Hepatic Hydrothorax

Hepatic hydrothorax is a pleural effusion exceeding 500 mL in cirrhosis, without cardiopulmonary or pleural disease.

• Occurs in 5 to 10% of cirrhotic patients with ascites.
• Mechanism: diaphragmatic defects (small fenestrations) allow ascites to move into the negative pressure pleural space, usually on the right (85%), left (13%), or bilateral.
• Transudative with the same biochemistry as ascites.
• Complications: dyspnoea, respiratory failure, spontaneous bacterial empyema (10 to 15%), hepatic hydrothorax with tension, mortality about 20% at 6 months.

• Progressive dyspnoea, cough, pleuritic pain, orthopnoea.
• Decreased breath sounds and dullness at the right base.
• May exist with minimal or no clinical ascites.
• Fever and pleuritic pain suggest infection.

• Chest radiograph or ultrasound confirms unilateral or bilateral effusion.
• Diagnostic thoracentesis: transudate (Light's criteria may misclassify after diuretics), protein under 2.5 g/dL, pleural to serum albumin gradient over 1.1, low cell count.
• Exclude cardiac failure (echocardiography, BNP), nephrotic syndrome, pulmonary embolism, tuberculosis, malignancy.
• Spontaneous bacterial empyema: pleural PMN 500 or more with positive culture, or PMN 500 or more with negative culture and no pneumonia. Culture in blood bottles.
• Intraperitoneal radionuclide (technetium sulfur colloid) scanning can show transdiaphragmatic communication.

• Dietary sodium restriction (under 2 g/day) and diuretics: spironolactone 100 to 400 mg daily with furosemide 40 to 160 mg daily. Refractory in about 25%.
• Therapeutic thoracentesis for symptomatic relief (avoid removing more than 2 to 3 L per session).
• Avoid chest tube placement: massive protein and fluid loss, infection, renal failure.
• TIPS for refractory cases (response about 70%) with lower mortality; contraindicated with high MELD, encephalopathy, heart failure.
• Liver transplantation is the definitive treatment.
• Pleurodesis (talc) has high failure rate, and video assisted thoracoscopic repair of diaphragmatic defects with pleurodesis for transplant ineligible patients.
• Indwelling pleural catheter is generally avoided because of infection risk.
• Spontaneous bacterial empyema: ceftriaxone 2 g IV daily for 5 to 7 days (broaden for resistant organisms), albumin as in SBP, no routine chest tube unless frank pus.
• Secondary antibiotic prophylaxis with norfloxacin 400 mg daily after empyema.
• Non selective beta blockers should be reviewed in refractory ascites.