Hepatic Hydrothorax

A pleural effusion (>500 mL) in a patient with cirrhosis and portal hypertension, without primary cardiac or pulmonary disease.


🔍 Definition:

Hepatic hydrothorax is a transudative pleural effusion, typically right-sided, occurring in patients with decompensated liver cirrhosis and ascites, though it can occasionally occur without ascites.


📊 Epidemiology:

  • Occurs in 5–10% of patients with cirrhosis.
  • 85% are right-sided, 13% left-sided, 2% bilateral.
  • Can be large and recurrent, leading to dyspnea and respiratory failure.


🔬 Pathophysiology:

Step

Explanation

1. Portal hypertension

Leads to ascites due to increased hydrostatic pressure and low oncotic pressure (↓ albumin).

2. Diaphragmatic defects

Small fenestrations (congenital/acquired) allow ascitic fluid to pass into pleural space.

3. Negative intrathoracic pressure

Promotes unidirectional flow from peritoneum to pleural cavity.

4. One-way valve effect

Fluid accumulates more in pleural space, even when ascites is minimal.



🧪 Clinical Features:

  • Dyspnea (often disproportionate to ascites)
  • Non-productive cough
  • Orthopnea or platypnea
  • Chest discomfort or pleuritic pain
  • Decreased breath sounds, dullness to percussion
  • Signs of decompensated liver disease (ascites, jaundice, encephalopathy)


📷 Investigations:

1. Imaging:

Modality

Findings

Chest X-ray

Massive unilateral effusion (usually right), mediastinal shift

USG Thorax

Confirms effusion, helps with thoracentesis guidance

CT Thorax

Excludes malignancy, TB, or pulmonary causes

Tc-99m peritoneal scintigraphy

Shows flow of ascitic fluid into pleural space via defects



2. Pleural Fluid Analysis (via thoracentesis)

Parameter

Finding in Hepatic Hydrothorax

Appearance

Clear/straw-colored

Protein

<2.5 g/dL (transudate)

LDH

Low (<0.6 serum LDH)

pH

>7.4 (normal or slightly alkaline)

Glucose

Normal

Cell count

<250 cells/mm³; lymphocyte or mesothelial predominant

Culture

Sterile unless infected (→ spontaneous bacterial empyema)


Note: 5–10% may show atypical exudative pattern due to repeated procedures or infection.


Management

A. Medical Management

Step

Intervention

1. Sodium restriction

<2 g/day

2. Fluid restriction

Especially if hyponatremia

3. Diuretics

Spironolactone ± furosemide (watch renal function)

4. Therapeutic thoracentesis

For symptomatic relief; avoid >1.5 L per tap

5. Albumin infusion

If large-volume paracentesis or low serum albumin

6. Avoid NSAIDs, nephrotoxins

To prevent hepatorenal syndrome



B. Definitive Management

Option

Indication

TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Refractory hydrothorax unresponsive to medical therapy

Pleurodesis

Often fails due to continuous fluid transfer; rarely effective

Surgical repair of diaphragm

For isolated large defects (rare)

Liver transplantation

Definitive treatment



⚠️ Complications

  • Spontaneous bacterial empyema (SBEM) – similar to SBP, may occur even without pneumonia
  • Respiratory distress
  • Tension hydrothorax (rare)
  • Infection post-thoracentesis
  • Electrolyte imbalance and renal dysfunction due to aggressive diuresis


🧪 Spontaneous Bacterial Empyema (SBEM)

Parameter

Diagnostic Criteria (in hepatic hydrothorax)

PMN count

>250 cells/mm³

Culture

Positive without pneumonia

Treatment

Cefotaxime/Ceftriaxone + albumin ± chest tube (if purulent)



🔍 Differential Diagnosis

  • Malignant pleural effusion
  • Tubercular effusion
  • Parapneumonic effusion/empyema
  • Congestive heart failure
  • Chylothorax
  • Nephrotic syndrome-related effusion