Abstract
Hepatic hydrothorax (HH) is a complication in patients with cirrhosis and portal hypertension. Clinical criteria require a pleural effusion in the absence of primary cardiopulmonary disease. Here we describe a challenging case of refractory hydrothorax. A 43-year-old female with a history of alcohol abuse presented to the hospital with generalized abdominal pain and cholestatic pattern of liver function tests. Laboratory tests data: direct bilirubin 7 mg/dl(0-0.3), AST 175 u/l(10-40), alkaline phosphatase 328 u/l(135-145). On imaging was found to have CBD stricture, followed by stent placement with no improvement in symptoms. Over next three months, she developed ascites and the liver biopsy revealed steatohepatitis and following month CT scan of abdomen noted Liver cirrhosis. She had multiple hospitalizations, for paracenteses, hepatic encephalopathy(HE). Due to high MELD (Model of end-stage liver disease) score of 16 and HE she wasn't a candidate for TIPS and was on medical therapy, but soon developed pre-renal azotemia and couldn't tolerate diuretics. She later developed a right-sided pleural effusion, the pleural fluid analysis was transudative and negative for pathology or cardiopulmonary source, hence she was diagnosed with HH. Numerous thoracentesis was performed for recurrent effusion over 2 months. She was evaluated for liver transplantation but declined due to poor compliance and nutrition status. Eventually, patient's encephalopathy resolved and with the improvement of MELD 7 she underwent TIPS (Transjugular intrahepatic portosystemic shunt) recently with improvement in symptoms. Our patient presented with alcoholic hepatitis and stricture in CBD from chronic alcoholic pancreatitis and was ultimately diagnosed with cirrhosis. She developed refractory ascites, followed by refractory HH. Once the patient had HH her ascites improved. HH results, from the passage of peritoneal fluid via the diaphragm. HH is more symptomatic than ascites, as the pleural space cannot accommodate large volumes of fluid. Initial therapy of HH is salt and fluid restriction, diuretics and alcohol cessation. Thoracentesis is offered to patients not responding to medical therapy. For refractory HH, can consider pleurodesis or TIPS. The only definitive treatment is liver transplantation. Our patient initially did not undergo TIPS due to HE and high MELD score, making management more challenging. She eventually underwent TIPS with improvement in symptoms.