technetium-tc-99m-sulfur-colloid and Hydrothorax

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.

Topics: Humans; Hydrothorax; Hypertension, Portal; Liver Cirrhosis; Liver Transplantation; Paracentesis; Portasystemic Shunt, Transjugular Intrahepatic; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid; Thoracoscopy

Massive hydrothorax occurring during continuous ambulatory peritoneal dialysis is a rare complication that may appear at any time during the course of the treatment. Most of the time, it is right-sided and is more frequent in female patients. A case is presented that was investigated by peritoneopleural scintigraphy. A rapid accumulation of the radiopharmaceutical over the right hemithorax was observed. To explain that finding, a macroscopic diaphragmatic defect was suspected. Different therapeutic approaches are presented.

Topics: Female; Humans; Hydrothorax; Middle Aged; Peritoneal Cavity; Peritoneal Dialysis, Continuous Ambulatory; Pleura; Pleural Effusion; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Topics: Child, Preschool; Female; Fistula; Humans; Hydrothorax; Nephrectomy; Nephrotic Syndrome; Peritoneal Dialysis; Peritoneal Diseases; Pleural Diseases; Radionuclide Imaging; Radiopharmaceuticals; Respiratory Tract Fistula; Technetium Tc 99m Sulfur Colloid

Talc pleurodesis can be offered to patients with hepatic hydrothorax. The authors wanted to determine their patient's eligibility for talc pleurodesis by excluding a pleural-peritoneal shunt.. The authors measured the size of the talc particles and matched them with the radionuclide particle size. After injecting radiopharmaceutical into the pleura, the authors imaged the abdomen for possible migration.. In their patient, there was no migration of radionuclide from the thorax into the abdomen.. Injecting radionuclide into the thoracic cavity and then imaging for an extended period of time is one way to determine whether the patient has a pleural-peritoneal shunt.

Topics: Aged; Female; Humans; Hydrothorax; Injections, Intraperitoneal; Liver Diseases; Patient Selection; Peritoneovenous Shunt; Pleurodesis; Radionuclide Imaging; Radiopharmaceuticals; Talc; Technetium Tc 99m Sulfur Colloid

Topics: Hernia, Inguinal; Humans; Hydrothorax; Male; Middle Aged; Peritoneal Cavity; Peritoneal Dialysis, Continuous Ambulatory; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Topics: Adult; Ascites; Humans; Hydrothorax; Liver Cirrhosis; Male; Pleural Effusion; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Topics: Aged; Aged, 80 and over; Ascites; Humans; Hydrothorax; Liver Cirrhosis, Alcoholic; Male; Pleural Effusion; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Twelve cases of right hepatic hydrothorax are reported. Tc-99m SC that was injected intraperitoneally and intrapleurally provided evidence of a one-way flow of fluid from the peritoneal to the pleural cavity. Eight patients, whose hydrothorax was refractory to sodium restriction, diuretics and repeated thoracenteses, were treated by endopleural tetracycline instillation. The pathogenetic role of the diaphragmatic defect and the diagnostic usefulness of radionuclide imaging are stressed.

Topics: Adult; Aged; Female; Humans; Hydrothorax; Liver Diseases; Male; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Topics: Ascites; Female; Humans; Hydrothorax; Liver Cirrhosis; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Topics: Female; Humans; Hydrothorax; Kidney Failure, Chronic; Middle Aged; Peritoneal Dialysis, Continuous Ambulatory; Technetium Tc 99m Sulfur Colloid

Topics: Female; Humans; Hydrothorax; Liver Cirrhosis; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Two cases of right hepatic hydrothorax occurring in the absence of clinical ascites are reported. Diagnosis was confirmed by the intraperitoneal and intrapleural injection of radioisotope 99mTc-sulfur colloid that demonstrated the one-way transdiaphragmatic flow of fluid from the peritoneal to pleural cavities. In contrast, radioisotope injected into the peritoneal cavity of 5 patients with pleural effusions secondary to pulmonary or cardiac disease failed to traverse the diaphragm and localize in the pleural space. Medical therapy with salt and water restriction and diuretics resulted in both of the patients with hepatic hydrothorax developing signs of intravascular volume depletion without significant mobilization of the pleural fluid. Thoracotomy allowed identification of the diaphragmatic defects that were repaired by chemical and traumatic pleurodesis followed by postoperative peritoneal and pleural drainage. This therapy resulted in complete resolution of the pleural effusions, which have not recurred despite the subsequent development of clinical ascites in both patients.

Topics: Ascitic Fluid; Female; Hepatitis, Alcoholic; Hepatitis, Chronic; Humans; Hydrothorax; Liver Cirrhosis, Alcoholic; Middle Aged; Pleural Effusion; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Hydrothorax occurs in 5.3 percent of ascitic patients. Our experience with 22 cases forms the basis of this report. Of the 22 cases, 21 were spontaneous and 1 was due to transdiaphragmatic incision. Eighteen occurred on the right side. Usually fluid enters the chest through tiny defects in the diaphragm. These defects are often covered by pleuroperitoneum, but the high abdominal pressure raises a bleb on the superior surface of the diaphragm. Rupture produces hydrothorax. The ascites is often relieved with the onset of the hydrothorax. Blockage of the thoracic duct has produced chylous ascites. The thoracoabdominal communication is immediately confirmed by a scan of the chest and abdomen after intraperitoneal injection of technetium-99 colloid. Fluid is tapped from the chest immediately before intraperitoneal injection. The rate at which the technetium-99 enters the chest is related to the size of the defect in the diaphragm. A significant transfer should occur within 12 hours. Immediate transfer occurs with large defects. The ruptured blister on the diaphragm forms a one-way valve. Intrathoracic injection does not migrate into the peritoneal cavity. The valvular characteristics of the leak force ascitic fluid into the thorax because the differential pressure between the abdominal and pleural cavities is intensified by inspiration. If tension hydrothorax has occurred, urgent thoracocentesis and paracentesis may be required. A chest tube should not be introduced. The main principle of surgery is to supply a low resistance pathway for the return of fluid to the venous system and to eliminate the diaphragmatic defect by obliteration of the pleural space. A LeVeen peritoneovenous shunt is performed after emptying the abdomen of its fluid load. After completion of the shunt operation, the chest is emptied of fluid, and a sclerosing agent (tetracycline or nitrogen mustard) is injected into the pleural cavity. Closure of the defect is verified by technetium-99 labeled scans which also confirm shunt patency. With this regime, the defect closed or was rendered insignificant in 18 of 22 patients. One patient had a post-transdiaphragmatic surgical defect which was too extensive to be closed by the aforementioned procedures. One patient remained well but did not have closure of the defect, one patient with a ruptured hiatal hernia did not have closure, and one patient who had previous placement of a chest tube could not be closed. Therefore, 18 of 22 patients were su

Topics: Ascites; Drainage; Humans; Hydrothorax; Intubation; Peritoneovenous Shunt; Pleura; Sclerosing Solutions; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Tetracycline

Topics: Adult; Ascites; Female; Humans; Hydrothorax; Middle Aged; Peritoneovenous Shunt; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Topics: Adult; Humans; Hydrothorax; Kidney Failure, Chronic; Male; Peritoneal Dialysis; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid