A 52–year year–old female presented with a chief complaint of 5 days dyspnea, four pillow orthopnea, chest pain when lying supine, and a non productive cough. She denied fevers, chills and night sweats but did report a weight gain of 15 pounds in the past 10 days. Her past medical history was significant for ESLD secondary to primary sclerosing cholangitis, portal hypertension and ulcerative colitis. She denied alcohol, tobacco, or illicit drug use. Exam was notable for tachycardia, tachypnea, no breath sounds and dullness to percussion throughout the right hemi thorax, soft, non–distended abdomen, and bilateral lower extremity edema. Labs were significant for anemia with hemoglobin of 10.2 mg/dL, potassium of 3.2 mg/dL, total bilirubin 2.8 mg/dL, and albumin 1.3 mg/dL. Her calculated MELD score was 14. A chest X–ray showed a large right pleural effusion. Chest and abdomen CT showed massive right pleural effusion findings of cirrhosis, with minimal ascites. Echocardiogram was within normal limits. Thoracentesis was performed and 2 liters of clear yellow fluid was aspirated and determined to be transudative, consistent with hepatic hydrothorax. Shortly after the procedure, the patient began coughing. A follow up chest X–ray showed a right apical pneumothorax and the patient was started on 100 percent non–rebreather mask. Due to persistence of the cough and continued respiratory distress, repeat chest X–ray was obtained, revealing increased edema on the right upper lobe consistent with reexpansion pulmonary edema (REPE). The patient was started on furosemide and spironolactone, placed on 1.5 liter fluid restriction and a 2 gram sodium restriction diet. Over the course of 4 days, serial chest X–rays showed gradual improvement with complete resolution of the pulmonary edema and pleural effusion. The patient was discharged on room air to home in stable condition.
REPE is a rare, but well–reported complication of thoracentesis, with a mortality–rate as high as 20%. While there are few reports of REPE occurring after thoracentesis of hepatic hydrothorax, few, if any, have been reported in the setting of minimal ascites. The goal of management of hepatic hydrothorax is focused on diuresis; while for REPE, the management is supportive measures including oxygen. In patients with hepatic hydrothorax, chest tube placement is relatively contraindicated. Prevention of REPE has been studied and recommendations include taking into account the duration of time the effusion has been present, the presence of underlying lung disease, the pleural pressure, and the presence of symptoms while doing the thoracentesis. In general, consensus appears to be that less than 1.5 liters should be removed, unless pleural pressures are used for guidance.
We present this patient with hepatic hydrothorax whose case was complicated by REPE. Hospitalists must be aware of the potential complications when performing a thoracentesis in patients with liver disease.