Hepatic hydrothorax

Question: Which of the following treatment options is most appropriate for a newly diagnosed hepatic hydrothorax?

A. diuretic therapy

B. thoracentesis

C. liver transplantation

D. pleurodesis

Answer: Hepatic hydrothorax is a common complication of portal hypertension when ascites is present.  The negative thoracic pressure generated during inspiration draws abdominal ascitic fluid through defects in the diaphragm and into the thorax.  In the majority of cases, the hydrothorax is unilateral (right sided).

The most appropriate treatment is diuretics.  As the total ascitic volume decreases, so too should the hydrothorax.  Thoracentesis should not be used as a first line of treatment, as the thoracic fluid would be expected to reaccumulate soon thereafter; it can be used in addition to diuretics if immediate symptomatic relief is needed.  If the hydrothorax is left sided or bilateral, pleural fluid sampling may be appropriate to rule out other causes.

Pleurodesis can be attempted in refractory cases, and outcomes are mixed.  Chest tubes are contraindicated. Liver transplantation is curative in most cases, but is not considered the first line of treatment.  Bear in mind that not all cases of refractory ascites (and therefore hepatic hydrothorax) are cured by liver transplantation.  One recognized risk factor for the reemergence of this condition following transplant surgery is the presence of hepatitis C.

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