Introduction: Hepatic hydrothorax is unilateral pleural effusion in individuals with cirrhosis and portal hypertension. It is reported in 6-10% of patients with cirrhosis and in conjunction with ascites. The pathophysiology is related to diaphragmatic defects causing a shift between the peritoneal and pleural cavity. Few cases have isolated hepatic hydrothorax without ascites, especially as a first sign of cirrhosis.
Case Description/Methods: 32-year-old man with history of asthma, psoriasis, and alcohol use, presented with a bleeding blister on his right foot. Patient was hypertensive 140/71, tachycardic 128 bpm, afebrile 37 °C, tachypneic 20 breaths/min, and saturating at 93% on room air. Labs included hemoglobin 6.8 g/dl, WBC 24K/mcl, INR 3.2, Lactic acid 6.4 mmol/L, ammonia 86 mcmol/L, total bilirubin 11.7 mg/dL, AST 103 IU, and ALT 18 IU. Hepatitis panel and HIV tests were negative. Autoimmune workup showed positive ANA 1:160, but otherwise grossly negative. Patient subsequently developed mild respiratory distress with CT scan showing right-sided pleural effusion, hepatic cirrhosis, splenomegaly, and portal hypertension. Thoracentesis showed RBC 8,000, WBC 102, and pH 7.47. By lights criteria, fluid was transudative. The following day, patient developed worsening hypoxic respiratory failure from postprocedural hemothorax with mediastinal shift. Patient underwent massive transfusion with hospital course further complicated by intercostal vessel cauterization, decompensated liver failure, and hepatorenal syndrome. Consequently, patient was transferred to tertiary hospital for liver transplant evaluation.
Discussion: Significant pleural effusion without ascites as the first sign of liver cirrhosis is rare. Directional transdiaphragmatic flow of ascites fluid into the pleural cavity by intraperitoneal injection of radioisotope can be a method to diagnose hepatic hydrothorax without ascites. Therapy included salt-water restriction, high protein diet, and diuretic therapy. However, medical therapy can sometimes result in volume depletion and impaired renal function. Thus, surgical repair of the defect combined with pleurodesis may be necessary to control effusions.
Disclosures: Farha Ebadi indicated no relevant financial relationships.
Farha N. Ebadi, DO. P0807 - Case Report: Hepatic Hydrothorax Without Ascites in Newly Diagnosed Cirrhotic Patient, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
