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Efficacy and safety of transjugular intrahepatic portosystemic shunt in difficult‐to‐manage hydrothorax in cirrhosis
Author(s) -
Jindal Ankur,
Mukund Amar,
Kumar Guresh,
Sarin Shiv K.
Publication year - 2019
Publication title -
liver international
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.873
H-Index - 110
eISSN - 1478-3231
pISSN - 1478-3223
DOI - 10.1111/liv.14200
Subject(s) - medicine , transjugular intrahepatic portosystemic shunt , hydrothorax , cirrhosis , ascites , thoracentesis , liver transplantation , hepatic encephalopathy , portal hypertension , hepatopulmonary syndrome , gastroenterology , surgery , pleural effusion , model for end stage liver disease , septic shock , transplantation , sepsis
Abstract Background Pleural effusions (PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large‐scale studies on interventions for refractory PE are limited. Methods Consecutive hospitalized cirrhotics having PE were retrospectively analysed. None had liver transplantation (LT) within 6‐month follow‐up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment (SMT), thoracentesis, catheter drainage and TIPS. Results Of 1149 cirrhotics with PE (mean Child‐Pugh 10.6 ± 1.8 and MELD 21.2 ± 7.4), 82.6% had hepatic hydrothorax (HH) and 12.3% were suspected tubercular PE (TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P < .01) on follow‐up. Among HH, 73.5% were symptomatic, 53.2% isolated right‐sided PE and 21.3% had SBE. Presence of SBP [Odd's ratio, OR: 4.5] and catheter drainage [OR: 2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. Fifty‐one patients were selected for TIPS [lower mean CTP 9.9 ± 1.6 and MELD score 18.7 ± 5.4]. Despite reduction in pressure gradient from 23.1 ± 3.8 mm Hg to 7.2 ± 2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post‐TIPS complications were portosystemic encephalopathy (eight patients, six resolved) and ischaemic hepatitis (four patients, two resolved). Overall, 35.9% patients with HH had 6‐month mortality and independent predictors were MELD > 25, SBP and septic shock. Conclusion Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. The role of haemodynamics in predicting post‐TIPS response and complications is limited. Early referral for LT is imperative.