A 56-year-old man with a history of cirrhosis and recurrent ascites acutely developed a right pleural effusion (Figure 1). A thoracentesis revealed the effusion to be transudative. The patient had no known history of pulmonary or cardiac disease.
Robert L. Emery, MD
of the Department of General Surgery and
Justin Q. Ly, MD
of the Department of Radiology and Nuclear Medicine, Wilford Hall
Medical Center, Lackland Air Force Base, San Antonio, TX.
A 56-year-old man with a history of cirrhosis and recurrent
ascites acutely developed a right pleural effusion (Figure 1). A
thoracentesis revealed the effusion to be transudative. The patient
had no known history of pulmonary or cardiac disease.
This patient's clinical history, radiographic findings (Figure
1), and thoracentesis results raised the possibility of a hepatic
hydrothorax. After consulting with nuclear medicine staff,
scintigraphic evaluation with technetium-99m sulfur colloid by
intraperitoneal injection through an indwelling catheter was
performed. A scintigraphic image obtained immediately following
injection of the radiotracer showed prompt uptake in an expected
distribution within the peritoneum (Figure 2A). Ten minutes later,
a right lateral decubitis image revealed a large amount of
radiotracer uptake layering in a dependent fashion within the right
hemithorax (Figure 2B). At 25 minutes postinjection, an upright
view showed radiotracer uptake involving nearly one-half of the
hemithorax (Figure 2C). These findings were indicative of an
abnormal communication between the peritoneum and the right
hemithorax, resulting in a hepatic hydrothorax in this patient with
known cirrhosis complicated by ascites. The patient underwent
transjugular intrahepatic portosystemic shunt (TIPS) placement,
which provided temporarily relief of the hepatic hydrothorax.
A pleural effusion noted in cirrhotic patients in the absence of
primary cardiac or pulmonary disease is most likely a hepatic
hydrothorax. This complication is noted in approximately 6% of
cirrhotic patients and is also an infrequent complication of
continuous ambulatory peritoneal dialysis.
Although the effusion may be bilateral or left-sided, the majority
(67%) are right-sided.
Unidirectional transdiaphragmatic defects allowing peritoneopleural
communication are believed to play a role in the transit of the
transudative ascites into the thorax, and there is debate as to
whether these communications are congenital or acquired.
Along with the identified diaphragmatic defects, other proposed
etiologies are transdiaphragmatic lymphatics and hypoalbuminemia.
The goal of treating hepatic hydrothorax is the removal of the
thoracic effusion and prevention of its reaccumulation by
minimizing ascitic fluid accumulation within the abdomen. Treatment
options include therapeutic thoracentesis, salt and water
restriction, and diuretics. A possible complication of this regimen
is volume depletion and impaired renal function.
Another treatment option is chemical pleurodesis. Prior to
performing this procedure, it must be proven that the
peritoneopleural shunt is unidirectional by injecting radiotracer
into the pleural space and observing the abdomen for uptake.
Ensuring that the radiotracer does not pass into the peritoneal
cavity will prevent accidental sclerosing of the abdominal organs.
Aside from a liver transplant, a TIPS procedure may be the most
effective therapeutic intervention, working to decrease portal
hypertension and thereby decrease ascitic fluid accumulation. Other
more invasive treatment options include surgical repair of the
diaphragmatic defect and the creation of a peritoneovenous shunt.
Hepatic hydrothorax is not an uncommon condition in cirrhotic
patients. When suspected clinically, the diagnosis can be confirmed
using intraperitoneal injection of a radiotracer, such as
technetium-99m sulfur colloid, which will demonstrate transit of
the radiotracer into the pleural space.