肝性胸水临床研究进展与挑战

马博; 尚天玲; 黄剑洁; 涂芷馨; 王妍; 韩雨金; 温晓玉; 金清龙

doi:10.3969/j.issn.1001-5256.2022.02.040

肝性胸水临床研究进展与挑战

DOI: 10.3969/j.issn.1001-5256.2022.02.040

a.
吉林大学第一医院肝胆胰内科，长春 130021
b.
吉林大学第一医院神经内科，长春 130021

基金项目:

国家自然科学基金 (81270484);

吉林省财政厅项目 (JLSCZD2019-027)

利益冲突声明：所有作者均声明不存在利益冲突。

作者贡献声明：马博、尚天玲负责选题，收集分析资料，撰写文章；黄剑洁、涂芷馨、王妍、韩雨金参与选题，收集资料；金清龙、温晓玉负责拟定写作思路，指导撰写文章，提供修改意见并最终定稿。

详细信息

通信作者:
金清龙, jinql@jlu.edu.cn

计量
- 文章访问数: 674
- HTML全文浏览量: 254
- PDF下载量: 83
- 被引次数: 0
出版历程
- 收稿日期: 2021-10-10
- 录用日期: 2021-11-15
- 出版日期: 2022-02-20

Advances and challenges in clinical research on hepatic hydrothorax

a.
Department of Hepatology, The First Hospital of Jilin University, Changchun 130021, China
b.
Department of Neurology, The First Hospital of Jilin University, Changchun 130021, China

Research funding:

National Natural Science Foundation of China (81270484);

Jilin Provincial Finance Department Project (JLSCZD2019-027)

More Information

Corresponding author: JIN Qinglong, jinql@jlu.edu.cn

摘要

摘要: 肝性胸水(HH)是肝硬化与门静脉高压相关的一种极具挑战性的并发症，其发生机制及治疗措施仍不完全明确。总结评述了HH的发病机制、临床表现、诊断治疗等方面最新研究进展与挑战，并提供一个多学科的治疗策略，包括减少腹水的产生、防止积液进入胸腔、胸腔积液清除、胸膜腔闭塞和肝移植5部分，以期为更多临床医生提供参考。
- 肝硬化 /
- 胸水 /
- 腹水 /
- 积脓, 胸腔
Abstract: Hepatic hydrothorax (HH) is a challenging complication of liver cirrhosis associated with portal hypertension, and its pathogenesis and therapeutic measures remain unknown. This article summarizes and reviews the advances and challenges in the research on the pathogenesis, clinical manifestations, diagnosis, and treatment of HH and proposes a multidisciplinary treatment strategy, including reducing the production of ascites, preventing effusion from entering the thoracic cavity, removing pleural effusion, occluding the pleural cavity, and performing liver transplantation, so as to provide a reference for more clinicians.
- Liver Cirrhosis /
- Hydrothorax /
- Ascites /
- Empyema, Pleural

HTML全文

表 1 单纯HH胸腔积液组成

细胞计数 < 1000/mm³
多形核白细胞计数 < 250/mm³
蛋白浓度 < 2.5 g/dL
胸水/血清总蛋白比值< 0.5
胸水/血清乳酸脱氢酶比值 > 0.6
胸水/血清白蛋白梯度 > 1.1 g/dL
pH > 7.4
积液葡萄糖浓度与血清相似

下载: 导出CSV

表 2 SBEM诊断标准

(1)血清/胸水白蛋白梯度 > 1.1 g/dL
(2)胸水培养阳性或多形核白细胞计数 > 500/mm³
(3)胸片未见感染或直接感染

下载: 导出CSV

表 3 HH不同治疗方式优缺点

治疗方式	优点	缺点	意见
药物治疗	费用少无创	不服从率高急性肾损伤和肾衰竭风险难治性HH无效	HH治疗第一步
胸腔穿刺术	缓解急性症状可行胸腔积液分析排除其他诊断，如SBEM	频繁穿刺并发症如气胸、血胸、复张性肺水肿	对于适合肝移植评估的，不需要频繁排水的患者，重复行胸腔穿刺术可能是最好的选择
留置胸膜导管	一种可控制的胸水引流	并发症包括脓胸、脱位、移位、渗漏和气胸	适用多于每2周1次行胸腔穿刺术的患者
TIPS	肝移植桥梁成功率70%~80%	易发生肝性脑病分流阻塞和血栓形成MELD评分 > 15分、CTP分级C级、手术前肌酐 > 2 mg/dL者生存率低	难治性HH的首选治疗方式
胸膜固定术	可行膈缺损修复CPAP、生长抑素可提高成功率TIPS有禁忌证者可考虑	手术可能需要重复多次电视胸腔镜手术需全身麻醉并发症如脓胸、败血症及感染性休克机械性胸膜粘连增加出血风险不能在肺不张时进行	推荐无临床腹水患者
外科修复横膈膜缺损	增加胸膜固定术成功率	难直观发现膈缺损有创	在TIPS有禁忌证患者中考虑
胸膜静脉分流术	HH通过泵系统有效的控制	胸痛空气栓塞风险高	在TIPS有禁忌证患者中考虑
肝移植	最有效的治疗方式	等候时间长	所有HH患者均应考虑

下载: 导出CSV

参考文献(46)

[1]	KROK KL, CÁRDENAS A. Hepatic hydrothorax[J]. Semin Respir Crit Care Med, 2012, 33(1): 3-10. DOI: 10.1055/s-0032-1301729.
[2]	BANINI BA, ALWATARI Y, STOVALL M, et al. Multidisciplinary management of hepatic hydrothorax in 2020: An evidence-based review and guidance[J]. Hepatology, 2020, 72(5): 1851-1863. DOI: 10.1002/hep.31434.
[3]	CARDENAS A, KELLEHER T, CHOPRA S. Review article: Hepatic hydrothorax[J]. Aliment Pharmacol Ther, 2004, 20(3): 271-279. DOI: 10.1111/j.1365-2036.2004.02081.x.
[4]	CHAABAN T, KANJ N, BOU AKL I. Hepatic hydrothorax: An updated review on a challenging disease[J]. Lung, 2019, 197(4): 399-405. DOI: 10.1007/s00408-019-00231-6.
[5]	MATEI D, CRACIUN R, CRISAN D, et al. Hepatic hydrothorax-an independent decompensating event associated with long-term mortality in patients with cirrhosis[J]. J Clin Med, 2021, 10(16): 3688. DOI: 10.3390/jcm10163688.
[6]	MORROW CS, KANTOR M, ARMEN RN. Hepatic hydrothorax[J]. Ann Intern Med, 1958, 49(1): 193-203. DOI: 10.7326/0003-4819-49-1-193.
[7]	ISLAM N, ALI S, KABIR H. Hepatic hydrothorax[J]. Br J Dis Chest, 1965, 59(4): 222-227. DOI: 10.1016/s0007-0971(65)80053-5.
[8]	MEIGS JV, ARMSTRONG SH, HAMILTON HH, et al. A further contribution to the syndrome of fibroma of the ovary with fluid in the abdomen and chest, Meigs' syndrome[J]. Am J Obstet Gynecol, 1943, 46: 19-37.
[9]	DUMONT AE, MULHOLLAND JH. Flow rate and composition of thoracic-duct lymph in patients with cirrhosis[J]. N Engl J Med, 1960, 263: 471-474. DOI: 10.1056/NEJM196009082631001.
[10]	EMERSON PA, DAVIES JH. Hydrothorax complicating ascites[J]. Lancet, 1955, 268(6862): 487-488. DOI: 10.1016/s0140-6736(55)90269-5.
[11]	ROUSSOS A, PHILIPPOU N, MANTZARIS GJ, et al. Hepatic hydrothorax: Pathophysiology diagnosis and management[J]. J Gastroenterol Hepatol, 2007, 22(9): 1388-1393. DOI: 10.1111/j.1440-1746.2007.05069.x.
[12]	HUANG PM, CHANG YL, YANG CY, et al. The morphology of diaphragmatic defects in hepatic hydrothorax: Thoracoscopic finding[J]. J Thorac Cardiovasc Surg, 2005, 130(1): 141-145. DOI: 10.1016/j.jtcvs.2004.08.051.
[13]	MVCKE VT, FITTING D, DULTZ G, et al. Application of contrast-enhanced ultrasound to detect hepatic hydrothorax in patients with liver cirrhosis[J]. Ultraschall Med, 2020. DOI: 10.1055/a-1189-2937.[Online ahead of print]
[14]	AJMI S, HASSINE H, ARIFA N, et al. Large diaphragmatic defect as the cause of hydrothorax in a cirrhotic patient: Demonstration with peritoneal scintigraphy and magnetic resonance imaging[J]. Magn Reson Imaging, 2004, 22(3): 431-433. DOI: 10.1016/j.mri.2004.01.001.
[15]	HEWETT LJ, BRADSHAW ML, GORDON LL, et al. Diagnosis of isolated hepatic hydrothorax using peritoneal scintigraphy[J]. Hepatology, 2016, 64(4): 1364-1366. DOI: 10.1002/hep.28634.
[16]	YUTAKA Y, FUKAO A, SHIRASE T, et al. A novel surgical approach to refractory hepatic hydrothorax[J]. Ann Thorac Surg, 2013, 96(3): e75-e76. DOI: 10.1016/j.athoracsur.2013.03.112.
[17]	NORVELL JP, SPIVEY JR. Hepatic hydrothorax[J]. Clin Liver Dis, 2014, 18(2): 439-449. DOI: 10.1016/j.cld.2014.01.005.
[18]	BADILLO R, ROCKEY DC. Hepatic hydrothorax: Clinical features, management, and outcomes in 77 patients and review of the literature[J]. Medicine (Baltimore), 2014, 93(3): 135-142. DOI: 10.1097/MD.0000000000000025.
[19]	CHRISTOFFERSEN S. CT verified cause of death in hepatic hydrothorax without ascites[J]. Forensic Sci Int, 2010, 198(1-3): e11-e13. DOI: 10.1016/j.forsciint.2010.01.009.
[20]	GURUNG P, GOLDBLATT M, HUGGINS JT, et al. Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax[J]. Chest, 2011, 140(2): 448-453. DOI: 10.1378/chest.10-2134.
[21]	MØLLER S, HENRIKSEN JH. Cardiovascular complications of cirrhosis[J]. Gut, 2008, 57(2): 268-278. DOI: 10.1136/gut.2006.112177.
[22]	XIOL X, CASTELLOTE J, BALIELLAS C, et al. Spontaneous bacterial empyema in cirrhotic patients: Analysis of eleven cases[J]. Hepatology, 1990, 11(3): 365-370. DOI: 10.1002/hep.1840110306.
[23]	SESE E, XIOL X, CASTELLOTE J, et al. Low complement levels and opsonic activity in hepatic hydrothorax: Its relationship with spontaneous bacterial empyema[J]. J Clin Gastroenterol, 2003, 36(1): 75-77. DOI: 10.1097/00004836-200301000-00020.
[24]	MOHAMED A, ATEF M, ALSEBAEY A, et al. Combined spontaneous bacterial empyema and peritonitis in cirrhotic patients with ascites and hepatic hydrothorax[J]. Arab J Gastroenterol, 2017, 18(2): 104-107. DOI: 10.1016/j.ajg.2017.05.010.
[25]	LV Y, HAN G, FAN D. Hepatic hydrothorax[J]. Ann Hepatol, 2018, 17(1): 33-46. DOI: 10.5604/01.3001.0010.7533.
[26]	MOORE KP, WONG F, GINES P, et al. The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club[J]. Hepatology, 2003, 38(1): 258-266. DOI: 10.1053/jhep.2003.50315.
[27]	IBRISIM D, CAKALOGLU Y, AKYUZ F, et al. Treatment of hepatic hydrothorax with terlipressin in a cirrhotic patient[J]. Scand J Gastroenterol, 2006, 41(7): 862-865. DOI: 10.1080/00365520500527441.
[28]	BARREALES M, SÁENZ-LÓPEZ S, IGARZABAL A, et al. Refractory hepatic hydrothorax: Successful treatment with octreotide[J]. Rev Esp Enferm Dig, 2005, 97(11): 830-835. DOI: 10.4321/s1130-01082005001100007.
[29]	SPENCER EB, COHEN DT, DARCY MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax[J]. J Vasc Interv Radiol, 2002, 13(4): 385-390. DOI: 10.1016/s1051-0443(07)61741-2.
[30]	DITAH IC, AL BAWARDY BF, SABERI B, et al. Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis[J]. World J Hepatol, 2015, 7(13): 1797-1806. DOI: 10.4254/wjh.v7.i13.1797.
[31]	MOUROUX J, PERRIN C, VENISSAC N, et al. Management of pleural effusion of cirrhotic origin[J]. Chest, 1996, 109(4): 1093-1096. DOI: 10.1378/chest.109.4.1093.
[32]	JUNG Y, SONG SY, NA KJ, et al. Minimally invasive surgical strategy for refractory hepatic hydrothorax[J]. Eur J Cardiothorac Surg, 2020, 57(5): 881-887. DOI: 10.1093/ejcts/ezz342.
[33]	HUANG PM, KUO SW, CHEN JS, et al. Thoracoscopic mesh repair of diaphragmatic defects in hepatic hydrothorax: A 10-year experience[J]. Ann Thorac Surg, 2016, 101(5): 1921-1927. DOI: 10.1016/j.athoracsur.2015.11.023.
[34]	NORTHUP PG, HARMON RC, PRUETT TL, et al. Mechanical pleurodesis aided by peritoneal drainage: Procedure for hepatic hydrothorax[J]. Ann Thorac Surg, 2009, 87(1): 245-250. DOI: 10.1016/j.athoracsur.2008.10.013.
[35]	GILBERT CR, SHOJAEE S, MALDONADO F, et al. Pleural interventions in the management of hepatic hydrothorax[J]. Chest, 2021. DOI: 10.1016/j.chest.2021.08.043.[Online ahead of print]
[36]	SOBOTKA LA, SPITZER C, HINTON A, et al. Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission[J]. J Gastroenterol Hepatol, 2020, 35(4): 641-647. DOI: 10.1111/jgh.14842.
[37]	RIDHA A, AL-ABBOODI Y, FASULLO M. The outcome of thoracentesis versus chest tube placement for hepatic hydrothorax in patients with cirrhosis: A nationwide analysis of the national inpatient sample[J]. Gastroenterol Res Pract, 2017, 2017: 5872068. DOI: 10.1155/2017/5872068.
[38]	RUNYON BA. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012[J]. Hepatology, 2013, 57(4): 1651-1653. DOI: 10.1002/hep.26359.
[39]	TREMBLAY A, MICHAUD G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion[J]. Chest, 2006, 129(2): 362-368. DOI: 10.1378/chest.129.2.362.
[40]	PATIL M, DHILLON SS, ATTWOOD K, et al. Management of benign pleural effusions using indwelling pleural catheters: A systematic review and meta-analysis[J]. Chest, 2017, 151(3): 626-635. DOI: 10.1016/j.chest.2016.10.052.
[41]	HAAS KP, CHEN AC. Indwelling tunneled pleural catheters for the management of hepatic hydrothorax[J]. Curr Opin Pulm Med, 2017, 23(4): 351-356. DOI: 10.1097/MCP.0000000000000386.
[42]	ARTEMIOU O, MARTA GM, KLEPETKO W, et al. Pleurovenous shunting in the treatment of nonmalignant pleural effusion[J]. Ann Thorac Surg, 2003, 76(1): 231-233. DOI: 10.1016/s0003-4975(03)00193-0.
[43]	SINGH A, BAJWA A, SHUJAAT A. Evidence-based review of the management of hepatic hydrothorax[J]. Respiration, 2013, 86(2): 155-173. DOI: 10.1159/000346996.
[44]	HOU F, QI X, GUO X. Effectiveness and safety of pleurodesis for hepatic hydrothorax: A systematic review and meta-analysis[J]. Dig Dis Sci, 2016, 61(11): 3321-3334. DOI: 10.1007/s10620-016-4260-9.
[45]	XIOL X, TREMOSA G, CASTELLOTE J, et al. Liver transplantation in patients with hepatic hydrothorax[J]. Transpl Int, 2005, 18(6): 672-675. DOI: 10.1111/j.1432-2277.2005.00116.x.
[46]	XIOL X, CASTELLVí JM, GUARDIOLA J, et al. Spontaneous bacterial empyema in cirrhotic patients: A prospective study[J]. Hepatology, 1996, 23(4): 719-723. DOI: 10.1002/hep.510230410.