1. Hepatic Hydrothorax

2. 63 year-old female with biopsy-proven cirrhosis secondary to alpha-1-antitrypsin deficiency complained of shortness of breath and cough productive of scant amounts of mucoid phlegm for 1 week.

3. She denied fevers or chills
She denied fevers or chills. In the post, she had undergone a total abdominal hysterectomy and radiation therapy for uterine cancer as well as a sigmoid resection for radiation colitis.

4. Follow up evaluations had not shown signs of cancer recurrence.

5. She did not smoke or drink alcoholic beverages.

6. On physical examination, she appeared in moderate respiratory distress
On physical examination, she appeared in moderate respiratory distress. The right hemithorax was dull to percussion and the vocal fremitus was markedly diminished. Shifting dullness was present on abdominal exam.

7. She had 2+ pitting edema up to her shins bilaterally.

8. A chest X-ray revealed a large right pleural effusion.

10. The combination of ascites and right-sided pleural effusion in a patient with cirrhosis raised the possibility of a hepatic hydrothorax.

11. A TC99 study demonstrated accumulation of tracer in right hemi-thorax after injection into peritoneal cavity.

13. The patient was placed on salt and fluid restriction and received diuretics, resulting in dramatic improvement of her symptoms.

14. Serial chest X-rays showed a progressively decreasing size of the pleural effusion. Two weeks after discharge the hepatic hydrothorax had completely resolved .

16. Discussion:
Hepatic-hydrothorax occurs in 1-5% of cirrhotic patients. Most cases affect the right side. These effusions are usually due to the passage of ascitic fluid into the pleural space through minute defects in the diaphragm.

17. Hepatic-hydrothorax has been reported even in the absence of clinical ascites.

18. Treatment is primarily medical with salt and fluid restriction, diuretics and if necessary drainage of ascites. Intractable cases may require a more aggressive approach. Transjugular intrahepatic portosystemic shunts (TIPS) is a viable option in selected patients.

19. Chemical pleurodesis by thoracoscopy carries a failure rate in excess of 33%. Thoracotomy to repair the diaphragmatic defects has been tried with very limited success.

20. Chest tube insertion is not indicated, as it does not address the underlying abnormality.