Management is focused on treating and preventing the relapse of ascites, as the main mechanism of the condition is ascitic fluid flowing through the diaphragm. Some cases respond to medical management. In up to 26% of cases, the condition does not respond to medical management, in which case it is known as a refractory<unk> . In these cases, the first treatment of choice is the insertion of a transjugular intrahepatic portosystemic shunt. The only curative treatment is a liver transplant. Medical management Medical management is the first method of treatment. Although it is simple, cheap, and noninvasive, it has a high rate of failure and comes with a risk of acute kidney injury and kidney failure. Reducing sodium in the diet and usage of diuretics may help reduce ascites and stop the growth of the effusion. The goal of medical management is a low sodium diet of 70-90 mmol per day, and lose .5 kg/day in cases without edema, and 1 kg/day in cases with edema. In most cases, diet modification is not enough to achieve the goal. In these cases, diuretics are the next line of treatment. A distal agent and a loop diuretic can be used together to cause the kidneys to excrete least 120 mEq/day of sodium via urine. The amount of sodium excreted in urine is monitored before and during treatment to adjust diuretic dosage based on response. Refractory<unk>  Fluoroscopic image of TIPS in progress In cases of refractory<unk> , the only definite treatment is a liver transplant. However, the majority of people with this condition are unsuitable for transplantation, and the majority of those that are die awaiting it. In these cases, other treatments can improve symptoms, increase survival, and, ideally, give time until a liver transplant in available. The first choice of treatment in refractory cases is the insertion of a transjugular intrahepatic portosystemic shunt (TIPS). TIPS is effective in 70-80% of cases. It decompresses the portal system, reducing portal hypertension and ascites. However, it does not improve the prognosis in cases with end-stage liver disease. Risk factors for death after placement of TIPS include a Child-Pugh score greater than or equal to 10, MELD score greater than 15, and higher creatinine levels. There is also a higher death rate if the disease does not respond to TIPS. Although there is limited information, it is estimated to have a success rate of 70-80%. The shunt can also cause liver failure in cases with serious liver dysfunction as it shunts blood away from the liver. Thoracentesis, though typically safe, only provides temporary benefit. It increases the risk of pneumothorax from 7.7% to 34.7%. Other possible complications may include pain, empyema, hemothorax, and subcutaneous emphysema. As a second resort, in cases where TIPS is contradicted, an indwelling pleural catheter (IPC) can be used. Pleurodesis is used as a last resort in cases without ascites or any other options. It can be used to repair any defects in the diaphragm. It has the disadvantage of requiring multiple procedures and general anesthesia. Complications may include empyema, sepsis, and septic shock. Chest tubes are not recommended, as it can result in loss of protein, infection, pneumothorax, hemothorax, and electrolyte imbalances. There can also be issues in removing them, as the fluid tends to return after the tube is shut.
Hepatic hydrothorax
Pneumoperitoneum
Subphrenic abscess
Liver abscess
Hemoperitoneum
Hepatopulmonary syndrome
Ascites
Hydrothorax