Clinical Review Lesson of the week

Treating hepatic hydrothorax

BMJ 2003; 326 doi: (Published 05 April 2003) Cite this as: BMJ 2003;326:751
  1. Jakob Borchardt, senior physiciana,
  2. Alona Smirnov, residentb,
  3. Lora Metchnik, residentb,
  4. Stephen Malnick, head of department (
  1. a Department of Internal Medicine C, Kaplan Medical Center, Rehovot 76100, Israel
  2. b Department of Geriatrics, Kaplan Medical Center
  1. Correspondence to: S Malnick
  • Accepted 20 May 2002

Do not use a chest drain to treat hepatic hydrothorax

When a patient presents with a large unilateral symptomatic pleural effusion many doctors will feel tempted to insert a chest drain. We caution against placement of a chest drain as a therapeutic reflex, particularly if the diagnosis is hepatic hydrothorax.

Case reports

Case 1

A 70 year old man was admitted to our department for shortness of breath. He was known to have cryptogenic liver cirrhosis. About two years before this admission he had developed ascites, and treatment with salt restriction, spironolactone, and frusemide (furosemide) was started. One year before admission his right kidney had been removed because of renal cancer. Subsequently he began to have recurrent right pleural effusion. Before he was admitted, weekly thoracenteses had become necessary as he continued to be short of breath.

On admission the patient seemed well except for mild tachypnea. We noted dullness to percussion above the right lung. The abdomen was mildly distended, but ascites was not evident. Jugular venous pressure was not raised, and the patient had no peripheral oedema. Blood count (except for platelets 65 000/mm3) and prothrombin time were normal; bilirubin was 30.8 μmol/l, and protein 71 g/l. The table shows additional results. Chest radiography confirmed a large right pleural effusion; abdominal ultrasonography showed only a small amount of ascitic fluid. Thoracentesis showed a transudate with protein 10 g/l and pH 7.49.

View this table:

Results of blood tests in a patient with hepatic hydrothorax and a chest drain

A chest drain was inserted and 2700 ml of fluid was drained. Subsequently the daily volume of drained fluid …

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