What You Need to Know About Hepatic Hydrothorax?

Living with chronic liver disease comes with different challenges. This can range from entirely minor to things that make it hard to breathe. Hepatic hydrothorax happens when there is fluid buildup in your lungs because you have liver problems. It can be scary when you can’t catch your breath. But, understanding the causes, symptoms, diagnosis, and treatment can help manage the condition.

Key Takeaways

• Hepatic hydrothorax refers to the accumulation of more than 500 mL of fluid in the chest cavity in patients with liver cirrhosis

• The condition primarily affects the right side of the chest in about 80% of patients, which is called uncomplicated hydrothorax

• The fluid moves from the abdomen to the chest due to small defects in the diaphragm

• Common symptoms include dyspnea (shortness of breath), difficulty performing physical activities, and dry cough

• Treatment options range from conservative (diet and medications) to specialized procedures to liver transplantation

• Without treatment, the median survival of these patients are only about 8-12 months

What is Hepatic Hydrothorax?

Hepatic hydrothorax is a condition where the fluid accumulates in the chest cavity due to a liver problem. It is defined as having > 500 mL of fluid (about 2 cups) inside the chest. It usually occurs in patients with liver cirrhosis who don’t have heart or lung disease. The fluid is called “transudate” because it has low protein content. It is linked to ascites, which is fluid accumulation in the belly, still due to liver problems.

About 5-11% of people with cirrhosis can develop hepatic hydrothorax. For uncomplicated hydrothorax, which occurs in 80% of cases, the fluid accumulation is usually on the right side of the chest.

What Causes Hepatic Hydrothorax?

When the liver problem is advanced and reaches the stage of cirrhosis, it can trigger a lot of reactions from the body. Fluid builds up in the chest cavity (pleural space) through several mechanisms.

There is increased blood pressure in the portal system, which makes the blood go back back up in the portal vein (portal hypertension).

Simultaneously, the liver cannot make enough albumin protein anymore because of the damage, which results in hypoalbuminemia. The combination of increased pressure and low albumin levels cause the fluid build-up in your belly, which is called ascites.

Direct movement of fluid from the belly upwards to your chest especially when there are minor damages or holes in your diaphragm (the muscle that divides your chest and your abdomen).

In some cases, the fluid can travel through tube-like structures called the lymphatic channels.

Since, the pressure in your belly is higher than that of the chest, which is the reason why the fluid can get pushed into your chest cavity.

What Role Does Liver Cirrhosis Play?

Liver cirrhosis is the root cause of hepatic hydrothorax. This occurs when the liver gets covered with tissue scarring. When this happens, the liver cannot function properly. The sick liver will hold on to salt and water, so fluid builds up.

The tissue scarring will also block blood flow through the liver, which will increase the pressure in the portal vein system. The high pressure will force the fluid out of your blood vessels and into the spaces (interstitial spaces) in your body. The fluid will accumulate first in the belly then at times in your chest.

Without liver cirrhosis, hepatic hydrothorax does not usually occur. When the liver damage is too much, the domino effect takes place, which leads to ascites. And, more often than not, ascites happens first before chest fluid builds up.

What Are the Symptoms of Hepatic Hydrothorax?

When fluid builds up in your chest cavity, it can make breathing really difficult. The most common symptoms of hepatic hydrothorax is shortness of breath (dyspnea) and cough, occurring in 34% and 22% of patients, respectively.

The shortness of breath gets worse when you lie down or you exert yourself to do something. You may find yourself needing to sit up or use more pillows before you can sleep. This is because lying flat would make you feel like you’re drowning.

You may also feel discomfort or pressure on your chest. Simple activities like climbing a flight of stairs and even carrying groceries can leave you feeling tired and out of breath.

Some patients, who only have small amounts of fluid in their chest, would feel nothing at all. But others with exceptionally large amounts of pleural fluid make it hard to catch their breath. Some patients would describe it as “breathing through a wet blanket all the time.”

When Should You See a Doctor for Hepatic Hydrothorax Symptoms?

If you have liver disease, you should not wait until you feel out of breath before you call for help. You should see a doctor right away if you notice:

• New or worsening dyspnea

• Coughing that doesn’t go away or get relieved

• Pain or pressure in the chest

• Trouble doing your normal daily activities because of difficulty breathing

Getting help early is important. This allows proper management and treatment. It can prevent the fluid from causing even bigger problems like infection or worse respiratory failure (breathing failure).

If you have been diagnosed with liver disease and started to have ascites, any change in your breathing patterns should warrant medical attention right away.

These symptoms can develop slowly so you may not notice how it worsens. If people around you notice some changes, chances are you are and so seek medical attention immediately.

How is Hepatic Hydrothorax Diagnosed?

Hepatic hydrothorax is diagnosed through a series of steps. The doctors often will get a detailed medical history, which includes asking you about your symptoms. 

Physical examination comes next, where they will listen to your chest using a stethoscope. Doctors may notice a decrease in your breath sounds particularly in areas where fluid has built up. Most often, the build up is on the right side of your chest.

If your doctor clinically suspects you have hepatic hydrothorax by history and physical examination, imaging tests may be requested. Imaging tests can also be used to check for other existing problems like pneumonia or tumors.

There are also times when thoracentesis (a procedure where a needle is inserted into your chest cavity to obtain a sample of the fluid) is necessary. But this is both therapeutic (treatment) and diagnostic (procedure that helps in diagnosis).

Once the fluid is collected through thoracentesis, the sample is sent to the laboratory for analysis. Hepatic hydrothorax fluid has low protein levels (<2.5 g/dL) and low lactate dehydrogenase (LDH) levels.

Still, some patients would need to undergo a special test of radionuclide scanning. This scan will confirm whether there is defect on the diaphragm that allowed communication between the two spaces.

What Tests Are Used to Diagnose Hepatic Hydrothorax?

There are several tests that can be performed to confirm the presence of hepatic hydrothorax:

• Chest X-ray demonstrates fluid accumulation in the lung cavity, which shows as white shadow—usually on the right side.

• Ultrasound can demonstrate both the liver damage and the fluid around the lungs

• Computed tomography (CT) gives a more detailed image of the chest and abdomen to check the fluid and to rule out other causes

• Pleural fluid analysis on a sample from a thoracentesis. It will check for:

• Protein content (low)

• LDH levels (low)

• Cell counts (few cells)

• Culture (to rule out infection)

• Radionuclide scan involves injection of radiocontrast in the abdomen to check if it moves towards the chest indicating a defect in the diaphragm

These tests are done to confirm that:

• You have cirrhosis of the liver

• The fluid is a transudate (which has low protein content)

• There is no infection or cancer that’s causing the fluid build-up

• No heart or lung disease explains the fluid

What Are The Treatment Options for Hepatic Hydrothorax?

The goal for the treatment of hepatic hydrothorax is to get rid of the extra fluid and prevent it from accumulating again. There are different approaches for the treatment, which depends on how severe your symptoms are and how well your liver is still functioning.

Most treatments start with conservative options and proceed to more aggressive ones if necessary. There are three main treatment approaches for hepatic hydrothorax:

• Conservative management (lifestyle and medications)

• Procedures to remove the fluid

• Liver transplantation

Different treatment approaches have different success rates. The first-line of treatment is salt restriction. This means a reduction of salt intake by 10-20%. However, this treatment is most of the time insufficient. So the addition of a medication called diuretic is often required. Some 5-10% of patients cannot tolerate diuresis well and will develop induced hyponatremia (low blood salt) and encephalopathy.

But about 25% of cases are refractory (does not respond to treatment). So more aggressive treatment options often come into play. Invasive options like transjugular intrahepatic portosystemic shunt (TIPS) procedure has a response rate of about 80%.

Another more invasive procedure is thoracentesis, which is both diagnostic and therapeutic management, where a needle is inserted into the lung cavity. This gives immediate relief but the effect could be temporary since the fluid usually comes back unless the underlying cause is fixed.

There are patients where the tube placed on the chest cavity is left to continuously drain the fluid but it is not a long-term solution.

Pleulodesis is another management option, where a lung wall and the chest wall are bound together so there is no more space in between. This prevents the buildup of fluid on the chest cavity. In some patients, this may work but there are those who won’t.

When is Liver Transplantation Considered?

Liver transplant is the best cure for liver cirrhosis that will address hepatic hydrothorax as well. This option is considered when:

• All other treatments are not working

• Your liver function is worsening

• You meet the criteria for liver transplantation:

• Good heart function

• No active infections

• Good support system

But not everyone qualifies for liver transplantation. Your medical team will review your overall eligibility for a transplant, such as:

• Health

• Age

• Other factors

• MELD (Model for End-Stage Liver Disease) scoring to determine who needs the most urgent transplantation

If you have undergone a successful liver transplant, the hepatic hydrothorax almost always resolves completely.

The only problem for this is the long wait times for a matched donor liver. Once you have undergone the transplant, your next problem is lifelong anti-rejection medications.

What is the Prognosis for Hepatic Hydrothorax?

Hepatic hydrothorax often signifies advanced liver disease. The outlook (prognosis) isn’t good without treatment.

Without treatment, the median survival of patients with hepatic hydrothorax only sits at about 8-12 months. This poor survival rate indicates a need for an effective treatment.

Many patients improve with proper treatment and management. It helps in managing fluid buildup, which makes breathing and overall daily life easier. But unless you undergo liver transplantation, the problem can come back.

Post-transplant, the survival rate differs based on various factors like age. One study published in the Annals of Surgery, the 18-year survival rate is at 59%. In another study published in the Iranian Journal of Public Health, the 10-year survival rate sits at 71%.

Complications can worsen the outlook. Bacterial infections in the chest fluid (called empyema) are serious and would require immediate treatment with antibiotics. About 13% of patients develop this type of infection, which further worsens the outlook of patients with hydrothorax.

What Factors Influence Prognosis?

There are several factors that affect how well you do with hepatic hydrothorax. Liver disease severity makes a difference when it comes to the outlook. Often, disease severity is measured by scoring systems used in healthcare, including:

• Child-Purgh score (grades A, B, or C, with C being the worst)

• MELD Score (higher score means worse liver function)

Also, how you respond to the initial treatment also matters. Those patients who are “refractory” (those who don’t improve with maximum medical therapy) usually have it worse.

Other factors that influence prognosis include the following:

• Presence or absence of infection

• Nutrition

• Access to specialized healthcare

• Age

• Overall health (meaning no other underlying disease like diabetes)

Conclusion

Hepatic hydrothorax is a serious consequence of liver cirrhosis. It can significantly impact a patient’s quality of life primarily because of symptoms like shortness of breath and decreased physical capacity. This condition can pose a lot of challenges but with early diagnosis it can improve outcomes significantly. Treatment methods include conservative management and invasive procedures or in advanced cases, liver transplantation. Thus, it is important to understand the cause, symptoms, and seek prompt medical treatment to address hepatic hydrothorax properly. The administration of proper intervention can lead to better symptom control and even result in resolution of the condition. This highlights the importance of comprehensive care and timely intervention for better prognosis.

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Written by Jaclyn P. Leyson-Azuela, RMT, MD, MPH
Jaclyn P. Leyson-Azuela, RMT, MD, MPH, is a licensed General Practitioner and Public Health Expert. She currently serves as a physician in private practice, combining clinical care with her passion for preventive health and community wellness.

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