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Hepatic hydrothorax

Definition
Hepatic hydrothorax is defined as a significant pleural effusion developing in patients with liver cirrhosis without any underlying cardiac or pulmonary disease.
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Pathophysiology
Hepatic hydrothorax is mainly caused by the direct passage of fluid from the peritoneal cavity through diaphragmatic defects. These defects can vary in morphology, ranging from no obvious defect to multiple gaps in the diaphragm.
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Epidemiology
The estimated prevalence of hepatic hydrothorax is estimated at around 4-6% in patients with cirrhosis.
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Disease course
Clinical manifestation includes symptoms of dyspnea on exertion, cough, and chest discomfort. Complications include infection and respiratory distress syndrome. Spontaneous bacterial pleural empyema may complicate hepatic hydrothorax, and diagnostic thoracocentesis is recommended in patients with suspected spontaneous bacterial empyema.
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Prognosis and risk of recurrence
The prognosis of hepatic hydrothorax is often linked to the underlying liver disease and the severity of cirrhosis. Liver transplantation remains the ultimate definitive management paradigm for these patients. Studies have shown that the presence of hepatic hydrothorax does not imply more postoperative complications, and long-term survival is similar to other indications of liver cirrhosis.
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Key sources
The following summarized guidelines for the evaluation and management of hepatic hydrothorax are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2021), the British Association for the Study of the Liver (BASL/BSG 2021), and the European Association for the Study of the Liver (EASL 2010).
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Guidelines

1.Diagnostic procedures

Diagnostic thoracentesis: recognize that spontaneous bacterial pleural empyema may complicate hepatic hydrothorax. Perform diagnostic thoracocentesis in patients with suspected spontaneous bacterial empyema with inoculation of fluid into blood culture bottles.
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2.Medical management

Diuretic therapy: initiate diuretics as first-line therapy in patients with hepatic hydrothorax.
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3.Nonpharmacologic interventions

Salt restriction: advise dietary sodium restriction as first-line therapy in patients with hepatic hydrothorax.
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4.Therapeutic procedures

Therapeutic thoracentesis: perform thoracentesis as required in the initial treatment of patients with hepatic hydrothorax.
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More topics in this section

  • Percutaneous drainage

  • TIPS

5.Surgical interventions

Liver transplantation: consider performing liver transplantation in patients with hepatic hydrothorax.
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6.Specific circumstances

Patients with spontaneous bacterial empyema: manage spontaneous bacterial empyema similar to SBP.