[Hepatic hydrothorax]

Hepatic hydrothorax was diagnosed in four patients with liver cirrhosis, three men aged 65, 41, and 48 and a woman aged 48. They presented with either right-sided or bilateral pleural-fluid accumulations in the absence of cardiopulmonary disease. In the first man with no concurrent ascites, the disorder was missed, resulting in prolonged chest tube drainage, multiple severe complications and death. In the 41-year-old man chest tube drainage was also associated with complications including renal failure and encephalopathy. Pleurodesis was effective in the woman while in the remaining man hepatic hydrothorax was only a temporary, asymptomatic finding. Pleural effusions in cirrhotic patients should be considered and managed as hepatic hydrothorax unless diagnostic studies reveal a different aetiology. Absence of ascites is not uncommon and should not delay the correct diagnosis. The gradient between pleural and serum albumin concentration is typically more than 11 g/l. Prolonged chest tube drainage is dangerous and should be avoided. In cases refractory to salt restriction and diuretic therapy, transjugular introduction of an intrahepatic portosystemic shunt is the treatment of choice. Recently, pleurodesis combined with thoracoscopic repair ofdiaphragmatic defects has been reported as a potentially effective form of therapy.