A 45-year-old man comes to the office due to progressive shortness of breath on exertion and fatigue for the past several weeks. Two years ago, the patient was diagnosed with alcoholic cirrhosis and esophageal varices after presenting with hematemesis. He underwent banding of the varices. Several months ago, the patient came to the office with massive ascites and a large-volume paracentesis was performed. His current medications include furosemide, spironolactone, and nadolol. He has had no alcohol for the past 2 years. The patient does not use tobacco or illicit drugs. Blood pressure is 114/72 mm Hg and pulse is 63/min. Pulse oximetry shows 95% on room air. There is no change in dyspnea on lying down or moving into an upright position. His neck veins are flat. Heart sounds are normal with no murmur or gallop. Dullness and decreased breath sounds are present on the right. Left-sided breath sounds are normal with no added sounds. The abdomen is moderately distended with shifting dullness. Bowel sounds are normal. Stool guaiac is negative. He has 1+ bilateral lower extremity pitting edema. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 45-year-old man comes to the office due to progressive shortness of breath on exertion and fatigue for the past several weeks.  Two years ago, the patient was diagnosed with alcoholic cirrhosis and esophageal varices after presenting with hematemesis.  He underwent banding of the varices.  Several months ago, the patient came to the office with massive ascites and a large-volume paracentesis was performed.  His current medications include furosemide, spironolactone, and nadolol.  He has had no alcohol for the past 2 years.  The patient does not use tobacco or illicit drugs.  Blood pressure is 114/72 mm Hg and pulse is 63/min.  Pulse oximetry shows 95% on room air.  There is no change in dyspnea on lying down or moving into an upright position.  His neck veins are flat.  Heart sounds are normal with no murmur or gallop.  Dullness and decreased breath sounds are present on the right.  Left-sided breath sounds are normal with no added sounds.  The abdomen is moderately distended with shifting dullness.  Bowel sounds are normal.  Stool guaiac is negative.  He has 1+ bilateral lower extremity pitting edema.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Patients with cirrhosis and portal hypertension frequently have abdominal ascites and peripheral edema due to low albumin levels and abnormal extracellular fluid volume regulation. A small number of these patients may also develop hepatic hydrothorax, a pleural effusion not due to underlying cardiac or pulmonary abnormalities. Hepatic hydrothorax generally results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm. These defects permit peritoneal fluid to pass into the pleural space, which occurs much more commonly on the right side due to the less muscular hemidiaphragm. Patients have dyspnea, cough, pleuritic chest pain, and hypoxemia. Diagnosis involves documentation of the effusion (eg, chest x-ray) and testing to exclude other causes (eg, thoracentesis, echocardiogram). Treatment involves salt restriction and diuretic administration. Therapeutic thoracentesis could be attempted in patients with prominent symptoms. Chest tube placement should be avoided as it can result in large-volume protein, fluid, and electrolyte losses as well as other severe complications (eg, renal failure). The definitive option for treatment is liver transplantation, although this may not be appropriate for all patients depending on other factors. (Choice A) This patient's lack of other findings suggestive of heart failure (eg, increased jugular venous pressure, S3, bilateral crackles) makes alcoholic cardiomyopathy much less likely. (Choice B) Tense ascites can result in dyspnea and decrease the range of diaphragmatic excursion due to increased intraabdominal pressure, but this is unlikely to cause right-sided dullness and decreased breath sounds. (Choice D) Hepatopulmonary syndrome results from intrapulmonary vascular dilations in the setting of chronic liver disease. Patients frequently have evidence of platypnea (increased dyspnea while upright) or orthodeoxia (oxygen desaturation while upright). (Choices E and F) Although beta blockers (eg, nadolol) or chronic anemia due to recurrent bleeding can result in increased fatigue and dyspnea, this does not explain the patient's pulmonary examination findings. Moreover, variceal bleeding is usually large volume and more clinically evident (eg, hematemesis, positive stool guaiac). Educational objective: Hepatic hydrothorax generally results in transudative pleural effusions and is thought to occur due to small defects in the diaphragm. Diagnosis involves documentation of the effusion and testing to exclude other causes. References: Pulmonary complications of hepatic diseases. (http://www.ncbi.nlm.nih.gov/pubmed/27468192)

A 45-Year-Old Man Comes to the Office Due to Progressive