Hepatic Hydrothorax

• Pathophysiology: passage of ascites from peritoneal to pleural cavity via diaphragmatic fenestrations, encouraged by negative intrathoracic pressure

• Clinical presentation: dyspnea, cough, hypoxia

  • 80% R-sided
  • Can be complicated by infection (spontaneous bacterial empyema) in 10% of cases, which is associated with high mortality

• Diagnosis:

  • Transudative thoracentesis
  • PMN count <250 cells/mm3
  • Serum to pleural albumin gradient >1.1
  • Pleural protein <2.5

• Management:

  • Symptomatic: sodium restriction, diruesis, serial thoracentesis
  • Definitive: transplantation, TIPS, pleurodesis, diaphragmatic repair
  • Chest tube should not be placed routinely: results in protein/electrolyte depletion and faciliates continuous fluid accumulation making removal difficultAlso increases risk of infection, bleeding, and AKI from volume depletion
  • In some cases (such as this), where ascites is complicated by SBP/abscess, drainage may be indicated to prevent secondary empyema

(Christopher Woo MD, 9/10/10)