Hepatic Hydrothorax

Abstract

Hepatic hydrothorax (HH) is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. Although the development of HH remains incompletely understood, the most acceptable explanation is that the pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm due to the raised abdominal pressure and the negative pressure within the pleural space. Patients with HH can be asymptomatic or present with pulmonary symptoms such as shortness of breath, cough, hypoxemia, or respiratory failure associated with large pleural effusions. The diagnosis is established clinically by finding a serous transudate after exclusion of cardiopulmonary disease and is confirmed by radionuclide imaging demonstrating communication between the peritoneal and pleural spaces when necessary. Spontaneous bacterial empyema is serious complication of HH, which manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. The mainstay of therapy of HH is sodium restriction and administration of diuretics. When medical therapy fails, the only definitive treatment is liver transplantation. Therapeutic thoracentesis, indwelling tunneled pleural catheters, transjugular intrahepatic portosystemic shunt and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality is high in these extremely ill patients.

Pulmonary manifestations of chronic liver disease: a comprehensive review

“…HH is a transudative pleural effusion that develops in a patient with liver cirrhosis in the absence of any other obvious cardiopulmonary or pleural pathology [133]. The most acceptable explanation for the development of HH is the direct passage of ascitic fluid into the pleural cavity through defects in the diaphragm as a result of the elevated abdominal pressure, compared to the negative intrathoracic pressure [134]. These defects, usually less than 1 cm in diameter, are mainly located on the right side of the diaphragmatic tendon.…”

“…Thoracentesis followed by pleural fluid analysis is performed to identify the nature of the fluid and confirm the diagnosis. HH is a transudative effusion with characteristics similar to the ascetic fluid and a serum-to-pleural-albumin gradient >1.1 mg/ dL, although increased water absorption in the pleural cavity may be responsible for slightly higher total protein and albumin values in HH compared to the ascitic fluid [134]. Pleural fluid analysis should routinely include fluid total protein, albumin and lactate dehydrogenase levels, and cell count.…”

Peer Review #1 of "Refractory ascites—the contemporary view on pathogenesis and therapy (v0.1)"

“…Therapeutic thoracentesis is the standard procedure for such patients. Although it is relatively safe, occasional complications may occur including pneumothorax, embolism, pleural empyema, and chest wall infection (Lv, Han & Fan, 2018). Rarely, re-expansion pulmonary edema has been observed as a result of largevolume thoracentesis with subsequent increased microvascular permeability and inflammatory reactions (Garbuzenko & Arefyev, 2017).…”

“…Therefore, it is recommended to stop fluid drainage from the pleural cavity when unpleasant sensations in the chest occur or when the pleural pressure at the end of exhalation decreases below -20 mmH2O. It is crucial to examine a pleural fluid sample to confirm the diagnosis and to rule out spontaneous bacterial empyema, as well as other etiology of pleural effusion (Al-Zoubi et al, 2016, Garbuzenko & Arefyev, 2017, Lv, Han & Fan, 2018).…”

“…In patients who need more than one therapeutic thoracentesis within 2 weeks, insertion of indwelling tunneled pleural catheter (ITPC) may be considered. Unfortunately, due to possible serious complications such as a massive protein, electrolyte and/or fluid loss, hemo-or pneumothorax, hepatorenal syndrome, and secondary infection, chest tube placement may be used as a palliative measure and should be avoided in uncomplicated HH (Al-Zoubi et al, 2016, Garbuzenko & Arefyev, 2017, Lv, Han & Fan, 2018. Recently, ITPC has been proposed as an acceptable treatment alternative for HH refractory to conventional medical management.…”