Hepatic hydrothorax as a manifestation of decompensated cirrhosis: An update on current management and future directions

Hepatic hydrothorax (HH) is an uncommon yet severe manifestation of portal hypertension which develops in 5%-10% of patients with liver cirrhosis. It typically presents as a unilateral, right-sided pleural effusion and in the context of end-stage liver disease and concomitant ascites. The most widely accepted explanatory model for HH accumulation is the formation of small diaphragmatic defects (pleuroperitoneal connections) facilitating migration of ascitic fluid from the peritoneal cavity directly to the pleural cavity. Medical management involves sodium restriction and diuretic therapy, with thoracentesis also offering symptomatic relief. In cases of refractory HH, a transjugular intrahepatic portosystemic shunt is considered either as definitive treatment or as a bridge to liver transplantation, which remains the only curative treatment option. HH refractory to medical therapy presents a challenging clinical dilemma, particularly in those who are ineligible for liver transplantation. In this mini-review, we aim to highlight the pathophysiology, clinical presentation, diagnosis and management of HH. Additionally, we discuss and appraise novel therapeutic options and offer future directions.