Hidrotórax hepático como complicación poco frecuente de la cirrosis. Un reto terapéutico en cirrosis avanzada / Hepatic hydrothorax as a rare complication of cirrhosis. A therapeutic challenge in advanced cirrhosis

El hidrotórax hepático es una entidad poco frecuente en pacientes con cirrosis. A la fecha se han propuesto varias alternativas terapéuticas, tanto médicas como quirúrgicas, previas al trasplante hepático como manejo definitivo. A continuación, se presenta el caso de una paciente de 78 años con cirrosis secundaria a infección por virus de la hepatitis C, que acudió al servicio de urgencias por dificultad respiratoria, donde se documentó un derrame pleural derecho masivo de tipo trasudado, que respondió parcialmente a terapia diurética e inserción de dren pleural; posteriormente falleció por complicaciones hemorrágicas asociadas a la cirrosis. Se considera importante describir esta patología, dada su baja frecuencia en pacientes con cirrosis y los retos terapéuticos a los que nos enfrentamos con la poca evidencia disponible en la actualidad.

Hepatic hydrothorax is a rare entity in patients with cirrhosis. To date, several therapeutic alternatives have been proposed, both medical and surgical, prior to liver transplantation as the definitive management. Here we present the case of a 78-year-old patient with cirrhosis secondary to hepatitis C virus infection, who consulted the emergency department for respiratory distress, documenting a massive right pleural effusion of transudate type, which responded partially to diuretic therapy and drainage with pigtail, and later died due to hemorrhagic complications associated with cirrhosis. It is important to describe this pathology given its low frequency in patients with cirrhosis and the therapeutic challenges we face with the limited currently available evidence.

Refractory Hepatic Hydrothorax in Chronic Hepatitis C Controlled by Direct-acting Antivirals / 대한소화기학회지

Hepatic hydrothorax is a transudative pleural effusion that complicates advanced liver cirrhosis. Patients refractory to medical treatment plus salt restriction and diuretics are considered to have refractory hepatic hydrothorax and may require transjugular intrahepatic portosystemic shunt (TIPS) or liver transplant. Successful antiviral therapy reduces the incidence of some complications of cirrhosis secondary to HCV infection. We report a case of hepatic hydrothorax in a 55-year-old female patient with HCV cirrhosis, which exhibited a spontaneous decrease in pleural effusion after direct antiviral agent (DAA) therapy. In cases of HCV cirrhosis, DAAs are worth administering before treatment by TIPS or liver transplantation.

Fetal anesthesia for twin-to-twin transfusion syndrome and fetal hydrothorax drainage: case report / Anestesia fetal para síndrome de transfusión gemelar y drenaje de hidrotórax fetal: reporte de caso

Abstract Fetal surgery in utero is an alternative for treatable congenital malformations. Prognosis will improve with early correction. Once the surgical technique is planned, the anesthetist's knowledge of maternal and fetal physiology is crucial for the selection of the ideal anesthetic technique for each individual case, considering the type of surgical procedure and the expected degree of fetal stimulation. In this way, the optimal surgical field with maternal and fetal safety will be ensured. This article describes 1 case of twin-to-twin transfusion syndrome under spinal anesthesia and sedation, and a second case of hydrothorax drainage under sedation.

Resumen La cirugía fetal in útero es una alternativa para las malformaciones congénitas tratables, su intervención temprana mejora el pronóstico del feto. Una vez planeada la técnica quirúrgica el conocimiento del anestesiólogo sobre la fisiología materna y fetal es fundamental, puesto que deberá determinar la técnica anestésica ideal acorde al contexto de cada caso considerando el tipo de procedimiento quirúrgico a realizarse y el grado de estimulación fetal esperado. De esta manera se asegura un campo quirúrgico óptimo ofreciendo seguridad materno fetal. En este artículo se describen dos casos: el primero síndrome de transfusión gemelar se realizó bajo anestesia raquídea y sedación, en el segundo caso de drenaje de hidrotórax bajo sedación.

Hidrotórax hepático: presentación de 3 casos con diferentes enfoques terapéuticos / Hepatic hydrothorax: presentation of 3 cases with different therapeutic approaches

El hidrotórax hepático (HH) se define como un derrame pleural mayor de 500 ml en pacientes con cirrosis e hipertensión portal. Representa una complicación infrecuente por lo general asociada con ascitis y su origen se relaciona con el paso de líquido ascítico a través de pequeños defectos en el diafragma de predominio en el hemitórax derecho. Una vez establecido el diagnóstico por imágenes, la toracentesis diagnostica permite confirmar un trasudado. La terapia inicial está basada en la restricción de sodio y el uso combinado de diuréticos. El 20-25% de los pacientes desarrolla un HH refractario, el cual requiere intervenciones invasivas tales como la derivación percutánea portosistémica intrahepática (DPPI), la reparación de los defectos diafragmáticos por videotoracoscopia asistida asociada a pleurodésis química y el uso de un catéter pleural tunelizado. No se recomienda la inserción de un tubo de tórax por su elevada morbilidad y mortalidad. El tratamiento definitivo del HH es el trasplante hepático el cual alcanza una excelente sobrevida. Presentamos tres casos de hidrotórax hepático con diferentes enfoques terapéuticos que incluyeron el manejo conservador con dieta y diuréticos, la inserción fallida de un tubo de tórax con pleurodesis y una DPPI.

Hepatic hydrothorax is uncommon transudative pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. Ascites is also present in most of the patients and the pathophysiology include the passage of ascites fluid through small diaphragmatic defects. After diagnostic thoracentesis studies, the first line management is restricting sodium intake and diuretics combination including stepwise dose of spironolactone plus furosemide. Therapeutic thoracentesis is a simple and effective procedure to relief dyspnea. Hepatic hydrothorax is refractory in approximately 20-25% and treatments options include repeated thoracentesis, transjugular intrahepatic portosystemic shunts (TIPS) placement, chemical pleurodesis with repair diaphragmatic defects using video-assisted thoracoscopy surgery (VATS), and insertion of an indwelling pleural catheter. Chest tube insertion carries significant morbidity and mortality with questionable benefit. Hepatic transplantation remains the best treatment option with long term survival. We present three cases of hepatic hydrothorax with different therapeutic approach including first line management, failed chest tube insertion and TIPS placement.

Hidrotórax agudo: complicación poco frecuente en diálisis peritoneal en pediatría. Reporte de un caso / Acute hydrothorax: rare complication in pediatric peritoneal dialysis. Case report

Se comunica un caso de hidrotórax agudo derecho en un adolescente de 13 años con Insuficiencia renal crónica terminal (IRCT) en Diálisis Peritoneal Crónica Ambulatoria (DPCA) de sostén. Es una complicación poco frecuente, siendo en nuestra experiencia en el Programa de DPCA del Hospital del Niño Jesús en 12 años de duración, el primer caso. Describimos su evolución, diagnóstico y resolución

A case of right acute hydrotorax is reported in a 13 years old boy with terminal chronic renal failure in CPD (chronic peritoneal diálysis); it is a rare complication and in our experience in the chronic peritoneal dialysis program in Hospital del niño Jesus, Tucuman, in 12 years of duration is the first case. We inform the evolution, diagnosis and resolution.

Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

PURPOSE: Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage. MATERIALS AND METHODS: Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled. RESULTS: The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index 10, and history of severe encephalopathy (grade >2) were associated with poor survival. CONCLUSION: Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Manejo terapéutico de hematoma mediastinal después de un acceso venoso central / Therapeutic management of mediastinal hematoma after a venous access

Introducción: el hematoma mediastinal es una causa rara de complicación en el abordaje de la vía venosa central (VVC). Estudio de Gupta 2011 reportó uno y revisó varios casos clínicos analizando la conducta terapéutica. Caso clínico: mujer de 51 años con ventilación mecánica invasiva en terapia intensiva por encefalitis viral, que después de la colocación de VVC subclavia presentó inestabilidad hemodinámica, dificultad para ventilar con resistencias elevadas y compliance disminuida, hace paro cardiaco que revierte con maniobras, se precisa diagnóstico de hematoma mediastinal y se indica manejo conservador con el que evoluciona satisfactoriamente. Discusión: el hematoma de mediastino siempre debe sospecharse y es evidente en radiografías de tórax en los casos graves, con ensanchamiento mediastinal. La ventilación mecánica establece una presión positiva intratorácica permitiendo contener el hematoma, el manejo conservador se reporta beneficioso. Conociendo que las complicaciones de colocación de VVC son mínimas pero con elevado riesgo de inestabilidad, prolongación de hospitalización y aumento de la mortalidad, se recomienda evitar abordajes innecesarios, en especial subclavios.

Background: Mediastinal hematoma is an uncommon complication from the central venous access. The Gupta's trial 2011 reported one case and a review of other similar cases, 3 cases were treated with coil embolisation by vascular lesion, another 3 cases who needs thoracotomy for hemothorax complication and just 2 cases was established a conservative management in which only one survived. Clinical case: 51-year-old female in invasive mechanical ventilation admitted to intensive care unit (ICU) due to viral encephalitis, present hemodynamic instability and difficulty to ventilate by high resistance and low compliance after of a subclavian venous access, then complicated with cardiac arrest that reverted in 5 min with resuscitation maneuvers, we made a conservative management with continuous infusion of norepinephrine and invasive mechanical ventilation with protective technique (PEEP 10, TV6cc/kg), the requirements of norepinephrine decrease progressively, then the patient was disconnected from mechanical ventilation and was discharged from the intensive care satisfactorily. Discussion: Mediastinal hematoma should always be suspected and is evident with chest X-rays just when it is a severe case and it is suspicioned with wide mediastinum. Conservative management to this case into intensive care unit could be beneficial. Mechanical ventilation establishes a positive intra-thoracic pressure allowing the hematoma to be contained. Knowing that the complications of central venous access are minimal but these complications have high risk of instability, prolonged hospitalization and increased mortality. It is recommended avoid unnecessary central venous access, mainly subclavian access

Hidrotórax hepático en paciente con cirrosis por colangitis esclerosante primaria / Hepatic hydrothorax in a patient with cirrhosis due to primary sclerosing cholangitis

Se presenta el caso de un paciente de sexo masculino de 39 años, portador de colangitis esclerosante primaria desde hace 9 años, complicado con síndrome de hipertensión portal más insuficiencia hepática, en plan de trasplante hepático, en seguimiento por el Servicio de Gastroenterología. Ingresa por dificultad respiratoria, constatándose derrame pleural izquierdo extenso con características de trasudado con ascitis moderada, por lo que se procede al drenaje del líquido pleural y ascítico con goteo concomitante de albúmina endovenosa. El paciente presenta buena tolerancia y disminución importante tanto del derrame pleural como del líquido ascítico. Es dado de alta en mejores condiciones y con aumento de dosis de fármacos para el tratamiento de la ascitis

We present the case of a male patient 39 years old, with a history of primary sclerosing cholangitis for 9 years, complicated with portal hypertension and liver failure, he is in liver transplant program, followed up by Gastroenterology Service. He was admitted for respiratory failure, and massive left pleural effusion, with of features transudate and moderate ascites was noted aswell, we performes pleural and ascitic fluid drainage with concomitant infusion of intravenous albumin. The patient shows good tolerance and significant decrease in both pleural effusion and ascitic fluid. He was discharged in better condition and with increased doses of drugs for the treatment of ascites

Utility of indocyanine green for diagnosing peritoneal dialysis-related hydrothorax

No abstract available.

An Experience of Judicial Autopsy for a Death by Muscular Dystrophy: An Autopsy Case / 대한법의학회지

Progressive muscular dystrophy (PMD) is a primary muscle disease characterized by progressive muscle weakness and wasting, which is inherited by an X-linked recessive pattern and occurs mainly in males. There are several types of muscular dystrophies classified according to the distribution of predominant muscle weakness including Duchenne and Becker, Emery-Dreifuss, facioscapulohumeral, oculopharyngeal, and limb-girdle type. Clinical manifestations of PMD are clumsy, unsteady gait, pneumonia, heart failure, pulmonary edema, hydropericardium, hydrothorax, aspiration, syncopal attacks, and sudden cardiac death. The deceased was a 34-year-old man, and the onset of the first clinical symptom, gait disturbance, was in his late teens. His elder brother had the same disease and experienced brain death after a head trauma and died after mechanical ventilation was discontinued. After an autopsy, we found contracture of the joints, pseudohypertrophy of the calf, wasting and fat replacement of the thigh muscle, pericardial effusion (80 mL), fibrosis and fat replacement of the cardiac ventricular wall, pulmonary edema, and froth in the bronchus. The cause of death was heart failure and dyspnea due to muscular dystrophy. There was no sign or suspicion of foul play in his death.

Transjugular intrahepatic portosystemic shunt creation for portal hypertension in patients with hepatocellular carcinoma: A systematic review

BACKGROUND: To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation for the management of portal hypertension in patients with hepatocellular carcinoma (HCC). METHODS: A literature search of the MEDLINE/PubMed and Embase databases was conducted. All articles reporting the outcomes of TIPS creation for variceal bleeding and refractory ascites and hepatic hydrothorax in patients with HCC were included. Exclusion criteria were non-English language, sample size < 5, data not extractable, and data reported in another article. RESULTS: A total of 280 patients (mean age, 48–58; male gender, 66%) from five articles were included. TIPS creation was performed for variceal bleeding in 79% and refractory ascites and/or hepatic hydrothorax in 26% of patients. Technical and clinical success was achieved in 99% and 64% of patients, respectively. Clinical failure occurred in 36% of patients due to rebleeding or recurrent bleeding (n = 77) or no resolution or improvement of refractory ascites and hepatic hydrothorax (n = 24). One percent of patient had major complications, including accelerated liver failure (n = 1) and multi-organ failure resulting from hemorrhagic shock (n = 1), all of which resulted in early (i.e., within 30 days) death. Hepatic encephalopathy occurred in 40% of patients after TIPS creation. Lung metastasis was found 1% of patient 5 months (n = 1) and 72 months (n = 1) after TIPS creation. CONCLUSION: TIPS creation seems to be safe and effective for the management of portal hypertension in patients with HCC.

Compromiso pulmonar en la enfermedad hepática: una actualización / Pulmonary commitment in hepatic disease: uma atualização / Compromisso pulmonar na doença hepática

La enfermedad Hepática es una causa importante de morbilidad y Mortalidad en el mundo; asociada a compromiso orgánico múltiple. En el pulmón, tres condiciones clínicas han sido descritas; estos cuadros Incluyen, el Síndrome Hepatopulmonar (SHP), que obedece a un trastorno de la oxigenación por dilatación de la vasculatura pulmonar. La hipertensión portopulmonar (HPP), mediada por desequilibrio entre agentes vasodilatadores y vasoconstrictores que conducen a un aumento de la presión media de la arteria pulmonar y por último el Hidrotórax Hepático (HH), que es la condición menos prevalente, se fundamenta principalmente en anomalías anatómicas del diafragma, con o sin relación a la presencia de ascitis. La presencia SHP o HPP es predictor independiente de mortalidad, resaltando su importancia en la elegibilidad de pacientes para trasplante hepático ortotópico como medida curativa.

Liver disease is a major cause of morbidity and mortality in the world; it is associated with multiple organ involvement. In the lung, three clinical conditions are described; these conditions include, Hepatopulmonary Syndrome (HPS), which is due to a oxygenation defect by the development of pulmonary vascular dilatation. Portopulmonary (HPP) hypertension, it's mediated by an imbalance between vasodilator and vasoconstrictor agents leading to an increase in mean pulmonary artery pressure and finally the Hydrothorax Liver (HH), that is the least prevalent condition, it's based on anatomical diaphragm abnormalities, with or without ascites. The presence of SHP or HPP is an independent predictor of mortality, highlighting its importance in the eligibility of patients for orthotopic liver transplantation as a curative measure.

A doença hepatica é uma das principais causas de morbidade e mortalidade no mundo; está associado ao compromisso de vários órgãos. No pulmão, três condições clínicas são descritas; estas condições incluem, Síndrome Hepatopulmonar (HPS), que é devido a um defeito de oxigenação do dilatação vascular pulmonar. A hipertensão portopulmonar (HPP), é mediada por um desequilíbrio entre vasodilatadores e agentes vasoconstritores, levando a um aumento da pressão arterial média da artéria pulmonar e, finalmente, ao hidrotorax hepatico (HH), essa é a condição menos prevalente, é baseada em anormalidades anatômicas do diafragma, com ou sem ascite. A presença de SHP ou HPP é um preditor independente de mortalidade, destacando sua importância na elegibilidade de pacientes para transplante de hepatico como medida curativa.

Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax

Background and study aims: Spontaneous bacterial empyema [SBEM] is an underestimated condition in patients with ascites and hepatic hydrothorax with a high mortality. This study aimed to find whether spontaneous bacterial peritonitis [SBP] is a prerequisite for SBEM

Patients and methods: 3000 HCV-related cirrhotic patients with ascites and hydrothorax were screened for the presence of SBP [ascitic fluid neutrophils >250/mm[3]] and SBEM [positive pleural fluid culture and neutrophils >250/mm[3] or negative pleural fluid culture and neutrophils >500/mm[3] with no evidence of pneumonia/parapneumonic effusion on chest radiograph or CT]

Results: The prevalence of SBEM in cirrhotic patients was 1.2% [36/3000] unlike SBP [1.6%; 48/3000]. SBEM was detected in 51.4% of the patients with hepatic hydrothorax [36/70]. A total of 70 patients had concomitant ascites and hydrothorax, namely SBP [n = 17], SBEM [n = 5], and dual SBP and SBEM [n = 31], whereas 17 patients had sterile concomitant ascites and hydrothorax. Age, sex, liver function, kidney function tests, complete blood count, INR, MELD, MELD-Na, blood chemistry, and culture/sensitivity for ascitic and pleural fluid were statistically not different [p > 0.05] between SBP and dual SBP and SBEM patients. Escherichia coli and Klebsiella pneumoniae were detected in the culture. From univariate analysis, no predictors of dual SBP and SBEM were detected

Conclusion: SBEM is a part of SBP in cirrhotic patients with ascites and hydrothorax

Tension hydrothorax induced by malposition of central venous catheter: A case report

Central venous catheterization is a useful method for monitoring central venous pressure and maintaining volume status. However, it is associated with several complications, such as pneumothorax, hydrothorax, hemothorax, and air embolism. Here we describe a case of iatrogenic tension hydrothorax after rapid infusion of fluid into the pleural space, following the misplacement of an internal jugular vein catheter. Despite ultrasonographic guidance during insertion of the central venous catheter, we were not able to avoid malposition of the catheter. The patient went into hemodynamic compromise during surgery, necessitating chest tube drainage and a mechanical ventilator postoperatively. This case shows that central venous catheter insertion under ultrasonographic guidance does not guarantee proper positioning of the catheter.

When one port does not return blood: two case reports of rare causes for misplaced central venous catheters / Quando uma porta não apresenta retorno sanguíneo: relato de dois casos de causas raras de mau posicionamento de cateter venoso central

We present two cases of misplaced central venous catheters having in common theabsence of free blood return from one lumen immediately after placement. The former is acase of right hydrothorax associated with central venous catheterization with the catheter tipin intra-pleural location. In this case the distal port was never patent. In the latter case therewas an increased aspiration pressure through the middle port due to a catheter looping.The absence of free flow on aspiration from one lumen of a central catheter should not beundervalued. In these circumstances the catheter should not be used and needs to be removed.

Apresentamos dois casos de mau posicionamento de cateter venoso central. Têmem comum a ausência do retorno sanguíneo livre em um dos lúmens imediatamente após acolocac¸ão. O primeiro é um caso de hidrotórax direito associado ao cateterismo venoso central,com a ponta do cateter em localizac¸ão intrapleural. Nesse caso, a porta distal nunca estevepatente. No segundo caso houve um aumento da pressão de aspirac¸ão através da porta medialpor causa da formac¸ão de alc¸a no cateter.A ausência de fluxo livre na aspirac¸ão de um lúmen do cateter central não deve ser subesti-mada. Nessas circunstâncias, o cateter não deve ser usado e deve ser removido.

Etiology of Pleural Effusions in Cancer Patients

PURPOSE: The purpose of this study is to examine the causes of Pleural effusion (PE) in cancer patients and to compare the clinical characteristics between malignant PE (MPE) and non-MPE. METHODS: All consecutive cancer patients with PE who underwent diagnostic thoracentesis from January 1, 2008 to March 31, 2011 were analyzed retrospectively. RESULTS: A total of 719 patients were included; mean age was 58.4+/-13.6 years and 44.5% were female. The most common cause of PE was MPE (57.7%), followed by parapneumonic or empyema in 16.3%. However, the etiology was significantly different according to primary tumor origin and subtypes of lung cancer. While MPE was most common in lung, breast, and gynecologic cancer, hepatic hydrothorax was the main cause in Hepatocellular carcinoma (HCC). MPE accounted for 85.2% in adenocarcinoma, and 30.2% and 58.8% in squamous cell and small cell carcinomas, respectively. Patients with MPE were younger (57.0 vs. 60.2 years) and female-dominant (55.4% vs. 29.6%) compared to those with non-MPE. MPE had the large size (53.5% vs. 34.9%) and left location of PE (31.3% vs. 19.4%) more frequently than non-MPE, and fewer neutrophils (15.4% vs. 30.6%) and more lymphocytes (32.2% vs. 28.2%), higher levels of pH (7.33 vs. 7.29), and lower levels of glucose (111.5 vs. 129.7 mg/dL) than non-MPE (p<0.001 for all). CONCLUSION: Overall, MPE was the most common cause of PE in cancer patients. However the etiology of PE was significantly different according to primary tumor origin and subtypes of lung cancer. A difference in age, gender, size and location of PE, cell count, pH, and glucose was observed between MPE and non-MPE.

Intoxicação por Metternichia princeps (Solanaceae) em caprinos no estado da Bahia / Poisoning by Metternichia princeps (Solanaceae) in goats in the state of Bahia, Brazil

Descreve-se um surto de intoxicação por Metternichia princepsem caprinos no Estado da Bahia. De oito caprinos, três morreram, dos quais dois foram necropsiados; cinco não adoeceram. Os principais sinais clínicos caracterizaram-se por secreção nasal mucosa, emagrecimento, diarreia, apatia, debilidade leve, andar cambaleante, flexão dos membros torácicos e pélvicos, decúbito esterno-abdominal e decúbito lateral, seguidos de morte após aproximadamente dois dias de evolução clínica. Na necropsia foi observado edema pulmonar, hidrotórax, hidropericárdio, ascite, rins pálidos, edema perirrenal e hemorragias no tecido subcutâneo. Microscopicamente nos rins havia acentuada necrose de coagulação do epitélio tubular e túbulos com regeneração do epitélio. No pulmão havia acentuada congestão associada a edema interalveolar e interseptal. Na bioquímica sanguínea observou-se aumento na ureia, creatinina e creatinina fosfoquinase.

An outbreak of poisoning by Metternichia princepsis reported in goats from the State of Bahia. Out of eight goats three showed symptoms of poisoning and died; on two of them post-mortem examinations were performed. The main clinical signs were nasal mucous secretion, weight loss, diarrhea, lethargy, mild weakness, staggering gait, flexion of the fore and hind limbs, sternal recumbence, and lateral recumbence followed by death after approximately two days of clinical manifestations. The serum concentration of urea and creatinine and the serum activities of creatine phosphokinase were increased. At necropsy pulmonary edema, hydrothorax, hydropericardium, ascites, pale kidneys, perirenal edema and hemorrhages in the subcutaneous tissue were observed. Microscopically the kidneys showed accentuated coagulation necrosis of the tubular epithelium and tubules and epithelial regeneration. In the lungs there was accentuated congestion associated with interalveolar and interseptal edema.

Central Venous Catheter-Related Hydrothorax / 대한중환자의학회지

This report describes a case of 88-year-old women who developed central venous catheter-related bilateral hydrothorax, in which left pleural effusion, while right pleural effusion was being drained. The drainage prevented accumulation of fluid in the right pleural space, indicating that there was neither extravasation of infusion fluid nor connection between the two pleural cavities. The only explanation for bilateral hydrothorax in this case is lymphatic connections. Although vascular injuries by central venous catheter can cause catheter-related hydrothorax, it is most likely that the positioning of the tip of central venous catheter within the lymphatic duct opening in the right subclavian-jugular confluence or superior vena cava causes the catheter-related hydrothorax. Pericardial effusion can also result from retrograde lymphatic flow through the pulmonary lymphatic chains.

Central Venous Catheter-Related Hydrothorax / 대한구급학회지

This report describes a case of 88-year-old women who developed central venous catheter-related bilateral hydrothorax, in which left pleural effusion, while right pleural effusion was being drained. The drainage prevented accumulation of fluid in the right pleural space, indicating that there was neither extravasation of infusion fluid nor connection between the two pleural cavities. The only explanation for bilateral hydrothorax in this case is lymphatic connections. Although vascular injuries by central venous catheter can cause catheter-related hydrothorax, it is most likely that the positioning of the tip of central venous catheter within the lymphatic duct opening in the right subclavian-jugular confluence or superior vena cava causes the catheter-related hydrothorax. Pericardial effusion can also result from retrograde lymphatic flow through the pulmonary lymphatic chains.

Hydrothorax with alveolar-pleural fistula mimicking re-expansion pulmonary edema during liver transplantation: a case report / 대한마취과학회지

We present a case of an alveolar-pleural fistula with hepatic hydrothorax in a patient undergoing orthotropic liver transplantation, which was detected by drainage of transudate through an endotracheal tube during operation. A standard endotracheal tube was changed to a double-lumen tube to provide differential lung ventilation. The patient was diagnosed with an alveolar-pleural fistula by direct vision of an air leak during positive-pressure ventilation through a diaphragmatic incision. There was still a concern about worsening his ventilation due to persistent aspiration of pleural effusion towards the ipsilateral lung during the remaining operation period. Surgeon repaired the defect on the exposed lung surface via diaphragmatic opening. Anesthesiologists should consider an alveolar-pleural fistula as a possible differential diagnosis with re-expansion pulmonary edema when transudate emanating from the endotracheal tube is obtained in patients with massive hydrothorax.