Hepatic hydrothorax (HH) is a significant complication of cirrhosis, associated with increased mortality. Liver transplantation (LT) remains the best treatment modality. We aim to assess predictors of mortality and the survival benefit of LT in patients with HH. A prospectively maintained cohort of adult patients with cirrhosis, being evaluated for LT at our institution, was retrospectively reviewed from 2015 to 2020. Primary outcome was death or LT. Cox proportional hazard regression identified associations between covariates and death. We calculated the years-saved due to LT by comparing patients who were on the waiting-list to patients who received a LT. This was done by calculating the area under the Kaplan-Meier curve. Censoring occurred at the time of last follow-up or death. Patients with refractory HH had the lowest median survival of only 0.26 years. Within the HH group, having refractory HH group was significantly associated with an increased risk of mortality [Hazard ratio (HR) 1.73; 95% confidence interval (CI) 1.06-2.81; p-value 0.03]. Refractory HH was also significantly associated with mortality when evaluated in the entire cohort and after adjusting for other co-variates (HR 1.48, 95%CI 1.03-2.11; p-value 0.03). Patients with refractory HH had the highest 1-year survival benefit with LT (0.48 y) followed by patients with non-refractory HH (0.28 y), then patients with other complications of cirrhosis (0.19 y). In this large study evaluating the prognostic impact of HH on patients with cirrhosis, refractory HH was an independent predictor of mortality. LT provides an additional survival benefit to patients with HH compared to those without HH.
We present a case of a 60-year-old woman status post failed pancreatic transplant, presenting with right lower extremity pain and large volume rectal bleeding. The team initiated a massive transfusion protocol. Investigations revealed an arterioenteric (AE) fistula between the right external iliac artery and terminal ileum. The patient was then emergently sent for right iliac artery stent placement, successfully stopping the active arterial haemorrhage. Afterwards, the surgical team transected the pancreatic jejunal anastomosis, subsequently resecting 7 cm of jejunum. On postoperative day 1, the patient became unstable, going into disseminated intravascular coagulation evidenced by low platelet count, elevated prothrombin time and bloody output from multiple sites. Resuscitation with pressors and blood product transfusion was unsuccessful. She was made comfort measures only and expired shortly after extubation. Although a rare aetiology, it is important to consider AE fistulas in patients presenting with vascular and gastrointestinal symptoms in the setting of a failed allograft.
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