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.
Diagnosis
Hepatic hydrothorax
Findings
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.
Discussion
DISCUSSION
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.1,2 Although
the effusion may be bilateral or left-sided, the majority (67%) are
right-sided.1,3 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.1,3,4 Along with the identified
diaphragmatic defects, other proposed etiologies are
transdiaphragmatic lymphatics and
hypoalbuminemia.1,3
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.3
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.3 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.4
CONCLUSION
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.
Prepared by 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.
1. Mittal BR, Maini A, Das BK. Peritoneopleural communication
associated with cirrhotic ascites: Scintigraphic demonstration.
Abdom Imaging. 1996;21:69-70.
2. Lepage S, Bisson G, Vereault J, et al. Massive hydrothorax
complicating peritoneal dialysis. Clin Nucl Med.
1993;18:498-501.
3. Hahn HH, Hahn PY, Gadallah SF. Hepatic hydrothorax: Possible
etiology of recurring pleural effusion. Am Fam Physician.
1997;56:523-527.
4. Hahn HH. Acute massive postoperative pleural effusion
associated with asymptomatic Hepatitis C-induced cirrhosis of the
liver. Am J Med Sci. 1997;314:47-50.