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Presents as a patient with ascites and dyspnea. Hepatic hydrothorax occurs after a period of difficult to treat ascites. This is a massive pleural effusion, mainly on the right. The right diaphragm has openings. The decreased intrathoracic pressure sucks the ascitic fluid from the abdomen. The treatment is to drastically control the portal hypertension, using TIPS if the MELD score is not too high. Ultimately, hepatic hydrothorax is an indication for liver transplantation.

Presents as drowsiness in a patient with indirect signs of cirrhosis. During the course of their disease, 30% of patients develop hepatic encephalopathy. This concerns psychological and neurological disorders in patients with liver disease. Hepatic encephalopathy occurs in patients with both acute liver failure and cirrhosis.

Clinical examination may reveal the following abnormalities:

- Foetor hepaticus;

- Flapping tremor;

- Parkinsonian extrapyramidal symptoms.

There are four stages:

- Stage 1: reversal of the day-night rhythm, with daytime sleepiness and constitutional apraxia (impaired writing and impaired digit connection test);

- Stage 2: disorientation in time and space, flapping tremor, hyperreflection and rigidity;

- Stage 3: stupor, hyporeflexia and foot clonus;

- stage 4: coma.

Clinically, three stages are distinguished:

- minimal HE (can only be determined by psychometric testing);

- 'covert' HE (grade &) (can be determined by means of the 'animal naming test', in which the patient has to name as many animals as possible in one minute);

- 'overt' HE (grade 2 to 4).

In a cirrhotic patient, hepatic encephalopathy occurs due to a combination of insufficient synthesis activity of the liver and pronounced shunting. The reduced synthesis capacity causes an increase in serum ammonia. There is an increase in Blood-Brain-Barrier permeability (mainly only permeable to water). This leads to swelling of the astrocytes and a mild form of cerebral edema.

Large portosystemic shunts (larger than 8 mm in diameter) can occur anywhere. The two most common are splenorenal shunts (between the vena lienalis and the vena renalis) and at the opening of the umbilical veins.

Hepatic encephalopathy can be provoked by an increase in ammonia supply due to gastrointestinal bleeding or constipation, by hypo- and hypernatremia (diarrhea due to lactulose), by acidosis (spironolactone overdose), by the use of conventional sleeping medication and sedatives, by infections and by TIPS. Over time, the additional breakdown of ammonia via the muscles and kidneys also fails.

There is no gold standard for making a diagnosis. Diagnosis is based on the clinic. A rise in serum venous ammonia may be helpful, but is not valuable in patients with known cirrhosis.

In patients with alcoholic cirrhosis who are found in a coma, a differential diagnosis with a subdural hematoma should always be made.

In patients without liver disease but with increased venous ammonia encephalopathy, the presence of a congenital urea cycle deficiency or congenital extrahepatic portosystemic shunts (Abernethy malformation) must be excluded.

Treatment consists mainly of finding and correcting the provoking factors. There is no place for low-protein diets. The first line of treatment is lactulose with the aim of obtaining at least two soft stools per day. This can be given orally, or in the case of stupor or coma, with the aid of enemas (dilute 150 ml lactulose with 350 ml water). Under the influence of the bacterial flora, lactulose is broken down into acids. These give rise to the formation of ammonium, which cannot diffuse into the blood. This results in acid dialysis with a decrease in ammonia. Another explanation is the laxative effect.

The current second-line therapy consists of rifaximin 550mg twice daily. It is a non-absorbable antibiotic. The exact mechanism of action is unknown, but the intestinal barrier function improves and there is an increased activity of the enzymes involved in liver detoxification.

In case of large spontaneous porto-systemic shunt and a preserved liver synthesis capacity: embolization of the spontaneous porto-systemic shunt. In case of TIPS: reduction stent.

Presents as cyanosis in a patient with advanced liver disease. This is a functional right-left shunt due to dilation of the vascular bed, due to the increased concentrations of nitric oxide in the blood. Clinically, the central cyanosis and tachypnea are noticeable. The patient may develop clubbing of the fingers.

Severe hepatopulmonary syndrome occurs when the PaO2 < 70 mm Hg. The diagnosis is made with echocardiography with contrast. In this case, the bubbles appear immediately in the left half of the heart, after three beats. The only good treatment is liver transplantation.

In every patient with dyspnea, this must be ruled out. Screening can be done using echocardiography. This examination usually overestimates the pulmonary pressures. The diagnosis is made using cardiac catheterization, to examine the right side of the heart. Failure to recognize this can lead to sudden death during a surgical procedure. The cause of death in these patients is sudden death.

The differential diagnosis must be made with pulmonary hypertension due to left heart failure and other forms of pulmonary arterial hypertension, such as systemic diseases and drug-induced forms. The patients are eligible for pulmonary arterial hypertension-lowering medication.

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