BilateralPleuralEffusionswithAscites

ByNancyLiao

81yearoldmalewithhistoryoftypeIIdiabetes,hyperlipidemia,andcongesAveheartfailurepresentsastransferfromextendedcarefacilityforevaluaAonofacute,progressiveshortnessofbreathandincreasingabdominalgirth.

Pulmonaryexamsignificantfortachypnea.Abdomenwasdistendedonphysicalexam.2+LEedemabilaterally.

CXRobtainedfordyspneashowedbilateralpleuraleffusions.

U/Sofabdomenwasperformed,whichalsodemonstratedlargebilateralpleuraleffusionsaswellasascites.

LeN‐sidedPleuralEffusionwithAscites

KidneySpleen

Pleuraleffusion

Diaphragm

Ascites

Right‐sidedPleuralEffusionwithAscites

Kidney

Ascites

Pleuraleffusion

Diaphragm

Liver

Right‐sidedPleuralEffusionwithLungTip

Pleuraleffusion

LungAp

RightLungwithPleuralEffusion

Lung

OverviewofPleuralEffusions•  AbnormalcollecAonoffluidinthepleuralspace•  Transudatevs.exudate•  Normalpleuralfluid:pH7.60‐7.64,protein<1‐2g/dL,<1000

WBCs/mm3,glucose~plasmaglucose,LDH<50%plasmaLDH•  Light’scriteriaforexudates:

–  Pleuralfluidprotein/serumprotein>0.5–  PleuralfluidLDH/serumLDH>0.6–  PleuralfluidLDH>200IU/Lor2/3normalupperlimitforserum

•  Exudate*–  Pleuralfluidtotalprotein>2.9g/dL–  Pleuralfluidprotein/serumprotein>0.5–  Pleuralfluidcholesterol>45mg/dL–  PleuralfluidLDH/serumLDH>0.6

*HeffnerJ,BrownL,BarbieriC(1997)."DiagnosAcvalueofteststhatdiscriminatebetweenexudaAveandtransudaAvepleuraleffusions.PrimaryStudyInvesAgators".Chest111(4):970–80.doi:10.1378/chest.111.4.970.PMID9106577.

OverviewofPleuralEffusions

•  Transudates–  CHF(asinthispaAent)–  Cirrhosis–  NephroAcsyndrome–  Others‐urinothorax,myxedema,peritonealdialysis

•  Exudates–  InfecAon–  Malignancy–  PE–  Chylothorax–  Hemothorax–  Others‐druginduced,SLE,RA,vasculiAs(Wegener’s,Churg‐

Strauss),GI(pancreaAAs,esophagealrupture)

DiagnosisandTreatmentofPleuralEffusions

•  DiagnosActhoracentesis•  TherapeuActhoracentesisforsymptomaAceffusions

•  Tubethoracostomyforhemothorax

•  Tubethoracostomyempyemas±tPA– pusonthoracentesis,aposiAveGramstain,glucose<60mg/dL,pH<7.20,orelevatedLDH

•  Treatunderlyingdisorder

OverviewofAscites

•  Theoriesonpathophysiology– Underfilling‐insufficientsequestraAonoffluidsecondarytoportalhypertensionleadingtoacAvaAonofrenin‐angiotensin‐aldosteronesystem

– Overflow‐inappropriateretenAonofNaandH2Obyrenalsystem,hepatorenalreflex

–  PeripheralarterialvasodilaAonhypothesis‐vasodilaAonsecondarytoportalhypertensionleadingtodecreasedeffecAvearterialvolumeandrenalNaretenAon

– DecreasedoncoAcpressuresecondarytohypoalbuminemia

EAologyofAscites

Serumascitesalbumingradient SAAG(g/dL)=SerumAlbumin‐AscitesAlbumin

Runyonetal(1992)

>=1.1g/dL <1.1g/dL

CirrhosisAlcoholichepa77sCHFMassivehepa7cmetastasesVascularocclusionFaAyliverdiseaseofpregnancyMyxedema

PeritonealcarcinomatosisPeritonealTBPancrea77sSerosi7sNephro7csyndromeBowelobstruc7on/infarc7on/perfora7on

Treatment

•  SodiumrestricAon•  DiureAcs

–  Spironolactone(25‐200mg/dPOqdordividedbid)±furosemide(40‐120mg/dayPOdividedqd‐bid;start20‐80mgPOx1,increase20‐40mgq6‐8hrsor20‐40mgmgIV/IM;Atrateup20mgq2hrs;Max:600mg/day)

•  TherapeuAcparacentesis–  Largevolume>4‐6Lwithalbuminreplacement

•  5gofalbumin/LofasciAcfluid(over5L)todecreaserateofcomplicaAons

•  TIPS–  FordiureAc‐refractoryascites–  Stentispercutaneouslyplacedfromtherightjugularveininto

thehepaAcvein.ConnectsportalandsystemiccirculaAons.

PaAent’shospitalcourseCHFexacerbaAon‐paAentwasiniAallydiuresedwithIVLasixforsevere

volumeoverloadandthentransiAonedtoPODemadex.HewasondobutamineforincreasedcreaAnine,whichwasbrieflyswitchedtomilrinoneforhiselevatedwedgeandPApressuresbyrightheartcath.LeNheartcathshowednewnon‐obstrucAvecoronaryarterydisease.StaAnACEinhibitorandaspirinwereaddedtohismedicaAonregiment.Cardiacechofinding:severetricuspidvalveregurgitaAon,moderatetoseveremitralvalveregurgitaAon,moderateaorAcregurgitaAon,andanEFof25%.PaAentwasinatrialfib/fluterduringhospitalizaAon.Coumadinwasheldduetorisks.

AtAmeofdischargepaAentremainedsignificantlyvolumeoverloadeddespitediuresisofasignificantvolume,howeverthepaAenthadimprovedshortnessofbreathandwasabletoambulatewithassistance.BUNandcreaAninehadincreasedfromadmissionandDemadexdosewasdecrease.