RESUMO
OBJECTIVE: This study aimed to evaluate outcomes in cirrhotic patients diagnosed with spontaneous bacterial empyema (SBE) compared with those without this complication. METHODS: We performed a retrospective cohort study of cirrhotic patients from a tertiary care center. The primary outcome was time to death or liver transplantation (LT) within one year after diagnosis of infection. We integrated three groups: patients with SBE (group A), patients with spontaneous bacterial peritonitis (SBP; group B), and cirrhotic patients without SBP or SBE (group C), matched by age, model for end-stage liver disease-sodium (MELD-Na) score and year of infection. Outcomes were analyzed using a Cox regression model adjusted for cardiovascular risk factors and MELD-Na score. RESULTS: Between January 1999 and February 2019, 4829 cirrhotic patients were identified. Among them, 73 (1.5%) had hepatic hydrotorax, of whom 22 (30.1%) were diagnosed with SBE. Median age in group A was 58 years, 50% were men, and median MELD-Na was 21.5. Compared with group C, the hazard ratio of death or LT during the first year after infection was 2.98 (95% confidence interval [CI] 1.43-6.22, P = 0.004) for group A and 1.23 (95% CI 0.65-2.32, P = 0.522) for group B. CONCLUSIONS: Our results suggest that patients with SBE have a worse outcome during the first year after infection is diagnosed. Patients who develop SBE should be promptly referred for transplant evaluation. SBE may emerge as new indication that could benefit from MELD exception points.
Assuntos
Empiema , Doença Hepática Terminal , Estudos de Coortes , Humanos , Cirrose Hepática/complicações , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Chronic liver disease (CLD) may be associated with pleural effusions (PEs). This article prospectively evaluates whether detection of PEs on thoracic ultrasound (TUS) at the bedside independently predicts mortality and length of stay (LOS) in hospitalized patients with a decompensated CLD. A total of 116 consecutive inpatients with decompensated cirrhosis underwent antero-posterior chest radiographs (CXR) and TUS to detect PEs. Their median age was 54 y (interquartile range, 47-62), 90 (70.6%) were male, and 61 (52.6%) fell into the Child-Pugh class C categorization. TUS identified PEs in 58 (50%) patients, half of which were small enough to preclude thoracentesis. CXR failed to recognize approximately 40% of PEs seen on TUS. The identification of PEs by TUS was associated with a longer LOS (10 vs. 5.5 d, p < 0.001) and double mortality (39.7% vs. 20.7%, p = 0.021). In multivariate analysis, PEs were independently related to poor survival (hazard ratio 2.08, 95% confidence interval [CI] 1.02-4.25; p = 0.044). Patients with both Child-Pugh C stage and PEs had the lowest survival rate (70 vs. 317 d, p = 0.001). In conclusion, PEs identified by TUS in hospitalized patients with decompensated CLD independently predict a poor outcome and portend a longer LOS.
Assuntos
Derrame Pleural , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Derrame Pleural/diagnóstico por imagem , Testes Imediatos , UltrassonografiaRESUMO
Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.
Assuntos
Hidrotórax/etiologia , Hipertensão Portal/etiologia , Cirrose Hepática/complicações , Derrame Pleural/etiologia , Infecções Bacterianas/microbiologia , Empiema/microbiologia , Humanos , Hidrotórax/diagnóstico , Hidrotórax/mortalidade , Hipertensão Portal/diagnóstico , Hipertensão Portal/mortalidade , Hipertensão Portal/terapia , Cirrose Hepática/diagnóstico , Cirrose Hepática/mortalidade , Cirrose Hepática/terapia , Transplante de Fígado , Derrame Pleural/diagnóstico , Derrame Pleural/mortalidade , Derrame Pleural/terapia , Derivação Portossistêmica Transjugular Intra-Hepática , Valor Preditivo dos Testes , Fatores de Risco , Toracentese , Toracoscopia , Resultado do TratamentoRESUMO
El hidrotórax hepático es una complicación poco común que se da en pacientes con cirrosis hepática. Sepresenta el caso de una paciente con cirrosis por esteatohepatitis no alcohólica y evidencia de hipertensiónportal, y quien se presenta al servicio de urgencias con tos y dolor torácico; se le encuentra un derramepleural tipo trasudado por criterios de Light, asociado a ascitis, sin hallarse una causa cardíaca, pleural opulmonar del derrame mencionado. Se inicia tratamiento diurético, pero este debe ser suspendido cuandola paciente desarrolla disfunción renal importante; se drena el líquido con toracostomía, pero la pérdida devolumen adicional deteriora aún más la función renal, por lo que se decide realizar un shunt transyugularportosistémico (TIPS). Se logra disminuir la presión portal y el nivel de líquido ascítico y el derrame pleuraldisminuyen progresivamente. En una revisión posterior de la paciente y de su seguimiento radiológico no seregistró reaparición de los síntomas ni del derrame pleural o de ascitis.
Hepatic hydrothorax is a rare complication that occurs in patients with liver cirrhosis. We report the caseof a patient with NASH cirrhosis and evidence of portal hypertension who was admitted to the emergencydepartment with coughing and chest pain. Transudative pleural effusions (according to Lights criteria) werefound in association with ascites, but no cardiac cause, pleural effusion or pulmonary effusion could be found.Treatment with diuretics was begun, but was suspended because the patient developed signifi cant renal dysfunction.Fluid was drained with a thoracostomy but additional loss of fl uid led to further deterioration of renalfunction. It was decided to insert a transjugular portosystemic shunt (TIPS) to signifi cantly decrease portalpressure and to progressively decrease ascitic fl uid and pleural effusion. A subsequent review of the patientand radiological follow-up found no recurrence of symptoms, pleural effusion or ascites.