S5720 Hepatic Hydrothorax in the Setting of Small Volume Ascites

Introduction: Hepatic hydrothorax (HH) is defined as pleural effusion that develops in the setting of underlying liver cirrhosis and portal hypertension without cardiopulmonary and pleural diseases. In the majority of cases, HH is seen in conjunction with ascites. Here we present a case of recurrent HH with small volume ascites. Case Description/Methods: A 71-year-old woman with past medical history of primary biliary cholangitis (PBC)/autoimmune hepatitis (AIH) with cirrhosis complicated by ascites and portal hypertension, rheumatoid arthritis, and gastroesophageal reflux disease who presented to the hospital for shortness of breath. Computed tomography angiography of the chest was significant for large right pleural effusion and partially imaged ascites with body wall edema. Labs were significant for total bilirubin 2.1, alkaline phosphatase 196, lactate dehydrogenase (LDH) 227, and protein 6.8. Thoracentesis revealed a transudative effusion with pleural fluid protein less than 1.0 and LDH of 6.8. Ultrasound of the abdomen was significant for cirrhosis with portal hypertension and small ascites. Hospital course was complicated by left upper lobe pneumonia requiring antibiotic treatment, pulmonary embolism, and recurrent transudative pleural effusion requiring repeat thoracentesis and chest tube placement. Patient required transfer to a tertiary hospital for transjugular intrahepatic portosystemic shunt (TIPS) for recurrent pleural effusions. After risk benefit discussions with the patient, it was decided to increase diuretics and midodrine doses to treat recurrent HH and to complete thoracentesis outpatient as needed. Discussion: Hepatic hydrothorax is an infrequent complication of cirrhosis and portal hypertension. It accounts for about 2%-3% of all pleural effusions and occurs in 5%-10% of patients with cirrhosis. The proposed mechanism involves ascites fluid moving from the peritoneal cavity to the pleural space secondary to a small defect in the diaphragmatic tendon on the right side due to the negative pressure of the intrathoracic space. Eighty-five percent of HH occurs on the right (like our patient), 13% occurs on the left, and 2% occurs bilaterally. Diagnosis is made by thoracentesis and evaluation of pleural fluid and is a diagnosis of exclusion. Treatment involves uptitration of diuretics, thoracentesis, Pleurx catheter, and/or TIPS. In patients with little to no ascites, clinical suspicion is imperative for diagnosis so treatment can be initiated promptly.