Hepatic hydrothorax is the presence of pleural effusion, often large, in a patient with cirrhosis who has no other cause of pleural effusion. Hepatic hydrothorax occurs in 5-15% of patients with cirrhosis.
These patients may experience severe symptoms (eg, dyspnea, cough, hypoxemia) with as little as 500 mL of fluid. Emergency physicians may be tempted to insert a chest tube if there is a large effusion or severe symptoms, or a consultant may recommend placement of a chest tube, but this is not recommended for hepatic hydrothorax due to high morbidity and mortality.
In fact, current practice guidelines from the American Association for the Study of Liver Diseases indicate that placement of a chest tube for the management of hepatic hydrothorax is contraindicated. A complication rate of up to 90% is reported, including acute kidney injury, electrolyte imbalance, bleeding and infection, ultimately leading to death in many cases. Most sources recommend thoracentesis as the initial approach if immediate drainage is warranted. (Clin Liver Dis (Hoboken). 2020;16:63; https://bit.ly/3LvozAL; Hepatology. 2020;72:1851; Practice of Gastroenterol Res. 2017;5872068; https://bit.ly/3syVpYT; Lung. 2019;197:399.)
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