Hepatic Hydrothorax: Dos and Donʼts

Abstract

Introduction: Hepatic hydrothorax is defined as a transudative pleural effusion, usually greater than 500 mL, in patients with portal hypertension without any other underlying primary cardiopulmonary cause. Case report: A 54-year-old patient with history of cirrhosis secondary to NASH came to the hospital secondary to worsening lethargy and fatigue. The patient also noticed a 10-lb weight gain, mild shortness of breath on excretion, and abdominal distention without any fever. Blood pressure was 100/50 mmhg and HR of 92/min. Physical examination revealed mild bibasilar crackles and distended abdomen with periumbilical tenderness. The patient refused paracentesis, and was started on furosemide and spironolactone with improvement in symptoms. On hospital day three, the patient started complaining of worsening abdominal pain, and then became confused. Lactate level was elevated at 4.1 mmol/L, along with ammonia level of 257 mcmol/L. CT scan of the abdomen showed possible ischemic colitis. The patient underwent emergent exploratory laparotomy, which did not show any necrotic bowel. The patient was intubated and transferred to ICU, and was weaned off after 4four days, and was then discharged to rehab facility. While in the rehab, the patient started feeling more SOB, and CXR showed large right sided plural effusion. Thoracentesis was performed with removal of 4300 cc of dark yellow fluid. Post-procedure CXR showed improvement, but CXR next day again showed worsening right-sided plural effusion. A chest tube was placed, which resulted in the worsening of patient's condition with leukocytosis. He was transferred to higher center, where the chest tube was removed, and was then treated with appropriate antibiotics and diuretics. Discussion: The most likely cause of pleural effusions in patients with cirrhosis is the passage of a large amount of ascites from the peritoneal to the pleural cavity, through diaphragmatic defects. Plural effusion is unilateral in the majority of cases, with right-sided predominance. Initial management consists of sodium restriction and diuretics. Other treatment options include thoracentesis, TIPS, and liver transplant. Thoracentesis is indicated for symptomatic relief, as well as for patients with refractory hepato-hydrothorax. Liver transplant is the only definite treatment. Dos: Suspect hepatic hydrothorax in patients with liver cirrhosis and unilateral plural effusion. Perform large volume paracentesis prior to thoracentesis. Consider alternative treatment when a thoracentesis is required more than once every two to three weeks in patients on maximal sodium restriction and optimal diuretics. Don'ts: Do not put chest tube unless frank pus is noted on thoracentesis. Do not remove more than two L of fluid during thoracentesis.