From the Guidelines
Yes, pleural effusion can be secondary to cirrhosis, a condition known as hepatic hydrothorax, which occurs in approximately 4%-12% of patients with cirrhosis, as reported in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
Key Points
- Hepatic hydrothorax is a transudative pleural effusion that occurs in portal hypertension, with the pleural fluid originating in the peritoneal cavity and drawn through defects in the diaphragm by negative intrathoracic pressure at inspiration 1.
- The prevalence of hepatic hydrothorax in cirrhosis is 4%-12%, and it is typically unilateral, with 73% of cases occurring on the right side, 17% on the left side, and 10% bilaterally 1.
- A serum to pleural fluid albumin gradient of >1.1 g/dL is suggestive of hepatic hydrothorax, and pleural fluid in hepatic hydrothorax may have higher protein content than concurrent ascites 1.
- Patients with hepatic hydrothorax have a poor prognosis, with a mortality risk that exceeds that predicted by the MELD score, and should be considered for liver transplantation (LT) 1.
Management
- Initial management of hepatic hydrothorax is similar to that of ascites, with sodium restriction and diuretics, such as spironolactone and furosemide 1.
- Therapeutic thoracentesis is indicated for symptomatic relief, but chronic pleural drainage is not recommended due to the frequent occurrence of complications 1.
- Transjugular intrahepatic portosystemic shunt (TIPS) insertion is recommended for recurrent symptomatic hepatic hydrothorax in selected patients 1.
- Liver transplantation remains the definitive treatment for eligible patients with end-stage liver disease 1.
Important Considerations
- It is essential to exclude other causes of pleural effusion in cirrhotic patients, such as infection, malignancy, or heart failure, through appropriate diagnostic testing of the pleural fluid 1.
- The diagnosis of hepatic hydrothorax should be made after ruling out cardiopulmonary and primary pleural disease 1.
From the Research
Definition and Prevalence of Hepatic Hydrothorax
- Hepatic hydrothorax is defined as the accumulation of significant pleural effusion in a cirrhotic patient without primary pulmonary or cardiac disease 2.
- It occurs in approximately 5-6% of patients with cirrhosis 3, 4, 5.
- Hepatic hydrothorax can occur in the absence of ascites, although ascites is usually present 2, 5.
Pathophysiology and Clinical Presentation
- The pathophysiology of hepatic hydrothorax involves the movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects 4, 5.
- Patients with hepatic hydrothorax usually have advanced liver disease with portal hypertension 3, 2.
- Clinical presentation includes chest pain, hypoxemia, cough, shortness of breath, and fatigue 5, 6.
Diagnosis and Management
- Diagnosis is usually confirmed by pleural aspiration, demonstrating typical features of a transudative effusion in the absence of co-existent cardio-pulmonary or renal pathology 6.
- Management includes sodium restriction, diuretics, and therapeutic thoracentesis 3, 4, 5.
- A transjugular intrahepatic portosystemic shunt may provide a bridge prior to liver transplantation 4.
- Liver transplantation remains the definitive treatment option 6.