Page 19 - Highlights of Napcon 2021

Hepatic Hydrothorax

Dr. Anirban Sarkar

Consultant Pulmonologist
Zenith Super speciality Hospital, ILS Hospitals
Kolkata

Hepatic hydrothorax, which accounts for 2%–3% of all pleural effusions, is defined as a significant pleural effusion,
usually greater than 500 mL, in a patient with cirrhosis of the liver but no primary cardiac or pulmonary disease.
Hepatic hydrothorax is a less common complication of cirrhosis with an estimated prevalence of 10-15%. Explaining
these aspects, Dr. Sarkar noted that although the exact mechanisms involved in the development of hepatic
hydrothorax have not been well-defined, several mechanisms have been postulated, including hypoalbuminemia, and
subsequently decreased colloid osmotic pressure, increased azygos system pressure leading to leakage of plasma
into the pleural cavity and transdiaphragmatic migration of peritoneal fluid into the pleural space via lymphatic
channels. He explained that the most widely accepted theory is the direct passage of ascitic fluid from peritoneal
to the pleural cavity via numerous diaphragmatic defects. The presentation then went on to describe the clinical
manifestations (Figure 1), laboratory features (Figure 2) and management approach for hepatic hydrothorax
(Figure 3) and treatment options (Figure 4).

‡ As HH most frequently occurs in the context of ascites and other features of portal ` Uncomplicated Fluid
hypertension due to decompensated liver disease, the prominent clinical manifestations ‡ Polymorphonuclear count < 250 cells/mm3
are QRQVSHFLÀF and related to cirrhosis and ascites in most cases. ‡ Total protein < 2.5 g/dL
‡ 3OHXUDOÁXLGWRWDOSURWHLQVHUXPWRWDOSURWHLQUDWLR
‡ More rarely, HH may be the index presentation for chronic liver disease. ‡ 3OHXUDOÁXLGODFWDWHGHK\GURJHQDVHVHUXPODFWDWHGHK\GURJHQDVH
‡ 6HUXPWRSOHXUDOÁXLGDOEXPLQJUDGLHQW!JG/
‡ The respiratory symptoms in patients with HH varied, mainly depending on the volume of ‡ pH 7.4-7.55
effusion, rapidity of the effusion accumulation in the pleural space and the presence of ‡ 3OHXUDOÁXLGVHUXPELOLUXELQUDWLR
associated cardiopulmonary disease. ‡ Glucose level similar to that of serum

‡ Patients may be asymptomaticLQZKRPSOHXUDOHIIXVLRQLVDQLQFLGHQWDOÀQGLQJRQ ` Spontaneous Bacterial Pleuritis
chest imaging performed for other reasons or they may have pulmonary symptoms of ‡ 3RVLWLYHSOHXUDOÁXLGFXOWXUHDQGSRO\PRUSKRQXFOHDUFRXQW!FHOOVPP
shortness of breath, cough, hypoxemia or respiratory failure associated with large pleural ‡ 1HJDWLYHSOHXUDOÁXLGFXOWXUHDQGDSRO\PRUSKRQXFOHDUFRXQW!FHOOVPP
effusions.
Figure 2: Laboratory features
‡ A recent case series including 77 patients with HH indicated that most patients typically
had multiple complaints, with the most commonly reported symptoms being dyspnea at
rest (34%), cough (22%), nausea (11%), and pleuritic chest pain.

Figure 1: Clinical manifestations of Hepatic hydrothorax

Figure 3: Approach to management ` Medical Management
of hepatic hydrothorax ‡ Salt restriction (< 2000 mg/day of sodium)
‡ Diuretics (furosemide and spironolactone)

` Thoracentesis
` Transjugular intrahepatic portosystemic shunt
` Surgical Management
` Pleurodesis
` VATS with surgical correction of diaphragm defects
` Liver Transplantation

Figure 4: Treatment options for hepatic hydrothorax

The presentation explained that treatment of hepatic
hydrothorax is primarily medical, with salt restriction
and diuretics. Liver transplantation should be considered
for all patients of hepatic hydrothorax. Dr. Sarkar
pointed out that many patients require repeated large
volume thoracentesis. The presentation concluded by
noting that pleurodesis, ITPC, and VATS are acceptable
treatment alternatives.

Highlights of NAPCON 2021 17