of breath following dialysate infusion. Case Presentation. We present the case of a 25-year-old female patient who had acute hydrothorax as a result of pleuroperitoneal leak complicating continuous ambulatory peritoneal dialysis (CAPD), which was confirmed on peritoneal scintigraphy. Conclusion. Continuous ambulatory peritoneal dialysis patients presenting with acute shortness of breath and/or recurrent unilateral pleural effusion should be investigated with peritoneal scintigraphy to exclude pleuroperitoneal leak.

Experimental model to evaluate the effect of hydrothorax and lobar resection on lung compliance

Abstract: OBJECTIVES: The objective of this study was to evaluate to what extent lung compliance is affected by the individual and combined action of lung resection and hydrothorax in an animal model. METHODS: Anaesthetized and mechanically ventilated rabbits (weight range 2÷2.2 kg) were randomized in two groups: (i) experimental hydrothorax (from 2 to 8 ml) (n= 5) and (ii) right lower lobe lobectomy (n= 4) and right middle plus lower lobe resection (n= 2). To obtain lung compliance, we measured alveolar, oesophageal pressures and lung volume during slow inflation manoeuvres in control conditions and after hydrothorax or lung resection. Lung compliance was estimated as the change in lung volume divided by the change in transpulmonary pressure. Based on the changes in compliance of the whole lung, we calculated the corresponding changes in compliance of the right lung, which was directly exposed to unilateral hydrothorax and lobectomy. RESULTS: Average total lung compliance in the control was 3.3 ± 0.8 (SD) ml/cmH2O. Eight millilitres of hydrothorax significantly decreased (P< 0.001) lung compliance to 2.7 ± 0.7 ml/cmH2O and increased pleural liquid pressure at the bottom of the cavity from �1 cmH2 Ou p to 2.5–3 cmH2O. Resection of the right lower lobe significantly decreased (P< 0.001) lung compliance to 1.75 ± 0.3 ml/cmH2O. Resection of the right middle plus lower lobes significantly decreased (P< 0.001) lung compliance to 1.52 ± 0.4 ml/cmH2O. CONCLUSIONS: Following hydrothorax, the decrease in right lung compliance (45%) was much greater than that expected based on the estimated decrease in right lung volume (20%). We attribute this difference to the fact that hydrothorax causes the lung to be exposed to positive, rather than sub-atmospheric, pressure, causing atelectasis. Following lobectomy, right lung compliance decreased by 62 and 80% for estimated decreases in lung volume of 30 and 60%. This difference could reflect inaccuracy in the estimate of lung volume reduction based on resected weight and/or surgical damage. We conclude that potential detrimental effects of hydrothorax and lobar resection decrease lung compliance and expose the lung to the risk of over-distension when a chest drain is applied.

Meigs' syndrome with elevated serum CA 125 level in a case of ovarian fibrothecoma.

Abstract: Meigs' syndrome is the association of benign ovarian tumor, pleural effusion, and ascites. Meigs' syndrome with marked elevated CA 125 is a rare clinical entity and only 42 cases have been reported. Although there is difficulty in discerning the diagnosis of Meigs' syndrome from that of an ovarian malignancy, it should be considered in the differential diagnosis in postmenopausal patients with an ovarian mass, hydrothorax, ascites, and elevated CA 125. In this report, the authors present the case of a 52-year-old postmenopausal woman with ovarian fibrothecoma, pleural effusion, ascites, and elevated CA 125 (319.2 IU/ml). Exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy was performed, and the pathologic diagnosis was ovarian fibrothecoma. After the surgery, the pleural effusion disappeared spontaneously and the CA 125 became normal. The authors also summarized other cases of Meigs' syndrome with elevated CA 125, and reviewed the mechanism of elevation of CA 125, ascites, and pleural effusion.

Anesthetic considerations in Demons-Meigs’ syndrome: a case report

Abstract: Demons-Meigs’ syndrome is characterized by the presence of a benign ovarian tumor associated with ascites and a right-sided hydrothorax. Its pathophysiology remains unclear. Anesthesia of this syndrome is a real challenge. Respiratory, hemodynamic, metabolic problems and abdominal hypertension are the main anesthetic risks. A 52-year-old African woman with Demons-Meigs’ syndrome was admitted for elective surgery under general anesthesia. An abdominal computed tomography scan showed a tumor mass, with tissue and cystic components associated with abundant ascites and a right pleural effusion of medium abundance. In the operating room after standard monitoring, a crash induction was performed. Just after, her saturation level decreased requiring the use of an alveolar recruitment maneuver followed by the application of positive end-expiratory pressure. Vasoconstrictor and vascular filling were used to correct the hypotension that occurred. Airway pressures remained at 35cm H2O. Maintenance of a slightly proclive position and opening of the abdomen with the progressive removal of 3200ml ascitic fluid allowed a lower thoracic pressure (airway pressures=24cm H2O). Her postoperative course was unremarkable. Clinical evolution after five months was marked by a complete recovery of our patient and no recurrence of effusion or ascites. Demons-Meigs’ syndrome is a benign disease with a good prognosis. Respiratory and hemodynamic problems and abdominal hypertension are the main anesthetic risks of this syndrome. Good management of these risks is necessary to preserve the prognosis.

Hepatic hydrothorax: The shower within.

Abstract: Hepatic hydrothorax (HH) is an infrequent but a well-known complication of portal hypertension. Transdiaphragmatic passage of ascitic fluid from peritoneal to the pleural cavity through numerous diaphragmatic defects has been shown to be the predominant mechanism in the formation of HH. Medical management of this condition often fails, and there are no large randomized-controlled trials establishing the best treatment strategies. HH thus represents a formidable entity in the management of end-stage liver disease, and the only definitive treatment is liver transplantation. However, in selected group of patients, medical thoracoscopy not only helps in establishing the diagnosis but can also be used as an effective management strategy, especially in patients awaiting liver transplantation.

Central venous line and acute neurological deficit: a case series.

Abstract: Central venous catheter (CVC) insertion is a practical way to assess patients hemodynamic specially in cardiovascular surgery but this relatively simple junior level procedure is not risk free and its common reported complications include; pneumothorax, hydrothorax, hemothorax, local hematoma, cardiac tamponade, vascular injury, thrombosis, embolism, and catheter disruption. Here in this article we are going to present 6 patients with very unusual presentation of CVC complication which was neurological deficit presented by agitation, unconsciousness, disorientation to time and place and hemiparesis. All patients undergone neurologic consult and brain computed tomography. Final diagnosis was brain ischemic damage and finally we kept them on conservative management; fortunately we did not have any permanent damage.

Accidental placement of central venous catheter in lung parenchyma causing hydrothorax.

Abstract: Central venous catheterization is associated with its share of complications. Most of these complications can be avoided and treated by appropriate patient selection, careful insertion technique and vigilance following catheter insertion. We report a patient presenting with unilateral hydrothorax due malposition of central venous catheter in lung parenchyma. Prompt recognition of complication and its treatment remedied the situation.

Recurrent hydrothorax and surgical diaphragmatic repair: report of 2 cases and review of the literature.

Abstract: Background Pleural effusions may result from intra-abdominal processes and sometimes present with dramatic clinical consequences. We present 2 cases of recurrent hydrothorax requiring surgical repair of diaphragmatic defects and describe when surgery may be the best treatment modality. Patient 1 : A 63-year-old man with end-stage renal disease requiring peritoneal dialysis presented with dyspnea on exertion that progressed to cardiac arrest. He was found to have a tension hydrothorax that was initially stabilized with thoracentesis and tube thoracostomy. He eventually underwent surgical repair of fenestrations with complete resolution of his effusion. PATIENT 2:: A 52-year-old man with recurrent hydrothorax in the context of hepatitis C cirrhosis and hepatocellular carcinoma following radiofrequency ablation to his liver had recurrent admissions with dyspnea and a large pleural effusion. When medical therapy failed, he underwent surgical repair of a large diaphragmatic defect. Conclusions Hydrothorax related to peritoneal dialysis or cirrhosis may cause life-threatening scenarios in which medical management may stabilize the patient. Ultimately, surgical corrections of diaphragmatic defects may be necessary for definitive management in selected patients. Although these scenarios are rare, clinicians should be aware of these possibilities as early collaboration between medical and surgical services is essential for optimal patient care.

Severe "sweet" pleural effusion in a continuous ambulatory peritoneal dialysis patient.

Abstract: Introduction Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) which can progress quickly to cause acute respiratory distress.

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids.

Abstract: A 44-year-old male had a PPH for circumferential prolapsed hemorrhoids. Soon after returning to the ward, the patient complained of moderate abdominal pain and tenesmus, which developed subsequently into rectal bleeding resulting in a deterioration of the vital signs. Abdominal CT exanimation showed rectal wall hematoma and pelvic collection. An emergency explorative laparotomy was performed, and the seromuscular laceration was apparent on the anterior rectal wall at the level of peritoneal reflection. A double-barreled colostomy was performed in the left iliac fossa (Fig. 1). One abdominal drain and additional transanal abdominal drain and anal drain were well placed (Figs. 2, 3, 4). However, the patient developed fever (38 C), tachypnea (30–40/min) and tachycardia (130 bpm) on the third postoperative day. Chest CT examination demonstrated bilateral hydrothorax resulting in pulmonary atelectasis (Fig. 5). Thoracocentesis was carried out. Since then, the patient underwent a

Pleural Effusion from Leaky Diaphragm—the Hepatic Hydrothorax

Abstract: A 76-year-old woman with liver cirrhosis presented with six weeks of progressive shortness of breath, and was found to have a large right pleural effusion with minimal ascites. Echocardiogram showed normal left ventricular ejection fraction. The portal venous system was patent by Doppler ultrasound. Pleural fluid analysis revealed a transudative effusion without evidence of infection or malignancy. Despite drainage and diuretics, her effusion recurred. When technetium was injected into the peritoneal cavity for nuclear imaging, there was strong uptake in the perihepatic fluid collection and diffuse uptake into the right hemithorax, suggesting a peritoneo-pleural communication, confirming the diagnosis of hepatic hydrothorax (Figs. 1 and ​and2).2). The patient underwent a transjugular intrahepatic portosystemic shunt (TIPS) procedure with improvement of symptoms. Figure 1 Intense uptake of technetium noted in the perihepatic region, with diffusely increased uptake of lesser intensity in the right hemithorax with minimal or no uptake in the left hemithorax. Figure 2 Sagittal view showing diffusely increased uptake in the hemithorax. Hepatic hydrothorax is a complication of portal hypertension and usually affects the right side of the chest. Leakage of fluid from the peritoneal to the pleural cavity through sub-centimeter diaphragmatic defects is the likely mechanism.1 Once cardiopulmonary causes of effusion are excluded, the investigation of choice is radioisotope-based nuclear imaging.2,3 Chest tube placement should not be performed, as it can cause large amounts of fluid loss, leading to renal failure and even death.2 TIPS procedure is recommended in diuretic resistant patients with recurrent effusions, although eventually a liver transplantation should be considered.1,3

Monocyte chemoattractant protein (MCP) 2 used as marker for tubercular hydrothorax detection, and applications thereof

Abstract: The invention relates to a MCP-2/CCL8 protein used as a marker for identifying and diagnosing tubercular hydrothorax, and applications of the protein. The invention provides applications of the MCP-2/CCL8 protein in preparation of diagnostic reagents or kits for identifying and diagnosing tubercular hydrothorax. The invention also provides a corresponding detection kit. The invention also provides a method for detecting or diagnosing tubercular hydrothorax.

Rare case of massive congenital bilateral chylothorax in a hydropic fetus with true mosaicism 47,XXX/46,XX.

Abstract: Fetal congenital chylothorax is a rare condition that occurs sporadically or can be associated with abnormal karyotype or structural chromosomal anomalies. We report a unique case of fetal congenital bilateral chylothorax associated with mosaicism 47,XXX/46,XX. A female fetus affected by massive bilateral hydrothorax and ascites was diagnosed at 34(+1) weeks of gestation. Previous ultrasonographic exams were completely normal. Immune causes of hydrops were excluded. Elective cesarean section was performed soon after bilateral thoracocentesis. The analysis of drained pleural fluid revealed its lymphatic nature. The fetal karyotyping, performed on chorionic villi at the 11th week, had shown mosaicism 47,XXX/46,XX, later confirmed in the newborn's blood. We hypothesized that chylothorax may be part of the phenotypic spectrum of 47 XXX karyotype and we suggest an ultrasound follow-up of the fetus at closer intervals than the routine timing for this condition, even if it is not usually characterized by severe phenotypic features.

[Video-assisted thoracoscopic surgery for pleuroperitoneal communications as a complication of continuous ambulatory peritoneal dialysis( CAPD)].

Abstract: A 54-year-old female who was started on continuous ambulatory peritoneal dialysis( CAPD) for endstage renal disease secondary to focal developed 2 pleuroperitoneal communications. At first, she developed chest pain and cough on the day following introduction. A 99m-technetium-macroaggregated albumin (99mTc-MAA) radionuclide scan showed a communication between the abdomen and the right pleural cavity. We diagnosed a right pleuroperitoneal communication. Four months later, she developed similar symptoms and was diagnosed with a left pleuroperitoneal communication. Video-assisted thoracoscopic surgery was performed for each lesion. However, the communications were detected using different methods. During the 1st surgery, the communication was detected using peritoneal dialysis fluid containing indigocarmine introduced through a CAPD catheter. During the 2nd surgery, the communication was detected by pneumoperitoneum. With regards to diaphragmatic pressure regulation, pneumoperitoneum was more rapid and convenient, so pneumoperitoneum was considered more effective for the identification and treatment of pleuroperitoneal communications. Diaphragmatic plication and pleurodesis with polyglycolic acid felt and fibrin glue on both sides were performed. No recurrence of hydrothorax was detected after treatment.

Fetal lung and diaphragm malformations

Abstract: Congenital lung abnormalities are relatively rare but very dangerous for the fetus and neonate. This article describes the most common pulmonary complications observed during pregnancy such as congenital cystic adenomatoid malformation, diaphragmatic hernia, bronchopulmonary sequestration, hydrothorax, chylothorax, lung agenesia, pulmonary hypoplasia. The diagnostic methods and available therapy methods are discussed. Appropriate growth and maturation of the fetal lungs are substantial for the survival of the neonate and it creates the limits of viability. Among others, these processes are regulated by shape and size of the thorax, fetal breathing movements and adequate amniotic fluid volume. Pulmonary abnormalities are rather rare however by changing anatomy of the thorax they can create dangerous complications for the fetus eg. pulmonary hypoplasia. The most common lung abnormalities include: congenital cystic adenomatoid malformation, diaphragmatic hernia, bronchopulmonary sequestration, hydrothorax, chylothorax, lung agenesia, pulmonary hypoplasia, congenital lobar emphysema and congenital high airway obstruction [14].

[Marginal zone lymphoma of mucosa-associated lymphoid tissue of the parietal pleura; report of a case].

Abstract: An 76-year-old man was referred to our hospital due to right hydrothorax. The diffuse thickening of parietal pleura with increased fluoro-2-deoxy-D-glucose (FDG) uptake was noted by computed tomography (CT) and positron emission tomography (PET). Surgical biopsy was performed and the tumor was diagnosed as mucosal associated lymphoid tissue (MALT) lymphomas of parietal pleura origin by pathology. Complete remission was achieved by postoperative chemotherapy (R-CHOP), and the patient is now alive without recurrence.

Symptomatic hepatic hydrothorax successfully treated with transjugular intrahepatic portosystemic shunt (TIPS)–role of titration of portosystemic gradient reduction to avoid post‐TIPS encephalopathy

Abstract: A 64-year old Indian female with Child's B liver cirrhosis secondary to nonalcoholic steatohepatitis (NASH) presented to our hospital with symptoms of increasing breathlessness over 5 days. Clinical examination revealed tachypnea and decreased air entry over the right chest wall. Chest X-ray (CXR) showed a massive right pleural effusion with “white-out” of the right hemithorax (Fig.​(Fig.1).1). Therapeutic thoracocentesis drained 1.4 L of clear straw colored fluid. Biochemical analysis revealed a transudative effusion (pleural fluid LDH 64 U/L, serum LDH 564 U/L, pleural fluid total protein <10 g/L, serum total protein 66 g/L). Microbiological and cytological analyses were unyielding. Her albumin was 26 g/L, bilirubin 12 μmol/L, and prothrombin time 11.9 sec. She was negative for viral hepatitis, autoimmune hepatitis, Wilson's disease and did not consume alcohol. CT abdomen revealed liver cirrhosis, splenomegaly, and ascites. Gastroscopy revealed nonbleeding small esophageal varices, fundal varices, and portal gastropathy. A clinical diagnosis of right hepatic hydrothorax (HH) was made and she was treated with spironolactone 100 mg om, intravenous furosemide 40 mg bd and was maintained on a low salt diet of less than 88 mmol/day. Repeat CXR showed reduction in the right pleural effusion with resolution of breathlessness and she was discharged 3 days later. Figure 1 Initial CXR demonstrating a large right hydrothorax. Two days after discharge, her breathlessness recurred. CXR showed re-accumulation of the right pleural effusion, requiring a second thoracocentesis which drained 1.6 L of clear transudative fluid. She could not tolerate prolonged increases in her diuretics (spironolactone 100 mg om and furosemide 40 mg om) due to worsening renal function that normalized on withdrawal of said diuretics. Despite close follow up at 1–2 weekly intervals and serial CXRs, she was readmitted a further three times over the next 2 months for respiratory compromise due to re-accumulation of the right pleural effusion. None of these admissions were accompanied by any significant accumulation of ascites. CT thorax and pleural biopsy were performed to exclude any underlying lung or pleural pathology. Transthoracic echocardiography demonstrated normal cardiac function. A peritoneo-pleural scintigraphy study was attempted but failed to show significant accumulation of radiotracer in the thorax. This study was, however, performed when the right pleural effusion was maximal. This is likely to have resulted in a false negative test due to a reduced gradient of ascitic fluid flow across the diaphragm. Hepatic venous pressure gradient (HVPG) measurement was 19 mmHg, confirming the presence of significant sinusoidal portal hypertension. In view of the recurrent HH despite adequate salt restriction and intolerance of diuretics, the decision was made to insert a transjugular intrahepatic portosystemic shunt (TIPS) for treatment of her symptomatic HH. She had no prior episodes of hepatic encephalopathy and was Child's B (9 points) with a Model for Endstage Liver Disease (MELD) score of 13. Her bilirubin level was 1.7 mg/dL (29 μmol/L) with a serum sodium of 129 mmol/L and a serum creatinine of 1.4 mg/dL (124 μmol/L). TIPS was performed from the right hepatic vein to the portal vein with an initial post-TIPS portosystemic gradient of 6 mmHg (Fig.​(Fig.22). Figure 2 TIPS procedure–The three stents can be seen bridging the hepatic vein to the right portal venous system. Forty-eight hours after TIPS insertion, the patient developed grade 3 hepatic encephalopathy. Plasma ammonia had increased from 50 μmol/L pre-TIPS to 147 μmol/L post-TIPS. She responded to fleet enema and lactulose but had two further episodes of encephalopathy within 1 month. The TIPS was thus revised using a 10 × 58 mm atrium V12 stent placed across the previous stents. The new stent was sequentially inflated to leave a residual waist in the centre (Fig.​(Fig.3).3). The resultant post procedure HVPG was 14 mmHg. She rapidly recovered from the encephalopathy with normalization of plasma ammonia but the HH re-accumulated and her breathlessness recurred within 2 weeks. Figure 3 The V12 stent can be seen within the proximal portion of the TIPS with the residual waist (at the level of the arrows) to moderate the level of HVPG reduction. A further TIPS revision was carried out by balloon dilatation of the V12 stent to reduce the HVPG from 14 mmHg to 9 mmHg. At this level of portosystemic gradient, the patient's HH and ascites resolved completely, allowing discontinuation of diuretics. The TIPS revision significantly reduced the frequency and severity of encephalopathy and she has remained encephalopathy-free for the past 12 months. She is currently well and is awaiting listing for liver transplantation.

Diagnostic Thoracoscopy: Nonmalignant Pleural Effusion

Abstract: Nonmalignant effusion is a term that covers a broad spectrum of both inflammatory and noninflammatory conditions, including pleural involvement by cardiac and hepatic disease (transudative hydrothorax). Cardiac disease accounts for about 90 % of all transudative effusions, and effusions of varying extent are present in 58–73 % of all unselected hospitalized cardiac patients (Weiss and Spodick 1984). Indeed, since there is usually no pleural pathology in transudative effusion, such patients rarely, if ever, need thoracoscopic exploration. As there is a high prevalence of cardiac disease, it is therefore extremely important to establish whether an effusion is transudative or exudative in nature. Traditionally, this is best achieved by means of simple thoracocentesis using the classical Light’s criteria (protein and LDH levels). An overall discriminatory accuracy of 90 % can be achieved with the expanded triple test using well-established cutoff values and including additional cholesterol determinations in pleural fluid and serum (Table 11.1) (Heffner et al. 1997). Very recently, the determination of the marker NT-proBNP (a precursor of B-type natriuretic peptide) has been shown to be equally successful in identifying effusions secondary to cardiogenic hydrothorax, having an overall accuracy of 92 % (Kolditz et al. 2006). On the basis of these criteria and current epidemiology, the pretest odds relationship of transudative vs exudative etiologies in unselected patients with pleural effusion will be about 0.4/0.6.

Demons-meigs pseudosyndrome mimicking the symptoms of pregnancy: a case report.

Abstract: Background: The Demons-Meigs syndrome should usually be evoked in case of presence of a typical triad: abdominopelvic mass, ascites and hydrothorax. Its diagnosis appears crucial to prevent the realization of unnecessary surgical procedures. Case Presentation: A 32-year-old woman presented in April 2012 to the emergency department of our maternity unit (General Hospital, Thiers, France) with an abdominal distension mimicking the symptoms of a pregnancy at term. Physical examination revealed a voluminous painful abdominopelvic mass, extended from the pelvis to the upper abdomen with a large right pleural effusion. Ultrasound and computed tomography showed it was a tumor measuring more than 300 mm in diameter with a right hydrothorax. Serum CA-125 level was 289 U/ml. Cytologic analysis of the pleural effusion didn’t show any malignant cells. In this study, Demons-Meigs syndrome was recognized. A laparoscopico-laparotomic management permitted an aspiration of 23 liters of a brownish liquid and an unilateral adnexectomy after pleural paracentesis was performed. Frozen section demonstrated benign mucinous cystadenoma. The final histologic findings objectified intracystic intestinal type ovarian mucinous borderline tumor. After multidisciplinary consultation, the patient was reoperated one month later. The exploration didn’t reveal any suspected lesions and appendectomy and omentectomy were performed. The postoperative course was uneventful. Serum CA-125 level was normal at the time of the reoperation and 24 months after the initial surgery. Conclusion: The preoperative recognition of a Demons-Meigs syndrome or a Demons’ pseudosyndrome is essential to avoid useless surgical procedures.

Intrauterine therapy for nonimmune hydrops fetalis (NIHF) – analysis of 38 cases

Abstract: Objective: The aim of the study was to perform an audit the results of fetal therapy in cases of nonimmune hydrops fetalis (NIHF), isolated hydrothorax and isolated ascites. Methods: A total of 38 fetuses (17-35 weeks of pregnancy) were included in the study, whereas 6 patients were excluded due to abnormal karyotype. NIHF was diagnosed in 24 cases, hydrothorax in 4 cases, and ascites in 4 cases. Shunts were implanted in 26 (81%) cases and 7 (19%) participants underwent therapeutic cordocentesis. Results: After therapy anterior-posterior diameter of the right and the left lung increased to 9.6 mm (27%) and 12.4 mm (35%), respectively. Early complications were observed in 5 (16%) cases: PROM 2 (40%), fetal death 1 (20%), infection 1 (20%), and preterm delivery 1 (20%). Out of the 27 patients, 65% had a caesarian section without early complications and 35% had a vaginal delivery, with 58% at term and 42% pre-term. Conclusions: Preceding results show that intrauterine therapy significantly improves prognisis of fetuses with NIHF.

Diagnostic value of hydrothorax Mononuclear cell and ADA in tuberculous pleuritis

Abstract: Objective:To investigate the diagnostic value of hydrothorax ADA and Mononuclear cell in tuberculous pleuritis.Methods:All patients were diagnosed clearly by medical thoracoscopy.Pleural effusion in 120 cases with tuberculous pleurisy and 147cases with non-tuberculous pleuritis was analyzed and the hydrothorax ADA value and the proportion of Mononuclear cell in pleural effusion were recorded and analyzed through the receiver operator characteristic curve(ROC) in order to find out the optimum critical value to diagnose tuberculous pleuritis and its sensitivity and specificity.Results:Through the ROC curve analysis,the percentage of the area under the curve of pleural effusion Mononuclear cell was 0.593; when the value was 84.5%,the diagnostic sensitivity and specificity were 63.3% and 53.7%,respectively,thereby indicating that the diagnostic value was lower.Hydrothorax ADA area under the curve was 0.925,when the value was 28.7U/L,the diagnostic sensitivity and specificity were 88.3% and 90.5%,respectively,thereby showing a better diagnostic value.When combing the proportion of Mononuclear cell of 84.5% with the hydrothorax ADA value of 28.7U/L,the diagnostic sensitivity,specificity,positive predictive value,and negative predictive value were 57.5%,98%,95.85and 73.8%,respectively; the higher specificity and positive predictive value were helpful to the diagnosis of tuberculous pleuritis.Conclusions:Hydrothorax ADA has a diagnosis value for tuberculous pleurisy.The combination of the formers will contribute to the identification between tuberculous and non tuberculous pleural effusion.

Detection of the communication site by dye injection method at the surgery for pleuroperitoneal communication

Abstract: A 65-year-old male with end stage renal failure due to IgA nephritis commenced continuous ambulatory peritoneal dialysis (CAPD). Three weeks after initiation of CAPD, right hydrothorax developed. Then, we strongly assumed pleuroperitoneal communication( PPC) although the pleural effusion did not show high concentration of glucose. He underwent thoracoscopic surgery for PPC. On the inner, central tendons part of the diaphragm, there were a few blebs. One hour after 3 l of peritoneal dialysis solution containing 15 ml indigocarmine was instilled into the abdomen through a CAPD catheter, the blebs were tense and colored blue by the dye solution. The blebs were directly sutured and diaphragm was covered by polyglycolic acid sheet and fibrin glue all over. Since then, he resumed CAPD, without recurrence of hydrothorax. Then we investigated the treatment outcome of video-assisted thoracic surgery (VATS) for PPC in Japan. The outcome was poorer in cases in which communication was not detected intraoperatively. These patients should be given sufficient consideration for surgical procedure.