Madeline Cleary, DO, Andrew Salgado, , John Tremblay, DO, Benjamin Bernier, MD Albany Medical Center, Albany, NY
Introduction: Hepatic hydrothorax (HH) is a large transudative pleural effusion in a patient with cirrhosis where a primary cardiopulmonary or malignant process has been eliminated via pleural fluid analysis. It is an infrequent complication associated with chronic liver disease and usually presents with the triad of cirrhosis, portal hypertension, and ascites. HH typically occurs in the setting of increased intraabdominal pressure, which allows ascites to pass into the pleural space. We present a case of right-sided hepatic hydrothorax occurring in the absence of ascites.
Case Description/Methods: A 60-year-old female with history of alcoholic liver cirrhosis complicated by esophageal varices presented to the hospital with progressively worsening dyspnea. Over the past few months, she had undergone multiple thoracenteses for recurrent right-sided pleural effusions. Initial laboratory studies showed lactate dehydrogenase (LDH) 406 IU/L, total protein 6.8 g/dL, and albumin 2.7 g/dL. Thoracic CT scan revealed a large right-sided pleural effusion and small left pleural effusion [Figure 1]. Abdominal ultrasound demonstrated diffuse nodular liver contour, consistent with hepatic cirrhosis, without evidence of ascites. Echocardiogram showed normal left ventricular ejection fraction. Thoracentesis was performed, which drained 1.9L of straw-colored fluid with symptomatic improvement. Pleural fluid analysis showed LDH 74 IU/L, total protein < 1.0 g/dL, pH 7.78, and glucose 168 g/dL. Light’s criteria was not met, indicating a transudative process. Fluid culture and cytology were negative. Days following the procedure, she developed hypotension with acute kidney injury, as well as hepatic encephalopathy. The patient was ineligible for TIPS procedure and ultimately decided not to pursue liver transplantation and was transitioned to hospice care.
Discussion: HH is a complication of advanced liver disease occurring in about 5-15% of patients, however, it rarely occurs in the absence of ascites. HH can be difficult to manage without treatment of the underlying liver disease. Liver transplantation is the gold standard, however, TIPS procedure can benefit patients with refractory pleural effusions despite sodium restriction and diuretic therapy. We present a rare case of recurrent right-sided pleural effusion secondary to HH with no clinical evidence of ascites. We recommend consideration of HH in patients with evidence of or known liver disease presenting with pleural effusion irrespective of the presence of ascites.
Figure: Figure 1 Thoracic CT scan
Madeline Cleary indicated no relevant financial relationships.
Andrew Salgado indicated no relevant financial relationships.
John Tremblay indicated no relevant financial relationships.
Benjamin Bernier indicated no relevant financial relationships.
Madeline Cleary, DO, Andrew Salgado, , John Tremblay, DO, Benjamin Bernier, MD. P3929 - A Rare Case of Hepatic Hydrothorax Without Ascites, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.