- Andrés Cárdenas, MD, MMSc, AGAF
Andrés Cárdenas, MD, MMSc, AGAF
- Institut de Malalties Digestives i Metaboliques
- Hospital Clinic, Barcelona, Spain
- University of Barcelona
- T Barry Kelleher, MD, FRCPI
T Barry Kelleher, MD, FRCPI
- Consultant Gastroenterologist
- Mater Misericordiae Hospital, Dublin, Ireland
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology; Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
- Section Editor
- Bruce A Runyon, MD
Bruce A Runyon, MD
- Section Editor — Cirrhosis and Its Complications
- Clinical Professor of Medicine
- University of New Mexico, Division of Gastroenterology and Hepatology
- Special Hepatology Consultant to the Indian Health Service
- Northern Navajo Medical Center, Shiprock, New Mexico
Hepatic hydrothorax refers to the presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis who does not have other reasons to have a pleural effusion (eg, cardiac, pulmonary, or pleural disease) [1,2]. Hepatic hydrothorax occurs in approximately 5 to 10 percent of patients with cirrhosis. In a retrospective analysis of 495 patients with cirrhosis and pleural effusion, 16 percent had hepatic hydrothorax . While patients with ascites can often tolerate up to 5 to 10 L of fluid with only mild symptoms, those with a pleural effusion can have severe symptoms (such as shortness of breath, cough, and hypoxemia) with as little as 500 mL of fluid.
This topic will review the clinical manifestations, diagnosis, and management of hepatic hydrothorax. Other complications of cirrhosis, including ascites and variceal hemorrhage, are discussed elsewhere. (See "Cirrhosis in adults: Overview of complications, general management, and prognosis" and "Ascites in adults with cirrhosis: Initial therapy" and "Ascites in adults with cirrhosis: Diuretic-resistant ascites" and "Primary and pre-primary prophylaxis against variceal hemorrhage in patients with cirrhosis" and "Prevention of recurrent variceal hemorrhage in patients with cirrhosis".)
Although the exact mechanisms involved in the development of hepatic hydrothorax are incompletely understood, it probably results from the passage of ascites from the peritoneal cavity into the pleural cavity through small diaphragmatic defects. These defects are typically less than 1 cm (and may be microscopic) and are generally located in the tendinous portion of the diaphragm [4-9]. Hepatic hydrothorax becomes apparent when the absorptive capacity of the pleural space is exceeded. The pathologic mechanisms behind the formation of ascites are discussed in detail elsewhere. (See "Pathogenesis of ascites in patients with cirrhosis".)
The diaphragmatic defects are more often found in the right hemidiaphragm, likely due in part to the fact that the left hemidiaphragm is thicker and more muscular. Hepatic hydrothorax develops on the right side in approximately 73 to 85 percent of patients, on the left side in approximately 13 to 17 percent, and bilaterally in approximately 2 to 10 percent [3,10,11].
The negative intrathoracic pressure generated during inspiration promotes the passage of fluid from the abdominal cavity to the pleural space. This could explain why some patients with hepatic hydrothorax do not have apparent ascites [12-14]. This theory is supported by studies using 99mTc-human albumin or 99mTc-sulphur colloid, which demonstrate unidirectional passage of these markers from the abdominal cavity to the pleural cavity [12,15-19].
- Cardenas A, Kelleher T, Chopra S. Review article: hepatic hydrothorax. Aliment Pharmacol Ther 2004; 20:271.
- Kinasewitz GT, Keddissi JI. Hepatic hydrothorax. Curr Opin Pulm Med 2003; 9:261.
- Badillo R, Rockey DC. Hepatic hydrothorax: clinical features, management, and outcomes in 77 patients and review of the literature. Medicine (Baltimore) 2014; 93:135.
- Huang PM, Chang YL, Yang CY, Lee YC. The morphology of diaphragmatic defects in hepatic hydrothorax: thoracoscopic finding. J Thorac Cardiovasc Surg 2005; 130:141.
- Lieberman FL, Hidemura R, Peters RL, Reynolds TB. Pathogenesis and treatment of hydrothorax complicating cirrhosis with ascites. Ann Intern Med 1966; 64:341.
- EMERSON PA, DAVIES JH. Hydrothorax complicating ascites. Lancet 1955; 268:487.
- Mouroux J, Perrin C, Venissac N, et al. Management of pleural effusion of cirrhotic origin. Chest 1996; 109:1093.
- Chen A, Ho YS, Tu YC, et al. Diaphragmatic defect as a cause of massive hydrothorax in cirrhosis of liver. J Clin Gastroenterol 1988; 10:663.
- Zenda T, Miyamoto S, Murata S, Mabuchi H. Detection of diaphragmatic defect as the cause of severe hepatic hydrothorax with magnetic resonance imaging. Am J Gastroenterol 1998; 93:2288.
- Lazaridis KN, Frank JW, Krowka MJ, Kamath PS. Hepatic hydrothorax: pathogenesis, diagnosis, and management. Am J Med 1999; 107:262.
- Alagiakrishnan K, Patel PJ. Left-sided hepatic hydrothorax with ascites. Int J Clin Pract 1999; 53:225.
- Rubinstein D, McInnes IE, Dudley FJ. Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management. Gastroenterology 1985; 88:188.
- Singer JA, Kaplan MM, Katz RL. Cirrhotic pleural effusion in the absence of ascites. Gastroenterology 1977; 73:575.
- Kirsch CM, Chui DW, Yenokida GG, et al. Case report: hepatic hydrothorax without ascites. Am J Med Sci 1991; 302:103.
- Benet A, Vidal F, Toda R, et al. Diagnosis of hepatic hydrothorax in the absence of ascites by intraperitoneal injection of 99m-Tc-Fluor colloid. Postgrad Med J 1992; 68:153.
- Serena A, Aliaga L, Richter JA, et al. Scintigraphic demonstration of a diaphragmatic defect as the cause of massive hydrothorax in cirrhosis. Eur J Nucl Med 1985; 11:46.
- Kakizaki S, Katakai K, Yoshinaga T, et al. Hepatic hydrothorax in the absence of ascites. Liver 1998; 18:216.
- Menteş BB, Kayhan B, Görgül A, Unal S. Hepatic hydrothorax in the absence of ascites: report of two cases and review of the mechanism. Dig Dis Sci 1997; 42:781.
- Giacobbe A, Facciorusso D, Tonti P, et al. Hydrothorax complicating cirrhosis in the absence of ascites. J Clin Gastroenterol 1993; 17:271.
- Falchuk KR, Jacoby I, Colucci WS, Rybak ME. Tetracycline-induced pleural symphysis for recurrent hydrothorax complicating cirrhosis. A new approach to treatment. Gastroenterology 1977; 72:319.
- Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology 1996; 23:719.
- Xiol X, Guardiola J. Hepatic hydrothorax. Curr Opin Pulm Med 1998; 4:239.
- Garcia N Jr, Mihas AA. Hepatic hydrothorax: pathophysiology, diagnosis, and management. J Clin Gastroenterol 2004; 38:52.
- Castellote J, Gornals J, Lopez C, Xiol X. Acute tension hydrothorax: a life-threatening complication of cirrhosis. J Clin Gastroenterol 2002; 34:588.
- Chen CH, Shih CM, Chou JW, et al. Outcome predictors of cirrhotic patients with spontaneous bacterial empyema. Liver Int 2011; 31:417.
- Xiol X, Castellote J, Cortes-Beut R, et al. Usefulness and complications of thoracentesis in cirrhotic patients. Am J Med 2001; 111:67.
- Strauss RM, Boyer TD. Hepatic hydrothorax. Semin Liver Dis 1997; 17:227.
- Gurung P, Goldblatt M, Huggins JT, et al. Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest 2011; 140:448.
- Singh A, Bajwa A, Shujaat A. Evidence-based review of the management of hepatic hydrothorax. Respiration 2013; 86:155.
- Borchardt J, Smirnov A, Metchnik L, Malnick S. Treating hepatic hydrothorax. BMJ 2003; 326:751.
- Runyon BA, Greenblatt M, Ming RH. Hepatic hydrothorax is a relative contraindication to chest tube insertion. Am J Gastroenterol 1986; 81:566.
- Liu LU, Haddadin HA, Bodian CA, et al. Outcome analysis of cirrhotic patients undergoing chest tube placement. Chest 2004; 126:142.
- Orman ES, Lok AS. Outcomes of patients with chest tube insertion for hepatic hydrothorax. Hepatol Int 2009; 3:582.
- Sese E, Xiol X, Castellote J, et al. Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema. J Clin Gastroenterol 2003; 36:75.
- Esteve M, Xiol X, Fernandez F, et al. Treatment and outcome of hydrothorax in liver cirrhosis. J Clin Nutr Gastroenterol 1986; 1:139.
- Sherman SC. Reexpansion pulmonary edema: a case report and review of the current literature. J Emerg Med 2003; 24:23.
- Collins TR, Sahn SA. Thoracocentesis. Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817.
- McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991; 31:164.
- Gordon FD, Anastopoulos HT, Crenshaw W, et al. The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt. Hepatology 1997; 25:1366.
- Strauss RM, Martin LG, Kaufman SL, Boyer TD. Transjugular intrahepatic portal systemic shunt for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol 1994; 89:1520.
- Siegerstetter V, Deibert P, Ochs A, et al. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001; 13:529.
- Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002; 13:385.
- Conklin LD, Estrera AL, Weiner MA, et al. Transjugular intrahepatic portosystemic shunt for recurrent hepatic hydrothorax. Ann Thorac Surg 2000; 69:609.
- Rössle M, Gerbes AL. TIPS for the treatment of refractory ascites, hepatorenal syndrome and hepatic hydrothorax: a critical update. Gut 2010; 59:988.
- Dhanasekaran R, West JK, Gonzales PC, et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010; 105:635.
- Wilputte JY, Goffette P, Zech F, et al. The outcome after transjugular intrahepatic portosystemic shunt (TIPS) for hepatic hydrothorax is closely related to liver dysfunction: a long-term study in 28 patients. Acta Gastroenterol Belg 2007; 70:6.
- Ditah IC, Al Bawardy BF, Saberi B, et al. Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis. World J Hepatol 2015; 7:1797.
- Milanez de Campos JR, Filho LO, de Campos Werebe E, et al. Thoracoscopy and talc poudrage in the management of hepatic hydrothorax. Chest 2000; 118:13.
- Ferrante D, Arguedas MR, Cerfolio RJ, et al. Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax. Am J Gastroenterol 2002; 97:3172.
- Northup PG, Harmon RC, Pruett TL, et al. Mechanical pleurodesis aided by peritoneal drainage: procedure for hepatic hydrothorax. Ann Thorac Surg 2009; 87:245.
- Huang PM, Kuo SW, Lee JM. Thoracoscopic diaphragmatic repair for refractory hepatic hydrothorax: application of pleural flap and mesh onlay reinforcement. Thorac Cardiovasc Surg 2006; 54:47.
- Huang PM, Kuo SW, Chen JS, Lee JM. Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience. Ann Thorac Surg 2016; 101:1921.
- Xiol X, Tremosa G, Castellote J, et al. Liver transplantation in patients with hepatic hydrothorax. Transpl Int 2005; 18:672.
- Barreales M, Sáenz-López S, Igarzabal A, et al. Refractory hepatic hydrothorax: successful treatment with octreotide. Rev Esp Enferm Dig 2005; 97:830.
- Ibrisim D, Cakaloglu Y, Akyuz F, et al. Treatment of hepatic hydrothorax with terlipressin in a cirrhotic patient. Scand J Gastroenterol 2006; 41:862.
- Tu CY, Chen CH. Spontaneous bacterial empyema. Curr Opin Pulm Med 2012; 18:355.
- CLINICAL MANIFESTATIONS
- Thoracentesis and fluid testing
- Imaging studies
- DIFFERENTIAL DIAGNOSIS
- Sodium restriction
- Refractory hydrothorax
- - Thoracentesis
- - Transjugular intrahepatic portosystemic shunt (TIPS)
- - Pleurodesis
- - Thoracoscopic repair
- - Liver transplantation
- - Other treatment options
- Treatment of infection
- SUMMARY AND RECOMMENDATIONS