A 54-year-old man comes to the emergency department with a 2-week history of exertional dyspnea and nonproductive cough. He has no known medical problems and does not use any medications. The patient has a long history of alcohol abuse and currently consumes a half-pint of vodka a day, although he is "trying to cut down." He smokes a pack of cigarettes a day and does not use illicit drugs. Temperature is 36.8 C (98.2 F), blood pressure is 123/78 mm Hg, heart rate is 114/min and regular, and oxygen saturation is 96% on room air. Lung examination shows decreased breath sounds on the right with dullness to percussion. The patient's abdomen is distended with flank dullness and a positive fluid shift sign. There is 1+ bilateral pitting lower-extremity edema. His hands are flushed over the palmar aspects, and small dilated blood vessels are visible over his upper chest. Laboratory results are as follows: Chest x-ray demonstrates a large right-sided pleural effusion. A thoracentesis is performed, and 1.2 L of straw-colored fluid is removed. The fluid shows a protein concentration of 1.2 g/dL and lactate dehydrogenase concentration of 60 U/L. Gram stain and cultures are negative. The patient's symptoms improve after the procedure, and counseling regarding cessation of alcohol and tobacco use is provided. Which of the following is the best next step in management of this patient's pleural effusion?

Question

A 54-year-old man comes to the emergency department with a 2-week history of exertional dyspnea and nonproductive cough.  He has no known medical problems and does not use any medications.  The patient has a long history of alcohol abuse and currently consumes a half-pint of vodka a day, although he is "trying to cut down."  He smokes a pack of cigarettes a day and does not use illicit drugs.  Temperature is 36.8 C (98.2 F), blood pressure is 123/78 mm Hg, heart rate is 114/min and regular, and oxygen saturation is 96% on room air.  Lung examination shows decreased breath sounds on the right with dullness to percussion.  The patient's abdomen is distended with flank dullness and a positive fluid shift sign.  There is 1+ bilateral pitting lower-extremity edema.  His hands are flushed over the palmar aspects, and small dilated blood vessels are visible over his upper chest.  Laboratory results are as follows:  Chest x-ray demonstrates a large right-sided pleural effusion.  A thoracentesis is performed, and 1.2 L of straw-colored fluid is removed.  The fluid shows a protein concentration of 1.2 g/dL and lactate dehydrogenase concentration of 60 U/L.  Gram stain and cultures are negative.  The patient's symptoms improve after the procedure, and counseling regarding cessation of alcohol and tobacco use is provided.  Which of the following is the best next step in management of this patient's pleural effusion?

Quizplus · Accepted Answer

Explanation: This patient's pleural effusion is consistent with hepatic hydrothorax. Patients with decompensated cirrhosis (evidenced by prolonged INR, lower-extremity edema, and abdominal distension with shifting dullness in the setting of chronic alcohol abuse) can develop pleural effusion due to passage of peritoneal ascites through the diaphragm. The effusion usually occurs on the right side, presumably because the right hemidiaphragm is thinner and more likely to have porous defects than the left hemidiaphragm. In addition, the effusion is typically transudative based on Light criteria, with fluid to serum total protein ratio <0.5, fluid to serum lactate dehydrogenase (LDH) ratio <0.6, and fluid LDH <2/3 the upper limit of normal for serum LDH. Light criteriasodium restriction in combination with loop (eg, furosemide) and potassium-sparing (eg, spironolactone) diuretics. Presence of hepatic hydrothorax signals advanced liver disease and should prompt consideration for liver transplantation. (Choice A) Chemical pleurodesis involves instillation of an irritant (eg, talc) into the pleural space to stimulate inflammation and fibrosis of the visceral and parietal pleural to fuse the 2 layers together. It is often effective in preventing recurrent exudative (eg, malignant) pleural effusion, but is typically ineffective in preventing recurrent transudative pleural effusion such as occurs in hepatic hydrothorax. (Choice C) Placement of an indwelling pleural catheter is a poor treatment option for hepatic hydrothorax because it results in excessive volume and protein loss that cannot be compensated for with intravenous albumin replacement (as is done with periodic therapeutic paracentesis for ascites). (Choice D) Thorascopic repair of diaphragmatic defects may correct hepatic hydrothorax in some patients, but it is highly invasive and should not be considered unless other therapies have failed. (Choice E) Transjugular intrahepatic portosystemic shunt (TIPS) placement creates a fistula between the portal vein and hepatic veins, which decreases hydrostatic pressure in the portal venous system. It is often effective in relieving ascites and hepatic hydrothorax, but it is associated with risks (eg, hepatic encephalopathy, hepatic decompensation) and is not pursued until medication therapy has failed. Educational objective: Hepatic hydrothorax usually presents as a right-sided transudative pleural effusion in patients with decompensated cirrhosis and ascites. The initial treatment is with sodium restriction and diuretics; transjugular intrahepatic portosystemic shunt placement may be pursued in refractory cases. References: Hepatic hydrothorax. (http://www.ncbi.nlm.nih.gov/pubmed/22447255) The Light criteria: the beginning and why they are useful 40 years later. (http://www.ncbi.nlm.nih.gov/pubmed/23411053)

A 54-Year-Old Man Comes to the Emergency Department with a 2-Week