Bi-directional hepatic hydrothorax.

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.