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Description
A 73-year-old man was admitted because of abdominal fullness and systemic oedema. He had been followed up as alcoholic cirrhosis for 3 years. He had been drinking about 70–80 g of ethanol every day. The model for end-stage liver disease (MELD) score and MELD-serum sodium (Na) (MN) score are used to estimate relative disease severity and likely survival of patients awaiting liver transplantation. MN score system adds a Na parameter to MELD score.1 Two years ago, his MN score was 7 points and Child-Pugh (CP) score was 5 points. On the other hand, at this admission his MN score was 14 points and CP score was 10 points. After admission, cell-free and concentrated ascites reinfusion therapy (CART) was performed five times, in which about 3–4 L of ascites was punctured.2 Right hydrocele with skin infection became bigger with his intensified feeling of squirming in his groin (figure 1). Abdominal CT showed that there was right communicating hydrocele leading from scrotum through the inguinal canal and into abdominal cavity (figures 2 and 3). Simple ligation of processus vaginalis was performed under iliopubic tract repair method with a little blood loss. On the following day of the operation of hydrocele, hypoxaemia and fever developed, and chest CT showed that his right-sided pleural effusion increased rapidly much more than on the previous day (figure 4). Aspiration of 2700 mL of pleural effusion was done followed by an intravenous infusion of 12.5 g albumin preparation. The ligation of hydrocele seemed to have upset the previous pressure balance between thoracic and abdominal cavity. Essentially, the primary objective was to reduce the rate of inflow of ascites into the right pleural cavity to less than the rate of outflow of pleural fluid into the abdominal cavity.3 Finally a right pleuroperitoneal shunt (Denver Mihama Medical, Tokyo, Japan) was placed under total anaesthesia 3 weeks after the ligation of communicating hydrocele, when his MN score worsened up to 21 points, CP score was 11 points.4 The number of pumping of the chamber with bulbs changed from 500 times a day up to 2600 times a day, which would mean the outflow of about 3900 mL of pleural effusion to the abdominal cavity a day if it is assumed that 1.5 mL would be transferred with each pumping. His sequential chest X-rays showed that his right-sided pleural effusion remained stable (figures 5–7). When his MN score increased up to 35 points and CP score was 13 points, hepatorenal syndrome (HRS) deteliorated to renal failure.5 His blood urea nitrogen and creatinine were 95.5 mg/dL and 3.16 mg/dL, respectively (figure 8). High concentration of norepinephrine was continuously given and 12.5 g of albumin preparation was infused intravenously. The acute respiratory distress syndrome (ARDS) accelerated the deterioration of liver and kidney failure. Although HRS or ARDS would be results of the natural course of end-stage cirrhosis, the effects of the two surgeries and nine CARTs could be undeniable as these causes.
A picture showing a scrotal hydrocele that is distended due to ascites and erythematous probably due to bacterial infection.
Abdominal CT coronal image showing the right communicating hydrocele leading from scrotum through the inguinal canal and into abdominal cavity (yellow dots).
Abdominal CT transverse image showing the right distended inguinal canal (yellow dot).
Chest CT image showing a rapidly increasing right-sided pleural effusion.
Chest X-ray on 7 days before a pleuroperitoneal shunt.
Chest X-ray on 9 days after pleuroperitoneal shunt.
Chest X-ray on 29 days after pleuroperitoneal shunt.
Clinical course of the patient after admission. CART, concentrated ascites reinfusion therapy; HRS, hepatorenal syndrome; MELD-Na, model for end-stage liver disease-serum sodium; P-P, pleuroperitoneal.
Patient’s perspective
My husband was a man who was obedient and never said No to doctors. However, when it came to me, his wife, he was arrogant and would not listen to what I had to say. Therefore, when I said, ‘No alcohol’, it was interpreted by my husband as, ‘No alcohol for a while now’. As a result, my husband ruined his chances for a liver transplantation.
Learning points
Inguinal hernia repair in adult right communicating hydrocele with decompensated liver cirrhosis deteriorated right-sided pleural effusion.
Model for end-stage liver disease-serum sodium score could be a parameter to predict the appearance of end-stage cirrhosis, such as hepatorenal syndrome or acute respiratory distress syndrome.
A pleuroperitoneal shunt combined with cell-free and concentrated ascites reinfusion therapy was effective for refractory hepatic hydrothorax in a patient with decompensated liver cirrhosis.
Ethics statements
Patient consent for publication
Acknowledgments
We thank Tomoko Yamamoto M.D. at Marunouchi Hospital for vigorous surgery, Shinnya Fukuzawa M.D. and Kaori Yamamoto M.D. at Marunouchi Hospital for their assistance in gastroenterological treatment of the patient.
Footnotes
Contributors All authors agreed with the article submission. YN conceived the study and wrote the manuscript. MY implemented CART vigorously. SO performed the surgery and provided critical and creative advice in conceiving and finalising the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.