Der hepatische Hydrothorax

Zusammenfassung

Der hepatische Hydrothorax ist eine seltene Komplikation der portalen Hypertension bei fortgeschrittener Leberzirrhose, der bei 5 - 10 % der Patienten mit Aszites zu beobachten ist. Zugrunde liegt ein Zwerchfelldefekt. Die Zusammensetzung des hepatischen Hydrothorax entspricht, wie die des Aszites auch, einem Transsudat, die des spontan bakteriellen Pleuraempyems einem Exsudat. Die Behandlung des hepatischen Hydrothorax besteht in der Therapie des Aszites. Persistiert der hepatische Hydrothorax trotz Flüssigkeits- und Natriumrestriktion, maximaler Diuretikatherapie und wiederholter Pleuraergusspunktion, so ist das Vorliegen eines therapierefraktären hepatischen Hydrothorax wahrscheinlich. Ursächlich kann auch ein spontan bakterielles Pleuraempyem, das einer antibiotischen Therapie bedarf, zugrunde liegen. Das spontan bakterielle Pleuraempyem tritt mit einer Häufigkeit von 13 %, der therapierefraktäre Hydrothorax mit einer Häufigkeit von 10 % bei Patienten mit hepatischem Hydrothorax auf. Die Implantation des transjugulären intrahepatischen portosystemischen Shunts (TIPSS) ist die effektivste Therapieoption des therapierefraktären Hydrothorax mit Ansprechraten von bis zu 80 %. Der TIPSS kann bei Patienten, die für eine Lebertransplantation geeignet sind, auch als so genanntes „bridging”-Verfahren zur Überbrückung der Wartezeit bis zur Lebertransplantation eingesetzt werden.

Abstract

Hepatic hydrothorax is a rare complication of portal hypertension secondary to liver cirrhosis affecting approximately 5 - 10 % of cirrhotic patients with ascites. Hepatic hydrothorax results from an accumulation of fluid migrating through a diaphragmatic defect from the abdominal cavity into the pleural cavities. The effusion of hepatic hydrothorax is typically transudative whereas the effusion of spontaneous bacterial empyema (SBEM) is exudative. The clinical management of hepatic hydrothorax is equivalent to that of ascites. Patients with persistent hepatic hydrothorax despite fluid and sodium restriction as well as the use of maximally tolerable doses of diuretics and repeated thoracentesis are considered to have refractory hepatic hydrothorax. SBEM is a frequent underlying condition. SBEM occurs in up to 13 % of patients with hepatic hydrothorax and should be treated by antibiotic therapy. Refractory hydrothorax is observed in 10 % of patients with hepatic hydrothorax. These patients should be considered for transjugular intrahepatic portal systemic shunt (TIPS) placement which is the most effective option for refractory hepatic hydrothorax with response rates ranging up to 80 % in most studies. Suitable patients with hepatic hydrothorax should be considered as candidates for liver transplantation. TIPS may help to bridge the time to liver transplantation.

Hepatischer Hydrothorax - Aszites - spontan bakterielles Pleuraempyem - TIPSS - Lebertransplantation

Hepatic hydrothorax - ascites - spontaneous bacterial empyema - TIPS - liver transplantation

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