Image Challenge

A 68-year-old man with alcoholic cirrhosis presents for evaluation of shortness of breath.

After a procedure...

What is the finding on the initial chest x-ray? (2 words)
Hepatic hydrothorax
This patient actually has radiographic evidence of tension hepatic hydrothorax. Hepatic hydrothorax occurs in approximately 5 to 10 percent of cirrhotic patients, and is defined by a pleural effusion in the absence of primary cardiac, pulmonary, or pleural disease. In the presence of tracheal deviation and hypotension, this process is termed tension hepatic hydrothorax. Though this patient has evidence of tracheal deviation, the patient was not hypotensive. Hepatic hydrothorax develops on the right side in approximately 85 percent of patients, while it is on the left side (such as in this patient) in approximately 13 percent and bilateral in approximately 2 percent.

A thoracentesis should be performed to confirm the diagnosis and to exclude alternate causes of a pleural effusion. Spontaneous bacterial empyema has been described in up to 13 percent of patients with hepatic hydrothorax, and is defined by pleural fluid with a polymorphonuclear cell count >500 cells/mm3 or positive culture with exclusion of a parapneumonic effusion.

Chest tubes should not be placed, as they can result in massive protein and electrolyte depletion, infection, renal failure, and bleeding.

The only cure is liver transplantation. Sodium restriction and diuretics are first-line therapy. Repeated thoracenteses can be done for large effusions. In this patient, 2L were drained between the first and second images and there was some improvement in the patient's dyspnea. TIPPS is another option of hepatic hydrothorax is refractory to medical therapy. Chemical pleurodesis does not work very well as it is often difficult to keep the two pleural surfaces apposed long enough for the inflammatory process to result in them sticking together.