Hep C fluid around lung

Question

I am on treatment taking Buceprevir/Pegasys.  I have cleared the virus for a few months, however, they said I have to stay on treatment because I have stage 4 cirrhosis.  Last night I went to ER with cough - they took fluid out from around one lung - they could not get all of it- I have to go back Monday.  Is this common?  What does this mean?
Thanks!

HectorSF · Accepted Answer

Hepatic hydrothorax (HH) is deﬁned as a signiﬁcant pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), usually greater than 500 mL, in a cirrhotic patient, without an
underlying pulmonary or cardiac disease. It is a rare complication of advanced cirrhosis.

Do you have or have you experienced ascites?
Are you currently reducing sodium in your diet and taking diuretics?
Was the fluid around the right lung?

Although ascites is usually present, hydrothorax can occur in the absence of ascites. Cirrhosis can cause fluid to build up between the lungs and the chest (pleural effusion ) and press on the lungs. Treatment can include taking medicines such as diuretics, restricting salt in the diet, and using procedures to remove the fluid.

This can be a sign of decompensation of the liver. Indicating End-Stage Liver Disease. It means the liver can no longer perform all of its functions because it is beginning to fail. This is a serious development with anyone that has cirrhosis. And you must notify your treating doctor, gastroenterologist or hepatologist ASAP. This can be an indication that the hepatitis C treatment is damaging your liver. It could cause your liver to fail at which point you will quickly need a liver transplant.

Are you listed for a transplant currently?

I hope you are being treated by a hepatologist at a liver transplant center as they are the only ones qualified to manage hepatic hydrothorax and End-Stage Liver Disease.

While all cirrhotics need to treat for 48 weeks to have the best chance of curing the virus your liver may not be able to handle the treatment drugs any longer without the risk of liver failure. 

Please discuss this matter with your treating doctor ASAP BEFORE continuing to treat your hepatitis C.

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From Tropical Gastroenterology
http://www.tropicalgastro.com/articles/30/3/Hepatic-hydrothorax.html

"The natural course of patients with cirrhosis is frequently complicated by the accumulation of fluid in the peritoneal or pleural cavities and interstitial tissue. Functional renal abnormalities that occur as a consequence of reduced effective arterial blood volume are responsible for fluid accumulation in the form of ascites and hepatic hydrothorax. Ascites is the most common complication of cirrhosis and poses an increased risk for infections, renal failure and mortality.
 
Hepatic hydrothorax

Hepatic hydrothorax is defined as a significant pleural effusion, usually greater than 500 mL, in a cirrhotic patient,without an underlying pulmonary or cardiac disease. It seems to be a relatively uncommon complication of portal hypertension with an estimated prevalence of 5–12% in patients with cirrhosis of the liver. In most cases (85%) hepatic hydrothorax develops on the right side, with 13% of cases occurring on the left side and 2% bilateral. A study has reported that pleural effusion was present in 10% of chest X-rays in cirrhotic patients. In the vast majority of cases, ascites is also present. It is well known that in cirrhotic patients, a large volume of ascitic fluid is generally well tolerated due to the capacitance of the peritoneal cavity. On the other hand, even modest volumes of pleural fluid can cause significant respiratory symptoms, including dyspnea and chest pain.
 
Pathogenesis of ascites and hepatic hydrothorax

Most patients with advanced cirrhosis are unable to maintain extracellular fluid volume within normal limits, which results in increased total extracellular fluid volume and subsequent accumulation of fluid in the peritoneal and/or pleural cavities and interstitial tissue. The main factor responsible for this increase in extracellular fluid volume is an abnormal increase in renal sodium reabsorption. Although the exact pathogenesis of abnormal fluid regulation in cirrhosis is unknown, a large body of evidence indicates that it is secondary to arterial splanchnic vasodilation with a subsequent fall in effective arterial blood volume (the volume sensed by arterial and cardiopulmonary  receptors). The accumulation of fluid and the abnormalities in renal function are the consequence of the homeostatic activation of vasoconstrictor and antinatriuretic factors triggered to compensate for the relative arterial underfilling. Several mechanisms have been proposed in order to explain the development of hepatic hydrothorax in patients with cirrhosis and portal hypertension.

Treatment options for refractory hydrothorax

Repeated thoracentesis
Therapeutic thoracentesis is the most effective way of reducing a large effusion. It is a simple and effective procedure indicated for relief symptoms of dyspnea in patients with large effusions (2 litres) and those with recurrent or refractory hydrothorax. Contrary to what occurs in the peritoneal cavity, where 2 litres does not cause discomfort, this amount of fluid collection in the pleural cavity causes discomfort and therefore these patients experience rapid relief of symptoms after thoracentesis.  

In the vast majority of cases, patients with hepatic hydrothorax have endstage liver disease (ESLD). Therefore, they should be considered potential candidates for orthotopic liver transplantation. Until the performance of transplantation, other therapeutic modalities, including a sodium-restricted diet, diuretics, therapeutic thoracentesis, and transjugular intrahepatic portosystemic shunts should be applied in order to relieve symptoms and prevent pulmonary complications.
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Best of luck to you!
Let us know what your doctor says.
Hector

Naugatuck · Answer

Thanks Hector for your information.
I decided to go off the treatment right now.  I was in the ER at the VA last Friday because my primary care doctor said to get a chest xray and it showed I had fluid around my right lung.  They did not get all of it out and I went to the VA today to have that procedure done.  My wife said she thought they had gotten at least a cup out in the ER and they did blood work and a EKG.  The nurse said the EKG was good.  
Today the doctor said he did not have a diagnosis and they did not get enough fluid in the ER and they have to do blood work and test the fluid when they do the procedure - I walked out today and did not have it done because I waited an hour and a half for the doctor - who only came after the nurse said I was leaving.  I am suppose to go back on Wednesday.

They have said that I have cleared the virus for a few months now - but they want me to stay on treatment until November because I have stage 4 cirrohosis.  
I have trouble breathing - I have diarrhea every day - it seems like hours in the morning-my ankles are swollen- and they have me Procrit because I am always anemic-
Just want your advice.

Thanks,

pcds · Answer

look up pleural effusion.  What you describes sounds like that.  Also people with advanced liver disease need to stay on meds longer, full course forty something weeks I think.

rivll · Answer

I am just posting to bump your question up. I know there are folks who can answer your question, but weekends are a bit slow.

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