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leural effusions occur in 5 to 10 of patients w ith

cirrhosis of the liver (1 ). In these patients, ascites is

usually evident but a pleural effusion m ay develop in a

cirrh otic p atien t in the ab sen ce o fd etectab le ascites (2 ).

The e ffu sio ns a re u su ally rig ht-s id ed , b ut ma y b e b ila t

eral or left-sided. The precise mechanism of fluid ac

cum ulation is not clear.

We describe a case w here a periton eopleural com

m unication has been dem onstrated by radioisotopic

meth od . T he p ossib le mec han ism s in vo lv ed in th e fo r

mation of pleural effusion in liver cirrhosis are dis

cussed.

CAS E RE POR T

A 5 4-y r-o ld w hite fem ale w as admitte d for p ro gressiv e

d ys pn ea o f re ce nt o nse t a nd sig ns o f u pp er re sp ira to ry in fe c

tion. H er past history included a background of considerable

a lc oh ol in ge stio n, a nd a d ia gn os is o f L ae nn ec c irrh osis h ad

b ee n p re vio us ly made by l iv er b io ps y.

On a dm iss io n, th e p atie nt lo ok ed c hro nic ally ill. S he was

afe brile w ith reg ular pu lse rate o f 1 20 /mm an d a b lo od p res

su re o f 1 80 /1 00 . T here w ere c lin ical sign s o f cirrh osis and

fra nk ja un dic e. C he st e xamin atio n re ve ale d e vid en ce fo r a

m as siv e rig ht p le ura l e ffu sio n. O th er p hy sic al fin din gs in

Rece ivedDec . 13 , 1985; revis ion accepted Apr . 23 , 1986.

For r ep rin ts c on ta ct: J ea n Ve rr ea ul t, MD, Dept. o f Nucle ar

Medicine,Centre Hospital ier Universitaire,Sherbrooke, Qué bec,

Canada, J 1H-5N4.

c lu de d e nla rg ed liv er a nd e vid en ce o f fre e liq uid in th e p en

tonea l cavity.

The ches t x -r ay demonst ra ted a l ar ge r igh t p leu ra l e ff us ion .

Othe r l abo ra to ry t es ts we re compa ti bl e wi th l ive r c i rr hosi s and

t ox ic e ff ec ts o fa lcoho l. Tho racen te si s r eveal ed a f lu id t ha t had

t he char ac te ri st ic s o fa t ransuda te a s d id a s amp le o f pent oneal

f lu id . Fo rt y- ei gh t hour s a ft er t he t ho racen te si s o f 1 ,800cc , t he

r igh t p leu ra l space was compl et el y r ef il led (Fi g. 1 ).

T o p ro ve th at rig ht p le ura l e ffu sio n was re la te d to a sc ite s,

5 mCi of technetium -99m (@mT c) s ulfur colloid w as injected

with a se ptic te chni qu e i nt o t he ri gh t l owe r a bdom in al c av ity .

A se ria l im ag in g stu dy was d on e in a nte rio r v iew a t in te rv als

of 5 mm for 30 mm and at 2 and 24 hr postinjection (F ig. 2).

Image s we re obta in ed on a l ar ge f ie ld -o f-v iew c ame ra w ith a n

a ll-p urp ose , p ara lle l c ollim ato r. A t 2 h r th e ra dio co llo id a p

peared in the right hemithorax and at 24 hr activity w as

fu rth er in cre as ed . It c on firm ed th e p re se nc e o f a p erito ne o

p le ur al c ommunic ati on . Th e p atie nt r es pond ed we ll to medi

ca l the rapy and pleura l e ffus ion reso lvedcomple te ly in 10

days.

DISCUSSION

The a ssoc ia ti on o fhyd ro thor ax with hepat ic c ir rhos is

h as b een reco gn iz ed fo r man y y ears b ut th ere h as b een

much spe cu la ti on a s to its o rig in .

In 1947, H ig gins and his colleagues suggested that

p le ura l e ffu sio n was r ela te d to th e fa ll in th e c on ce nt ra

tio n of plasm a pro teins (3). In 1958, M orrow , K antor

and A rm en suggested that the fluid m ight com e from

the blood stream as a result of hypoalbum inem ia or

17 6 Verreault epageBissontal

The J ou rn al o f Nuc le ar M ed ic in e

Case Reports

Ascites and Right

Pleural Effusion: Demonstration

of a Pentoneo P leural Communica tion

Jean V erreault, Serge L epage, G uy B isso n, and A nd re Plante

D ep artm en ts o fN uc ea r M ed icin e a nd In terna l M ed icin e C entre H osp ita lier U niversita ire

Unive r si ty o fShe rbrooke She rbrook e Québe c Canada

A 54-yr -o ldfemale wi th known l ive rci rrhos is presen ted wi th a r igh t t r ansuda tive pleura l

e ffus ion and asc ites . To f ind the source of p leura l f luid, [@“TcJsuIfurolloidwas injected

int ra pe ri tone al lyand a ser ia l imag ings tudy r evea led i ts pas sage to the r igh tp l eu ra l spac e on

2-hr and 24-hr images. M echanisms proposed in the formation of pleural effusion in liver

c irrh osis a re (a ) lymp ha tic d ra in ag e a nd (b ) d ia ph ra gm atic d efe ct. R ad io iso to pe m ig ra tio n

speed m ay be a clue for differentiating these tw o m echanism s, being m ore rapid in the

presence of a d iaphragmatic de fect .

J NucIMed 27:17 6—17 9986

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bum in from the peritoneal to pleural spaces in a patient

with rig ht h ep atic h yd ro th ora x. The a uto ps y s howed no

g ross def ec t i n the r ight d ia ph ragm.

S in ce lymphatic s a re mo re a bund an t in th e rig ht th an

 £ in the left diaphragm 10 , this m echanism m ight ex

p la in tha t hepat ic hyd ro thor ax a re more f re quen tl y r ight

sided. In addition to this, Leak (1 1) used electron

m icroscopy to show that pores of 4—1 @ zn diam eter

exi st between meso thel ia l c el ls a nd d iaph ragma ti c lym

phatics. They provide a system of open channels

th ro ugh whic h flu id s a nd c ells may ra pid ly b e remove d

from th e sero us cav ities . What remain s u nclear is h ow

and why the fluid leaves the lym phatic system and

en ters th e pleu ral sp ace instead o fbe in g exp elled to ward

the larg er collecting vessels. It m ay result from lym

pha ti c sys tem ove rload (12 ).

There is strong evidence to support the tw o m ech

anism s. W e think that each of these can explain the

form atio n of hyd rothorax from ascites depending on

the c ase. Lymphat ic d ra inage i sp r obably the f ir st mech

an ism to o ccu r in rea ctio n to th e p resen ce o f asc ites. It

can be th e w ay by w hich hydrothorax w ill be fo rm ed if

there is an overload of the lym phatic system . If it is

insufficient, the abdom inal pressure increases and m ay

c au se s ub se qu en t ru pt ure o fth e d ia ph ra gm . One obje c

tion to this assum ption m ay be that pleu ral effusion s

c an be p re sent i n l iver c ir rhos is w ithou t a sc it es . I n the se

cases, th e altern ativ e ex plan atio n is th at th ere is co n

genital diaphragm atic w eakness caused by an insuffi

dent deposition of muscle and tendon bundles. W e

p ropo se d th at th e c lu e to d is tin gu is h b etwee n th es e two

mechanisms may be the use of radioisotope injected

i nt ra pe ri tone al ly a s we d id .

Indeed, w hen w e assum e that the radiocolloid in

jected intrapentoneally is m ixed w ith ascites fluid and

consider that its m igration from peritoneal to pleural

space w as right sided as w as the pleural effusion, w e

c an p re sume th at th ere i s a re la tio ns hip b etwee n a sc ite s

fluid and pleural effusion. Furtherm ore, our proposal

extends to the tim e required to show accum ulation of

the agent in the pleural space. If it happens within a

few minutes, as it was reported by Faiyaz and Goyal

 13 , a diaphragmatic defect isprobably present partic

u la rl y when the a ccumu la ti on i s a s int en se a s per it onea l

activity. If it takes a longer period of time as was seen

fo r o ur p atie nt, th e p erito ne op le ura l c ommunic atio n

may b e a ttrib ute d to d ia ph ra gmatic l ympha tic s p artic

u la rly w hen th at accumu latio n is less in ten se th an p er

itoneal activity.

Such a study can b e done either by the use of[@mTc1

sulfu r c oll oid o r [9 9mTc]ma cro aW@ted a lb um in . The

ra dio ph arm ac eu tic al c an b e in je cte d in tra pe rito ne ally

at the end of th e usual diagno stic or therap eutic p eri

toneal puncture. It can show the source of pleural

effusions in liver cirrhosis and also in patients w ith

peritoneal dialysis (14). W e postulate that the speed at

 

I

hypertension in the azygous and hem iazygous system s

or be second ary to ascites either by direct p assage of

fluid through a diaphragm atic defect or by its transport

t hr ough the d iaph ragma ti c lymphat ic s ( 4) .

H ypoproteinem ia as a sole cause can be elim inated

for there are many patients, cirrhotic or not, w ho have

lo w serum pro tein lev els b ut n ev er d eve lop h yd ro th orax

 5 . I fazygous hypertension ispresent due to col laterals

b etw een th is sy stem an d th e p ortal sy stem , tran su datio n

of fluid into the chest m ight appear. However, this

can no t ex plain h yd ro th orax o ccu rrin g in Meig s sy n

drom e w here there is no portal hypertension. The m ost

probable explanation is that hydrothorax is derived

d irectly from the perito neal flu id eith er th ro ug h a d efect

in the diaphragm or through the lymphatic channels

th at p en etra te it.

A t l ea st t hr ee s tudi es ( 6—8)have p rovided evidenc e

that hydrothorax com plicating cirrhosis is generated

from a sc ite s t hro ugh a d ia ph ra gmatic d efe ct a cqui re d

a s a re su lt o f in cre as ed in tra -a bdom in al p re ss ure . This

has been dem onstrated eith er by rap id passage of d ye

from th e ascites in to th e p leu ral effu sio n, in du ctio n o f

a hyd ropn eumothora x by th e in tra -a bdom in al in sti lla

tion of oxygen, thoracoscopy, or by necropsy findings.

The other m echanism proposed in literature is that

p erit on ea l flu id p as se s to th e p le ura l s pa ce th ro ugh th e

diaphragm atic lym phatics. Johnston and Rodolfo (9)

support it by the dem onstration of unidirectional trans

port of carbon particles and radioiodinated serum al

FIGURE 1

Chest x-ray showing large r igh tp leura le f fus ion

Volume27 •umber11 •ovember1986

1707

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8/19/2019 J Nucl Med 1986 Verreault 1706 9

3/5

,) s

. .. â €¢ @ :,

N IP P LE : :@ ,@ â € ˜ @ @ -4 â €¢

LIN E . •

e

. . . . @ : .

. 1. ‘@ ‘ .‘—@: : ‘.@.: _k@

.;@ ).

r @

—@ ..

•;@; •@‘ ‘ ; ‘@

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FIGURE 2

Serial anteriorimaging study of abdomen and thorax. A:5 mm, B: 30 mm, C: 2 hr. D:24 hrafter intraperitonealinjection

of [@‘TcJsuffuro lloid.Migrationof radio iso tope is seen on 2 hr(C)and 24 hr(D)images

w hic h the radio iso to pe m ig rate s from pe rito ne al to

pl eural space may be a c lue for di ff erenti ati on be tween

the two pathophy sio lo gic al mechani sms propo sed in

the l iterature . Such a di ff erenti ati on may inf luence the

patient's tre atment. If trans it time i s rapid, a macro

sco pic diaphrag matic defect co uld be so ug ht. If transit

is slow, o nly medic al tre atm ent has to be c ontemplate d.

FOOTNOTE

  Picker In ternational H igh land Heights O H

170 8 Ve rre a u ft,e pa ge ,B is s one ta l

A C K N O W L E D G M E N T

The authors thank Mrs. LiseCôtéorherexcellentsecre

tanal assistance.

REFERENCES

1 . B ro dy iS : D iseases o f the pleura, mediastinum, dia

phragm and chestw all. In Cecil TextbookofMedicine,

Vol . 1 , Wyngaarden and Smith, Phi ladelphia, Saun

ders 1982 p 423

2 . S ing er JA , Kaplan M M, Katz RL: Cirrhotic pleural

effusion in the absence of ascites. Gastroenterology

73:575—577977

The Journal o f Nudear Medi cine

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3. Higgins G, Kelsall A R, O B rien JR. et al: Ascites in

chronic diseases of the liver. Q J M ed 16:263—274,

1947

4. Morrow CS, Kantor M , Armen RN: Hepatic hydro

thorax . Ann Interna l Med 49:193—202,958

5 M cKay D G Sparling H i Robbins SL: Cirrhosisof

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6. W illiam s MH: Pleural effusion produced by abdom

mo-p leu ral commun icatio n in a p atien t w ith L aen

nec s c ir rhosis ofthe l ive rand asc ites .Ann Intern Med

3 3 : 2 1 6 †” 2 2 195

7. Emerson PA, Davies JH: Hydrothorax complicating

ascites. Lancet 1:487—488,955

8. Lieberm an FL, H idem ura R, Peters R L, et al: Patho

ge nesis an d treatm en t o f h ydro th ora x complicating

cirrh osis w ith ascites. A nn In tern M ed 6 4:3 41â €”3 51 ,

1966

9 . J ohns to n RF , Loo RV : Hep at ic h yd ro th ora x: S tu die s

to det ermine the sou rc e o ff lu id and r epo rt o f t hi rt een

c a s e sAn n I n t e r nMe d 6 1: 3 8 5 â € ” 4 01I 9 6 4

10. Bra sh JC: Cunn ingham ‘ sextbook o fAnatomy , 9 th

ed., London, Oxford University Press, 1951, p 1423

1 1. Leak L: G ross and ultrastructural m orphologic fea

tu re s o f th e d ia ph ra gm . Am Rev Resp D is 119 :3 †”21,

1979

12. Dumont A E, M ulholland JH: Flow rate and compo

s itio n o fth or ac ic d uc t lymph i n p atie nts w ith c ir rh os is .

N EnglJ M ed 263:47 1—474 960

1 3. F aiy az U , G oy al P C: U nila teral p leu ral effu sion w ith

out a sc ite s in li ve r c irrh os is . P os tg ra d Med 74:3 09 †”

315 1983

1 4. S pad aro JJ, T hak ur V . N olp h KD : T ech netiu m-9 9m -

l abe lled macroaggregated a lbumin in demonstrat ion

of t rans-diaphragmat ic leakage of d ia lysate in pe ri to

n ea l d ia ly sis . Am J Neph ro l 2 :3 6â €” 38 ,1 982

Vo lume 27 •umber 11 â €¢ov ember1986

 7 9

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1986;27:1706-1709.J Nucl Med.

Jean Verreault, Serge Lepage, Guy Bisson and Andre Plante CommunicationAscites and Right Pleural Effusion: Demonstration of a Peritoneo-Pleural

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