Hepatic Hydrothorax without Ascites Successfully Treated with Octreotide Infusion

Abstract

Purpose: Hepatic hydrothorax is the presence of pleural fluid (>500 ml) in a cirrhotic patient without any underlying cardiopulmonary disease. We report a case of a 72-year-old Caucasian male with history of alcohol abuse who presented with hepatic hydrothorax without any ascites. The patient was brought to the ER with progressively worsening dyspnea and bilateral leg swelling for two weeks. Physical examination was remarkable for hepatosplenomegaly without any fluid thrill or shifting dullness, and pedal edema. CT Abdomen/Thorax showed large right-sided pleural effusion, cirrhosis of the liver without any ascites or lung disease. Echocardiogram showed a normal LVEF. The patient was admitted to medical ICU, started on a 2 g Na diet, diuretics, and a large volume thoracocentesis was performed. Pleural fluid revealed a low protein (<2.5 g/dL) effusion with serum-pleural albumin gradient (SPAG) > 1.1 suggestive of hepatic hydrothorax. On day 3, the patient developed acute respiratory distress requiring intubation and emergent placement of a chest tube. CXR showed complete opacification of the right hemithorax with massive pleural effusion (Figure 1). Despite aggressive diuresis, chest tube persistently drained large amounts of pleural fluid and could not be removed. An octreotide drip was then started to decrease the portal hypertension and pleural effusion. Subsequent serial radiographs showed decreasing pleural effusion (Figure 2) facilitating tube removal on day 7 and extubation on day 8. Although hepatic hydrothorax is often seen in association with ascites, our patient had an unusual presentation without any ascites. Moreover, chest tube placement must be avoided as it may be associated with the development of a peritoneal-pleural fistula and persistent drainage delaying the tube removal. Beneficial effects of octreotide have been reported (three-five cases in literature) in facilitating tube removal by decreasing the portal hypertension and subsequently the pleural effusion, as was the case with our patient.FigureFigure: [740]