Index Hepatic Decompensation: Hepatic Hydrothorax Without Signs of Clinically Significant Portal Hypertension Diagnosed With Radioisotope Scintigraphy

Hepatic hydrothorax (HH) occurs in 4%-12% of patients with cirrhosis and rarely presents without accompanying evidence of clinically significant portal hypertension (CSPH). We report the case of a 65-year-old man with cirrhosis without prior decompensation, congestive heart failure, and recurrent right-sided pleural effusion. CSPH was not otherwise observed despite thorough laboratory, radiologic, and endoscopic evaluation. However, pleural fluid analysis revealed a serum effusion albumin gradient of 1.6, raising suspicion for a hepatic etiology. Suspected HH was diagnosed by technetium-99m sulfur colloid peritoneal cavity scintigraphy. As the index decompensating event, the patient's HH initiated a liver transplant evaluation in the absence of other evidence of CSPH.