Letters To The Editor
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. May 8, 2017; 9(13): 642-644
Published online May 8, 2017. doi: 10.4254/wjh.v9.i13.642
Bi-directional hepatic hydrothorax
Madhan Nellaiyappan, Anastasios Kapetanos
Madhan Nellaiyappan, Anastasios Kapetanos, Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15212, United States
Author contributions: Nellaiyappan M gathered data and drafted the article; Kapetanos A critically reviewed and revised the article.
Conflict-of-interest statement: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Madhan Nellaiyappan, Resident, Department of Medicine, Allegheny Health Network, 7th Floor South Tower, 320 East North Ave, Pittsburgh, PA 15212, United States. drnmadhan@gmail.com
Telephone: +1-412-3302400
Received: November 9, 2016
Peer-review started: November 10, 2016
First decision: December 20, 2016
Revised: March 27, 2017
Accepted: April 18, 2017
Article in press: April 20, 2017
Published online: May 8, 2017

A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be tachypneic and hypoxic. He had a massive right sided pleural effusion with leftward mediastinal shift and gross ascites, with a tense, fluid-filled, umbilical hernia. Emergent paracentesis with drain placement and a large volume thoracentesis were performed. Despite improvement in dyspnea and drainage of 15 L of ascitic fluid, the massive transudative pleural effusion remained largely unchanged. He underwent a repeat large volume thoracentesis on hospital day 4. The patient subsequently developed a tension pneumothorax, which resulted in a dramatic reduction in the effusion. A chest tube was placed and serial radiographs demonstrated resolution of the pneumothorax but recurrence of the effusion. The radiographs illustrate the movement of fluid between the peritoneal and pleural cavities. In this case, the mechanism of pleural effusion was confirmed to be a hepatic hydrothorax via an unintended tension pneumothorax. Methods to elucidate a hepatic hydrothorax include Tc99m or indocyanine green injection into the ascitic fluid followed by its demonstration above the diaphragm. The unintended tension pneumothorax in this case additionally demonstrates bi-directional flow across the diaphragm.

Keywords: Hepatic hydrothorax, Bidirectional flow, Iatrogenic pneumothorax

Core tip: Hepatic hydrothorax is usually a clinical diagnosis in patients with cirrhosis and portal hypertension who present with a transudative pleural effusion. The authors herein report an interesting case of radiological confirmation of hepatic hydrothorax through a series of chest radiographs that depict the movement of ascitic fluid between the pleural and peritoneal cavities due to a iatrogenic pneumothorax.